A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A facility failed to keep the resident environment free of accident hazards when two 8.8-ounce spray bottles of Febreze Air Effects Gain Original were observed sitting on a shelf at the foot of a resident's bed. An LPN confirmed that confused residents moved around the unit and could enter rooms and access hazardous chemicals.
An EZ Sit to Stand lift was observed missing both safety pins, and an RN confirmed the issue before the lift was removed from the unit. In a separate observation, an unsecured container of CaviWipes was found on a med cart with no staff in sight; an MTA confirmed the wipes should have been secured because vulnerable and ambulatory residents were on the unit.
Damaged doors and protective coverings created accident hazards in common areas and on the Cove Unit. A small sitting room door had a broken protector sticking out and sharp, and a wooden double door in the lobby had a gouge with missing wood and sharp edges; an LPN and the Administrator both confirmed the observations.
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Unsecured Chemical Storage in Spa Area: An unlocked and ajar closet door in the [NAME] unit spa allowed resident access to 5 gallons of Cid-A-L ? II disinfectant stored inside. The SDS stated the chemical should be kept out of reach of children and identified it as toxic, with potential for eye, skin, inhalation, and ingestion harm. The DON and surveyor observed the unsecured chemicals, and the DON confirmed they were not secured.
Broken floor heaters exposed piping and sharp metal fins in resident areas, including rooms [ROOM NUMBER] and the TV room on the Passport Unit. The condition was observed by surveyors and confirmed with the Maintenance Director and the DCO.
Staff failed to promptly clean a spilled liquid on the floor in an ambulatory, legally blind resident’s room after being notified, leaving the resident to transfer and ambulate with a walker in the presence of the spill. In addition, a metal threshold plate at a main entrance used by residents was not properly secured, with loose edges and gaps causing it to shift under weight, following a complaint that the broken threshold impeded wheelchair exit.
The facility failed to maintain safe, unobstructed egress routes when two of three ground-floor exits were blocked by significant snow accumulation, leaving only an employee entrance cleared. Surveyors observed deep snow on the front walkways and ramps, while 25 residents would have needed to be moved either through locked doors and narrow corridors to the side employee entrance or through the snow-obstructed front exits. Two maintenance staff were seen performing other tasks, and the Administrator reported that she had instructed maintenance to clear the egresses, but this had not yet been done.
A resident was transferred using a sit-to-stand lift, contrary to recent therapy recommendations for a full mechanical lift due to instability and inability to bear weight. During the transfer, the resident's foot slipped, resulting in a fall and a femur fracture that required hospitalization and surgery. The care plan contained conflicting transfer instructions, and there was no evidence that nursing staff were notified of the updated transfer status.
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