A resident with dementia and a history of aggressive behavior was on constant observation/1:1 monitoring when he pushed another resident out of a chair and onto the floor, then attempted to strike the resident with a chair. Staff interviews and video review showed the assigned 1:1 aide observed the altercation but did not intervene quickly enough, and the resident who was pushed required hospital evaluation for a head injury.
Unsafe Water Temperatures: Water temperatures on two units were found to be too hot, with several resident rooms noted during observation and later measurements showing 125.1 degrees and 129.4 degrees. An LPN said there had been a prior problem that had to be fixed, residents reported inconsistent hot water, and the maintenance director stated the risk was potential scalding. The Administrator reported there was no policy for water temperatures.
A resident with Parkinson’s disease, weakness, and other chronic conditions was using a power wheelchair when the chair struck a curb in the facility parking lot and tipped, causing a fall with b/l SDH, C1/C2 fractures, a scalp laceration, abrasions, and a scalp hematoma. The record did not show a safety skills assessment or education for safe power wheelchair use, and staff stated no wheelchair safety evaluation had been completed on admission or after admission.
Unsecured hazardous chemicals were found accessible to residents when multiple janitor carts were observed unlocked or left with keys in the locks, and a housekeeping storage room was found unlocked with additional carts inside. The carts contained chemicals such as foam cleaner, Clorox urine cleaner, bleach-containing cleaner, disinfectant spray, and neutral floor cleaner, and one cart also had an unlabeled liquid in a water bottle. Staff interviews and MSDS information confirmed the products were hazardous and that unsecured access could expose residents to injury or poisoning.
Failure to Complete Post-Fall Assessment After Reported Fall: A resident reported a fall, but staff did not complete the required post-fall assessments. RN and DON interviews confirmed that the event should have triggered assessment and notification, and the record showed only an initial note with vital signs and no further documented VS, neuro checks, or skin assessments after the reported fall.
Staff failed to maintain a safe environment by leaving kitchen floor tiles missing at the kitchen entrance and by not repairing a damaged dining room entry door. The removed tiles were stored on a pellet warmer near the exposed area, and the Director of Maintenance acknowledged that the missing tiles created a potential trip hazard. The dining room entry door was observed splitting apart with the bottom hinge detached, and the door was being kept propped open; the Director of Maintenance stated the door could fall if staff attempted to close it, identifying it as a hazard. Facility leadership reported no additional concerns when interviewed about these conditions.
A resident with COPD, dementia, and moderately impaired cognition, who was care planned as a safe smoker only with staff supervision, was observed actively smoking alone in the designated courtyard with a lit cigarette that had not been provided or lit by staff. Facility policy required that residents needing supervision be within eyesight of staff while smoking and prohibited residents from keeping smoking materials on their person or in their rooms, with all supplies to be locked in a medication room. The resident reported that smoking was usually supervised at set times and denied possessing cigarettes or a lighter, while staff, including CNAs and an LPN, stated that they controlled and distributed smoking materials and that they were late to the scheduled smoking time on the day of the incident. When staff arrived later with the smoking box, they reported no residents were smoking and could not explain how the resident had obtained a cigarette or lighter prior to their arrival, and facility leadership confirmed that all smoking was supposed to be supervised.
Facility staff failed to maintain the fire alarm system in fully operational condition and did not implement Fire Watch according to policy, leading to an Immediate Jeopardy finding. Surveyors observed non‑working exit lights, a fire alarm panel in trouble mode, and no credible evidence of required annual testing, while the facility had been on Fire Watch for months without a dedicated, trained Fire Watch person. Multiple CNAs, LPNs, and other staff could not clearly explain why the facility was on Fire Watch, who was responsible, or the full scope of required surveillance, and Fire Watch rounds were largely limited to hallways and the building exterior rather than all risk areas. The Administrator and maintenance staff were unable to produce timely documentation of inspections, testing, or risk assessments for the fire alarm system, and the facility continued to accept new admissions while on Fire Watch, contrary to expectations outlined during the survey.
A resident with DM, Parkinson’s disease, dementia, adult FTT, severe cognitive impairment, and dependence for bed mobility and transfers was care planned as at risk for falls, with interventions including bed rails as an enabler and two-staff assistance for repositioning in bed. An agency CNA who had been at the facility about a week provided care without ensuring the low air loss mattress was in static mode, and the resident subsequently fell from bed and complained of left knee pain. Imaging showed a possible subtle distal femoral fracture. The DON described the resident as a one-person assist who held onto the bedrail and was alert but confused, and the facility’s falls policy required individualized interventions based on risk factors, which were not properly implemented in this instance.
Unsafe wheelchair transfer resulted in hip fracture. A resident with incomplete paraplegia and MS, who required a Hoyer lift with 2 staff for all transfers, was moved from bed to a tilt-and-space wheelchair when the chair backrest reportedly collapsed or unlocked and the resident slid/fell out of the chair. Staff accounts varied, but the resident was sent to the hospital and diagnosed with an acute closed right femoral neck fracture.
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