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.
Facility staff failed to adequately supervise a cognitively impaired, aggressive resident with documented wandering, sexual ideation, and intrusive behaviors, allowing him to freely enter other residents’ rooms and common areas. Over time, this resident pushed another resident to the floor causing a head bump, was found lying in bed with a cognitively impaired female whose brief was displaced and buttocks exposed, struck another resident in the mouth after being verbally provoked, and hit a resident on anticoagulation in the eye, leading to significant bruising, neurological decline, hospitalization, and subsequent death. Despite repeated incidents on the Memory Care Unit and care‑planned behavioral risks, supervision levels were reduced from 1:1 to Q15‑minute checks and then discontinued, while the resident continued to ambulate independently with direct access to other residents, contrary to the facility’s own safety and supervision policy.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
A resident with COPD, dementia, anxiety, and other diagnoses was observed smoking a lighted cigarette in the designated courtyard without staff present, despite a care plan and smoking assessment requiring supervision. The resident said staff had just gone back inside and later said staff usually supervised smoking. Staff reported that cigarettes and lighters were kept locked in the med room and that they were late taking smokers out that afternoon, while the administrator and DON said all resident smoking required supervision.
A resident with severe cognitive impairment and Wernicke’s encephalopathy, who was fully ambulatory and known to wander and seek exits, repeatedly entered other residents’ rooms, attempted to leave through exit doors, and eloped from an enclosed courtyard through a gate whose alarm had been turned off and was not monitored by staff. Despite a provider order and care plan for a Wander-Guard and elopement precautions, the device was removed and not replaced, and care plan interventions were not implemented or documented. The same resident was later found performing oral sex on another resident and, on a separate occasion, partially undressed on a female resident’s bed, despite lacking capacity to consent; required 1:1 supervision was care planned but not communicated to or followed by staff. Incidents of elopement and sexual contact were not accurately assessed or reported to the state agency, and documentation of elopement risk and abuse investigations was incomplete, leading surveyors to cite Immediate Jeopardy for accidents, hazards, abuse, and neglect.
A resident with diabetes, orthostatic hypotension, impaired mobility, and severely impaired cognition (BIMS 5/15) fell from bed to floor while a CNA was providing incontinence care. The resident had a history of intolerance to sitting up, low BP episodes, and resistance to sitting at the edge of the bed, but resistance to care was not included in the care plan. During the incident, the resident resisted care, tried to get out of bed, and slid to the floor, requiring two staff to return her to bed. The DON later stated the CNA should have stopped care when resistance occurred, reminded the resident she needed assistance to get out of bed, ensured safety, and then reapproached, indicating that adequate supervision and assistance were not provided to prevent the fall.
A resident with a history of falls and multiple fall risk factors had a care plan calling for bilateral floor mats, but staff observed only one mat in place while the resident was in bed and the other mat rolled up against the wall. An LPN stated that bilateral mats should be on the floor on each side of the bed when the resident is in bed.
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