A resident with moderately impaired cognition fell forward from his wheelchair when a CNA pushed him to the dining room without attaching the wheelchair foot pedals, despite a known history of putting his feet down while moving. He hit his face and sustained a forehead lump, nasal abrasions, and a small hand skin tear; staff interviews and the incident report confirmed the CNA had been trained on the pedal requirement and did not follow it.
A resident with hemiplegia after a stroke fell from the toilet after a CNA left him in the bathroom without his call light within reach. He reported that the stand aid was left in front of him with the brakes not locked, and when he reached for the call light cord, the device moved and he fell, hitting his head and sustaining a laceration to his arm. Staff interviews showed inconsistent practices for leaving the stand aid in the bathroom and ensuring the call light was accessible.
A resident spilled coffee that had been served too hot, and two other residents were observed drinking coffee without the lid precautions identified in their hot liquid safety evaluations and care plans. In a separate incident, a CNA left a resident alone in the shower despite a care plan requiring supervision/touching assistance, and the resident fell and bruised his knees.
A resident with moderate cognitive impairment, autism, and visual impairment was left unsupervised outside his room after it had been mopped and the floor was still wet. A CNA told him to wait, then walked away, while a Caution Wet Floor sign was posted at the entrance and environmental services said the floor had to be completely dry before re-entry. The resident later entered the room despite the wet floor.
A resident with advanced dementia fell out of a whirlpool chair when a CNA/bath aide raised the chair and tried to lock the wheels without using the required safety belt. The resident struck his head, had a forehead laceration, briefly lost consciousness, and was sent to the hospital where he received sutures.
Staff failed to follow a resident’s care-planned transfer needs. The resident had severely impaired cognition, a moderate fall risk score, and required dependent assistance with transfers, including a Hoyer lift with 2 staff or a sit-to-stand lift. Two CNAs lifted her by the underarms and pivoted her instead of using the ordered transfer method, and one CNA stated she did not use a gait belt because the resident was too tiny. The DON acknowledged the transfers were improper and unsafe because staff did not follow the care plan or Kardex.
The facility failed to maintain safe bed systems and prevent accidents, resulting in loose side rails, unsecured or poorly fitted mattresses, and unassessed entrapment zones for multiple residents, including one who was legally blind and had a prior brain bleed after falling from bed. Maintenance logs showed incomplete or inaccurate entrapment audits, with several entrapment zones marked not applicable and some residents with rails omitted from audits, while the DON acknowledged missing side rail assessments, consents, and orders. Additional incidents included a resident with post‑stroke weakness who fell from a bed left at waist height, a resident care planned for two‑person mechanical lift transfers who was transferred by a single CNA using an incorrect sling setup, a cognitively impaired resident at risk for elopement who exited through a door with its alarm deactivated and remained outside briefly in cold weather, and a resident on anticoagulants who fell and hit her head after 11 falls in 30 days without effective revision of fall‑prevention interventions.
A resident with mild cognitive impairment and a known elopement risk, who had refused a wander guard and was to be checked every three hours, was last documented as seen at midday and later left the building by independently using the front door keypad code, remaining unsupervised outside until returning the next day. The front door keypad code had been unchanged for years, was posted in reverse on a laminated sign above the keypad, and was known to some residents, allowing them to open the door. At the same time, after an EMR system update, staff stopped routinely completing the required elopement risk assessment on all new admissions, and several newly admitted residents had no documented elopement screening despite facility policy requiring universal admission screening.
The deficiency centers on unsafe resident transfers and unsecured chemicals. A resident with hemiplegia and severe cognitive impairment, care planned for a one-person sit-to-stand (STS) lift transfer, was instead manually transferred by a CNA without the lift, during which the resident’s legs gave out, he was lowered to the floor, hit his head, and later was found to have a subdural hematoma. Another resident with severe cognitive impairment and documented inability to meet STS criteria was nonetheless assessed and care planned for STS transfers, while staff and family intermittently pivot transferred her without a gait belt and with inconsistent use of mechanical lifts, amid reports that pocket care plans and Kardex information were not kept up to date. Additionally, surveyors repeatedly observed an open tub room with unlabeled and labeled chemical spray bottles accessible on the tub, and an unattended housekeeping cart in the dining room with toilet bowl cleaner and other disinfectants unlocked and reachable by residents, contrary to staff statements that such rooms and chemicals were to be secured.
Two residents who required two-person assistance with mechanical lifts were subjected to unsafe transfers when CNAs used improperly sized, mispositioned, or incompatible full-body slings and did not follow manufacturer instructions. In one case, a resident newly admitted with a hospital-provided sling was lowered to the floor during a lift transfer after sliding forward in the sling, resulting in reported rib pain but no fractures on X-ray. In another case, a resident’s wheelchair pad and handle became entangled in a large sling during a lift, causing the wheelchair and resident to be lifted off the floor; the sling remained incorrectly positioned at mid-back when the resident was lifted again and moved to bed. Multiple CNAs and nurses reported no recent facility-specific training or competencies on mechanical or sit-to-stand lifts, selected sling sizes by guessing based on body type or using whatever sling was in the room, and lacked clear, updated care plan or Kardex documentation specifying lift type and sling size for residents who required mechanical lifts.
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