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.
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.
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.
Surveyors identified that an exit door on the 400 unit was obstructed by a bath/shower bed, wheelchair, bedside commode, and fan, despite facility policy requiring exits to remain clear at all times. The blocked exit was observed on two separate occasions the same day, including during an observation with the Administrator present, who acknowledged that nothing should be blocking the exit door.
Surveyors observed a container of Clorox wipes left on the bathroom sink in a resident room during a facility tour, indicating that hazardous cleaning supplies were not properly stored. An LPN confirmed that such wipes should not be kept in a resident bathroom, and facility leadership acknowledged that this storage practice was not appropriate.
Staff failed to use a proper carrier when transporting a full oxygen cylinder, and a resident's fall resulting in injury was not documented or treated at the time of occurrence. The resident, who has Alzheimer's disease and osteoporosis, later returned with a spinal brace and was receiving IV antibiotics for a hip infection.
A medicine cup containing a half tablet of Senokot was found left on the bedside table of a resident during a medication pass performed by an employee. The DON verified the incident, and a review of other residents showed this was an isolated occurrence. Facility leadership acknowledged the deficiency after it was observed and reported.
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