A resident with a smoking safety evaluation requiring a smoking apron and supervision was observed in the smoking area and allowed to start smoking without the apron. The Corporate RN confirmed the evaluation required the apron for safety, and a CNA verified it was not used.
An unlocked medication cart was observed unattended near the nursing station, and the assigned RN confirmed she had given her keys to another nurse. In a resident room, three tubes of Bio-Freeze ointment were found on a resident’s bedside shelf in sight and within reach; the DON confirmed the ointment could not be left in the room.
Failure to maintain required fall protection and secure hazardous rooms. A resident with a fall risk had a physician-ordered fall mat and care plan intervention for the left side of the bed, but the mat was not in place when the resident was observed in bed. In addition, two doors in the A Hall, including the shower room and clean utility room, were found unlocked and would not lock properly after repeated attempts, and the Admin and maintenance staff confirmed the issue.
Medication Left at Bedside: A resident was observed with two inhalers and a medication cup containing one TUM at the bedside. When asked about it, the resident said the medications had not yet been taken and that they were getting dressed and putting lotion on. An LPN acknowledged the issue, and the DON stated that medication is not supposed to be at bedside.
A resident with poor cognition and a fall history had ordered bed rails for turning, repositioning, and safer bed exit, but after a room change the rails and floor mats were not moved with him. He later had an unwitnessed fall from bed, was found on the floor beside the bed, and was sent to the ER after the HCS requested further evaluation. Hospital imaging showed an intracranial hemorrhage and a small occipital hemorrhage, and the ER documented fall from bed with head trauma.
Failure to address repeated bruising and impact injuries: A resident with Huntington's Disease, no meaningful cognition, and a history of hitting the wall had ongoing bruising, scabs, abrasions, and discoloration documented by hospice staff over several weeks. Hospice staff reported the resident frequently kicked or hit the wall, and a fresh bruise observed by hospice was not documented on the facility skin checks. The surveyor later observed bruise-like discoloration on the resident's leg and feet, and the DON confirmed the bruising while noting the most recent skin check had no skin issues documented.
A resident was found deceased after staff discovered her with her head and arm between the bed assist rail and mattress. The record showed she had bilateral bed assist rails ordered, limited mobility, and a care plan calling for a safe environment and side rails as ordered. Staff statements and police documentation described her being found kneeling or halfway off the bed with her head wedged between the rail and mattress, and the report stated the facility had not assessed the need for the hand rail assist bars.
Open Cleaner Left in Shower Room: A resident was observed in the bathroom adjacent to the shower room, where the bathroom door could be opened into the shower area. An open gallon jug of Medco Prewash MP2017 was sitting on top of the wheelchair washer machine, and an LPN confirmed the cleaner was open in the shower room. The SDS listed the product as causing skin and eye irritation.
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.
Surveyors found an unlocked, unattended medication cart on the 400 Hall on two occasions, and a medicine cup with milk of magnesia left on a resident’s bedside table despite facility policy stating medications should not be left unattended or at bedside. Surveyors also found an unsecured blender stored under a sink in the activities area, with the DON confirming it should not have been stored there. The cart and blender were both in areas accessible to residents, unauthorized persons, or visitors.
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