The facility failed to keep the main laundry room free of hazards for 2 of 2 dryers. Surveyors observed lint buildup on the back of the dryers, including the top, openings, gas lines, and inside the machine openings, with gas dryer flames visible through the openings. Laundry staff stated no one cleans behind the dryers and that they only clean the floor and what they can reach.
Failure to use a gait belt during a resident transfer. A resident’s care plan required assist of 1 with transfers and use of a gait belt, and facility policy stated gait belts are to be used for residents who cannot independently ambulate or transfer. During observation, a CNA assisted the resident to the bathroom without a gait belt. The resident stated therapy uses a gait belt, but CNAs typically do not, and an admin nurse stated she expected staff to use a gait belt during transfers.
Failure to supervise a wandering resident led to repeated access to unsafe areas, hazardous items, and other residents’ rooms. The resident, who had vascular dementia and moderately impaired cognition, was documented entering storage and supply areas, attempting to elope, and urinating/defecating in common areas and other residents’ rooms. The care plan did not address the resident’s wandering, rummaging, or toileting behaviors, and an admin nurse agreed the behaviors posed a risk to all residents.
A resident with chronic fatigue syndrome, a prior R humerus fracture, OA, repeated falls, and substantial transfer assistance needs fell while ambulating with a walker. Staff found the resident on the floor in the tub room with severe pain, and the facility determined that a CNA had transferred the resident without using the required gait belt during the assisted transfer.
Standing water was not promptly cleaned from a central hallway and near the Dakota Dining Room, with water observed trailing across the floor and dripping from a ceiling AC unit into a bucket that created a puddle extending into the doorway threshold. The water remained in place for extended periods, and a yellow caution sign was later placed over the area while the puddle continued to grow. An MNT supervisor stated staff are expected to monitor for water and other safety hazards and clean them up promptly.
A resident with dementia, cleft palate, and dysphagia was ordered an IDDSI Level 6 soft and bite-sized diet, but marshmallows were left in the room and later eaten, leading to a choking episode with cyanosis, pulselessness, apnea, and hospitalization. Staff also served a meal tray with a whole Salisbury steak patty and other foods not prepared into bite-sized pieces, and interviews showed staff were not consistently educated on the resident’s diet restrictions or IDDSI requirements.
Failure to use wheelchair footrests for a resident seated in a wheelchair. A CNA transported the resident back to his room to assist with dressing, but did not place the footrests on the wheelchair or cue the resident to raise his legs and feet, and the resident's legs and feet bounced along the floor.
Improper Use of Mechanical Sit-to-Stand Lift During Resident Transfers: Staff failed to properly use a mechanical sit-to-stand lift during transfers for multiple residents. One resident was transferred without removing heel boots as directed, another was left hanging in the lift after letting go of the handlebars while the CNA continued care, and two CNAs completed a transfer without securing the sling around a resident’s abdomen.
Inadequate supervision during a sit-to-stand lift transfer resulted in a resident’s hand being bumped against a bathroom door frame, causing a skin tear to the back of the R hand. The resident had fragile skin, diabetes, immobility, and required assist of 1 staff with a PAL lift for transfers.
Improper Sit-to-Stand Lift Transfer: Two CNAs assisted a resident with left-sided weakness, paralysis, and a history of falls during a PAL transfer. The resident was raised to standing while the abdominal strap buckle and leg straps were not secured, and morning care was provided while the resident remained connected to the lift.
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