The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Bed Gaps and Unsecured Medication Observed: During a tour, two residents’ beds were observed with large gaps between the mattress and the bed frame, and a third resident’s bed also had a large gap at the foot of the bed. The DON and Administrator verified the bed gaps. In a separate observation, Aspercreme with lidocaine was left on top of a treatment cart with no staff nearby, and an NP confirmed it was unsupervised.
A resident with a fall care plan did not have the documented fall interventions in place. The plan called for non-skid socks and non-skid strips on the left side of the bed, but surveyors observed that the socks were not on while the resident was in bed and the strips were not present. An LPN confirmed the findings.
Surveyors identified multiple failures to keep the environment free of hazards and to follow safe transfer and fall-prevention practices. Hazardous bleach wipes were left within reach at a bedside, loose drywall and debris were present in a bathroom and in dining room cabinets accessible to residents, and a topical medication was left at a bedside for self-use despite the resident not being care planned to self-administer. One resident care planned as dependent on a mechanical lift with two staff was repeatedly transferred to the toilet via wheelchair with one staff and no lift, while the resident reported staff often refused to assist to the bathroom and directed use of briefs or a bedpan instead. Another resident designated as a gait belt transfer was moved from bed to wheelchair by a NA without a gait belt, a resident care planned for a low bed with a fall mat had the bed left above the lowest position, and a resident assessed for total lift transfers had a bedside commode in the room despite the DON stating such residents should not have one.
An unlocked, unattended treatment cart was observed in an area accessible to residents, visitors, and unauthorized persons, and an LPN confirmed it was left unsecured because she did not have a key. Three oxygen tanks were also stored behind the nurses station in rolling carts without regulators and not in proper metal cages after staff said the medication room could not be used because the required sign was not approved.
Accident Hazards Found in Resident Room Storage and Shared Bathroom: Surveyors found razors, shaving cream, and other personal care items stored in accessible vanity drawers in a resident room, and a resident reported another resident had been getting into his drawers. In a shared bathroom, surveyors observed a broken baseboard heater with jagged edges and a damaged wall night light exposing the bulb and wiring; the EAM and ADM were aware of the hazards.
A resident reported being afraid she would trip on the bathroom floor transition and said she had reported the issue several times. Surveyors observed a bent-up transition strip and a downward-bent wooden floor beneath it at the bathroom doorway, creating a gap and a potential tripping hazard. The NHA was shown the condition and stated maintenance would get it fixed.
A resident with a history of falls, confusion, and poor memory had repeated falls documented in the chart. The care plan called for bilateral hip protectors in bed, a visible "Call don't fall" sign, and a fall mat on the right side of the bed, but observation found the mat on the left side, no sign in the room, and an LPN confirmed the resident was not wearing hip protectors.
Surveyors found multiple unsecured hazards in resident-accessible areas, including cleaning chemicals, food waste, and sharp or medical items. In one hall, residents could access a mini-kitchen where Scrubbing Bubbles and vinegar were stored under the sink and a manual can opener was left on the stovetop, while uncovered food waste carts were left unattended in dining and hallway areas used by residents. Elsewhere, oxygen tanks were improperly stored in a cubby without regulators or full/empty labels, Sani-Wipes were left on an unattended treatment cart, and a linen cart and an unlocked cabinet contained accessible lotions, hand sanitizer, and other supplies. An open, unattended shower room also contained an overflowing sharps container with razors, an open can of Scrubbing Bubbles, and an open whirlpool disinfectant container, all within easy reach of residents.
A facility failed to keep resident areas free of accident hazards when surveyors found a ceiling leak with a partially blocked wet floor, missing conduit with exposed electrical wiring, separated wall rub rails, open lighting boxes with exposed bulb/wires, broken drywall, protruding bolts, and supplies left in a resident bathroom cabinet. The maintenance supervisor and ED acknowledged the hazards and needed repairs.
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