Surveyors found that the facility failed to keep the environment free of accident hazards when a resident’s room contained an unattended shaving razor on the sink and additional razors in a nightstand, despite leadership stating razors were not permitted in resident rooms. An LPN disposed of unused lancets in regular trash instead of a sharps container, contrary to acknowledged policy. On two occasions, an unattended housekeeping cart on an upper floor had germicidal wipes left on top and easily accessible, even though housekeeping leadership and staff stated that chemicals and disinfectant wipes were to be kept locked in the cart for safety.
Failure to supervise smokers and secure smoking materials. Surveyors found that 27 smokers were not adequately monitored and that residents were able to keep cigarettes and lighters in their possession despite care plan directions to return them after smoking. One resident with severe cognitive impairment, dementia, schizophrenia, and continuous oxygen use was observed with cigarettes and a lighter while on oxygen, and staff confirmed she was an unsafe smoker requiring direct supervision.
Surveyors found that staff failed to adequately supervise multiple cognitively impaired residents on a secured dementia unit, allowing one severely impaired resident to poke and shove a wheelchair-bound resident and then slap another resident in the dining room while staff attention was focused elsewhere. Residents with dementia and agitation, including those known to wander and exhibit sexually inappropriate behaviors, were allowed to move freely into others’ rooms and around the halls with inconsistent monitoring. A resident with severe cognitive impairment and identified as an elopement risk was found wandering and had previously been discovered in another resident’s room while that resident groped her breast, despite prior similar behavior by the same resident. Staff interviews described frequent wandering, insufficient engagement activities, uncertainty about how often residents were checked outside the dining area, and acknowledged that supervision on the locked unit was inadequate to prevent resident-to-resident altercations and inappropriate contact.
A resident who smoked was found in bed with two boxes of cigarettes and a lighter stored on and under the cushion of his wheelchair in his room. The resident was cognitively intact and independent with ADLs, and his care plan identified him as a supervised safe smoker. Facility policy stated residents shall not keep lighters with them or in their rooms, yet staff interviews showed the resident kept smoking supplies in his room and the lighter was later obtained from him.
A resident on the fall management program was observed in a bed left in a high position with the call light out of reach and no staff present; the resident had Alzheimer’s disease, severe cognitive impairment, and was dependent on staff for toileting and hygiene. In a separate observation, a housekeeping cart on the fourth floor was left unattended with a spray bottle easily accessible, and staff stated chemicals are supposed to be kept locked.
Surveyors found multiple hazardous cleaning and disinfectant chemicals stored in unlocked lower cabinets in two nourishment areas, one adjacent to a common living area and one within a dining room, both accessible to residents. Products such as disinfectants, insecticide aerosol, bleach germicidal wipes, hydrogen peroxide wipes, an acidic delimer, and other cleaners were observed without secure storage or access controls, despite SDS guidance that they be stored securely. The Dietician and the Administrator acknowledged that all chemicals were expected to be locked and secured, but this was not implemented in these dietary service areas.
The facility failed to provide adequate supervision and maintain a hazard‑free environment, resulting in multiple physical altercations among cognitively impaired residents with dementia, behavioral symptoms, and wandering. One resident with Alzheimer’s and PTSD was pushed to the floor, hit his head, and sustained skin tears, and in another incident he was found pinning another resident to a bed with his hands around the resident’s neck while the victim trembled. Other events included a resident being struck with a walker in a common area, a resident in a wheelchair being pushed and pulled by another resident, and two residents engaging in a fistfight in a room, with one being pushed to the floor, kicked, and developing bruising around the eye. Surveyors observed common areas and hallways with residents present but no staff in sight, especially during busy mealtimes, while CNAs reported difficulty monitoring residents due to workload and unit busyness. A supervision list showed several residents on 15‑minute and 30‑minute checks and one on 1:1, yet CNAs were unaware of some residents’ increased supervision status, and required monitoring documentation was missing for part of a shift, demonstrating inconsistent implementation of ordered supervision.
Unlocked Soiled Utility Room and Housekeeping Cart Left Accessible: Surveyors observed a second-floor soiled utility room left unlocked on multiple occasions while it contained biohazardous and sharp materials, with a CNA and housekeeping staff exiting without securing the door. Surveyors also observed a housekeeping cart left open and unattended with chemicals visible and accessible. The ADON, RN, and Housekeeping Director stated the room and carts are to be kept locked when unattended, and staff involved said they did not realize the items were left unsecured.
Surveyors found that hazardous cleaning chemicals, including Virex II 256 and Virex TB, were stored in an unlocked, easily accessible lower cabinet in the main dining room, which is open to ambulatory residents throughout the day. The cabinet lacked any locking mechanism or security measures. SDS information for both products indicated they are industrial/institutional disinfectants that can cause eye, skin, and respiratory irritation or burns and must be stored safely to prevent exposure. The Administrator acknowledged the chemicals were not secured and stated that all cleaning products are expected to be secured when not in use by staff.
Unsafe Solo Hoyer Lift Transfer: A CNA transferred a dependent resident with a Hoyer lift without the required second staff member, while the resident was suspended and swinging side to side above a shower bed. The resident knew two staff were required, and both the CNA and an LPN/unit manager confirmed the lift should not have been used alone. The resident had paraplegia, a colostomy, dysphagia, and intact cognition.
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