F0689

J

Unsecured Medications and Exposed Heater Elements Create Accident Hazards

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for two residents. One resident with recurrent moderate major depressive disorder, atrial fibrillation, seizures, and severe cognitive impairment was found asleep in bed with a clear plastic bag on the nightstand containing three prescription medication bottles: Sertraline 50 mg, Eliquis (Apixaban) 5 mg, and Levetiracetam 500 mg. These bottles were labeled with the resident’s name and contained medication. Facility policy on administering medications stated that medications were never to be left at the bedside and that medications brought in with a resident would be returned to the family or health care proxy, with medications to be reordered and filled by the facility or vendor pharmacy.

Staff interviews revealed that a CNA stated they would remove medications found at the bedside and report them to a nurse, and an LPN stated that medications from home were to be locked in the medication cart and then either taken home by family or destroyed. When the surveyor showed the medications on the nightstand to the LPN, the LPN identified the fill dates on the bottles and removed them from the room. Another LPN stated they were not aware the resident had medications on the nightstand and that staff should have seen and removed them, noting that the resident was cognitively impaired and unable to self-administer medications. The Acting DON/Acting ADON stated that the medications at the bedside could have caused serious harm if taken by another resident and described all three as lethal medications that could cause serious harm depending on what and how much was taken. The family member reported that, at admission, a nurse told them the medications were not needed because they would be ordered at the facility and instructed them to put the medications in the bedside table.

The second component of the deficiency involved an environmental hazard in another resident’s bathroom. This resident, who had ataxia, a history of falling, spinal stenosis, and used a wheelchair for mobility, was cognitively intact and able to make themselves understood and understand others. During observation, the bathroom door was open and a small electric baseboard heater was seen with its front cover removed and lying on the floor in front of the running heater. The heater was producing heat and a burning smell, and when the surveyor placed a hand close to the exposed heating elements, they were hot enough to cause injury if they came into direct contact with skin or clothing. A CNA reported having seen the heater cover on the floor the previous day and acknowledged they should have reported it to Maintenance but did not, and also did not report it on the day of the survey. The Director of Maintenance and an LPN confirmed that the heater was hot and that the cover had to be put back on, and the LPN stated staff should have reported the missing cover immediately.

Removal Plan

• Resident #2's home medications observed at the bedside were removed from the room and secured.
• Nurse Practitioner #1 was notified regarding the medications found in Resident #2's room.
• The family was to be notified according to facility process.
• Education was provided to all staff on medication administration and continued until all staff were educated.
• Staff rounds occurred during care delivery, activities, therapy, and routine safety checks multiple times a day.
• A full-house in-service was conducted to reinforce medication safety, admission procedures, and environmental monitoring.
• Administrator #1 was notified regarding the prescription medications left at Resident #2's bedside.
• A facility-wide audit of each resident room (including drawers and cabinets) was conducted to ensure no other residents had medications in their rooms.
• A second facility-wide audit of each resident room (including drawers and cabinets) was conducted to ensure no other residents had medications in their rooms.
• Administrator #1 and Assistant Administrator #1 reviewed the facility policy 'Administering Medications' and made no revisions.
• Medications from Resident #2's room were returned to Family Member #3 to take home and destroy.
• Mandatory education/re-education was initiated for all staff that residents were not to have medications in their room and any medications found must immediately be given to a nurse.
• Education was to be conducted verbally (in person or by telephone) by the Nursing Supervisor and/or designee.
• Staff not reached by telephone would not be permitted to work until they received the education.
• Director of Maintenance #1 replaced the cover on the baseboard heater in Resident #3's bathroom.
• Director of Maintenance #1 conducted an audit of the electric baseboard heaters in the facility to ensure covers were in place.
• Assistant Administrator #1 and Director of Maintenance #1 reviewed the facility Work Request Policy and made no revisions.
• Mandatory education was initiated for all staff regarding the process for reporting damaged, broken and/or malfunctioning equipment.
• Education on reporting damaged/broken/malfunctioning equipment was to be conducted verbally (in person or by telephone) by the Nursing Supervisor and/or designee.
• Staff not reached by telephone would not be permitted to work until they received the education on reporting damaged/broken/malfunctioning equipment.