Failure to Provide Adequate Supervision and Remove Environmental Hazards
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent falls for one resident and to maintain a safe, hazard‑free environment for another resident. Resident B, who had diagnoses including subarachnoid hemorrhage and chronic respiratory failure, was not cognitively intact for daily decision making and was dependent on staff for toileting and transfers. Her care plan identified her as at risk for falls and required staff to anticipate and meet her needs, keep the call light within reach, respond promptly to requests for assistance, and ensure appropriate footwear. Despite this, she experienced multiple falls, including an unwitnessed fall in the bathroom. The North Unit Manager reported that on one occasion the resident was left alone on the toilet and fell while attempting to transfer herself, even though she should not have been left unattended. The deficiency also includes the presence of an accident hazard in another resident’s room and the resulting injury. Resident C, who was cognitively intact and required supervision with ADLs, was observed with visible swelling of the right foot, ankle, and lower leg and reported that he injured his foot when a broken closet door in his room hit him while he was trying to fix it. The closet door was observed hanging off its track and away from the closet on multiple days, and the resident stated that staff were aware of the issue. He reported difficulty walking due to pain and swelling, at times ambulating with a cane and at other times propelling himself in a wheelchair with only his left shoe on because the right shoe would not fit. A nurse practitioner note documented that the resident had previously reported right foot pain after hurting his foot on the closet in his room, and the closet door remained hanging off the track during subsequent observations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.