A resident with cerebral palsy, severe cognitive impairment, wheelchair use, and a care plan requiring a mechanical lift for all transfers was manually transferred by a CNA instead of using the lift. During observation, the CNA lifted the resident by the upper back and moved him between the wheelchair and bed without mechanical assistance, despite having completed lift competency training and despite the DON confirming the resident required a mechanical lift for all transfers.
A facility failed to keep the resident environment free of fire hazards after a dining room fire and a later smoke incident in the same area. A resident with asthma, COPD, and anxiety reported being in the dining room with two other residents when smoke appeared, leaving with breathing difficulty afterward, and not being assessed. The Administrator and Maintenance Supervisor described a ceiling light fire linked to incorrect bulb wattage, but the dining room lights were not checked afterward, the later smoke event was not investigated or reported to the fire department, and staff interviews showed confusion about code red response, extinguisher use, and resident evacuation.
Gas-Powered Lawn Equipment Stored Indoors in Renovation Area: A gas-powered lawn [NAME] with half a tank of gas was found stored inside a vacant area in the 2400 hall temporary storage area within an active renovation zone. The Maintenance supervisor stated it should have been stored outside by the dumpster, acknowledged it was a safety hazard because it could leak gas or oil and become a fire risk, and said he had not completed his daily rounds that day.
Smoking Supervision and Assessment Deficiencies: The facility failed to ensure adequate supervision and required smoking assessments for three residents. Two residents with significant cognitive and medical impairments were observed smoking with tubing devices, and one of them was not wearing the smoking apron at the time of observation. A third resident was observed smoking independently, but none of the three charts contained the required smoking assessment, and the DON stated the assessments were supposed to be completed quarterly.
Unsecured Mechanical Lift Left in Room: A mechanical lift was found unlocked and unattended in a resident room after staff used it for a resident with hemiplegia, hemiparesis, inability to walk, and moderate cognitive impairment. LVN, CNA, and DON interviews confirmed the lift should have been locked and stored when not in use, and the facility’s in-service also stated Hoyers should be locked and stored appropriately.
A resident with dementia, severe cognitive impairment, and wheelchair dependence was left sitting in her wheelchair for hours without being transferred to bed or checked on. Video showed her calling for help, then rolling out of the wheelchair onto the floor while the room door remained closed. Staff interviews confirmed the RN and CNA did not complete expected rounding or ensure the resident was put to bed, and the DON and Administrator stated residents were expected to be checked every 2 to 3 hours.
Unsecured Oxygen Cylinder Left in Resident Room: A resident with severe cognitive impairment, pneumonia, acute and chronic respiratory failure with hypoxia, and an order for nocturnal O2 had an E-cylinder observed laying unsecured across an extra bed in the room. CNA and RN staff stated cylinders were to be secured in a wheelchair bag or rolling cart and never left on beds or loose in resident rooms; the DON and Administrator confirmed cylinders were required to be secured, and the facility policy required tanks to be stored in a cylinder cart or securely chained.
Unsafe Resident Transfers Without Required Lift Equipment: Staff attempted to transfer a resident with hemiplegia, hemiparesis, and dependence for transfers by lifting her under the arms instead of using the ordered mechanical lift or other safe assistive device. Video showed one CNA nearly dropping the resident, then multiple staff members manually moved her to bed without a gait belt or lift pad, while the ADON did not document the near-drop or unsafe transfer after being told about it.
Overflowing Sharps Container on Nurses’ Cart: A sharps container on a hall nurses’ cart was observed full and overflowing with insulin syringes near spilling onto the floor. The charge nurse said she knew it was full on the prior shift and again when she came on duty, but she got busy and forgot to replace it. The DON stated nurses were expected to check sharps containers each shift and replace them when half full, and the facility policy said sharps containers must not be overfilled.
A resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and tobacco use, was observed smoking without the required smoking apron during a supervised smoke break. His physician order required the apron on all smoke breaks, and the care plan and smoking assessment identified direct supervision and apron use. Staff interviews showed confusion about the requirement, and one staff member allowed the resident to smoke even when he refused the apron.
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