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Emergency exit doors on two units were found secured shut with zip ties and rolled gauze, preventing egress. Staff, including nurses, aides, and maintenance, were unaware of the obstructions, which were likely put in place to stop frequent alarms caused by high winds. The facility's policy required exits to remain unobstructed, but the deficiency was only discovered during a survey, placing residents in immediate jeopardy.
A resident with cognitive impairment and a history of agitation was allowed unsupervised access to a courtyard, where he climbed onto the facility's roof after becoming upset about a potential move to a secured unit. Staff observed the resident on the roof and called the fire department for assistance. Prior to the incident, increased agitation and unsafe behaviors had been noted, but the resident's care plan and supervision level were not updated accordingly. The facility also failed to complete required smoking assessments for another resident.
A resident with a full code status did not receive immediate or effective BLS/CPR when found unresponsive, as staff delayed initiating CPR while searching for code status, failed to use a backboard or Ambu-bag, and performed inconsistent chest compressions. Some staff lacked current BLS/CPR certification, and the emergency cart was not properly stocked, resulting in inadequate life-saving measures.
A resident with a history of substance abuse was repeatedly found in possession of illicit drugs and drug paraphernalia, and tested positive for multiple substances while under facility care. Despite documented incidents and hospitalizations, staff failed to consistently monitor, investigate, or implement effective interventions to prevent further drug use, and did not thoroughly document supervision or follow facility policy regarding contraband and substance abuse.
A resident with chronic lung disease and ventilator dependence developed severe pneumonia and tested positive for legionella after the facility failed to maintain an effective water management plan, including proper flushing and documentation of water systems, and did not update protocols following flooding and unit closure. Environmental observations revealed mold, water damage, and lack of signage or communication about water restrictions. Additionally, a respiratory therapist provided care to a resident in contact isolation for C. diff without proper PPE, putting multiple residents at risk.
Emergency Exit Doors Obstructed with Zip Ties and Gauze
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards by allowing emergency exit doors on two units to be secured shut with zip ties and rolled gauze, preventing egress. The facility's policy required that exit doors remain unlocked and unobstructed at all times to allow for rapid evacuation, and maintenance logs indicated that door operations were checked daily, with no mention of obstructions. However, on the day of the survey, observations revealed that the emergency exit doors on the short halls of two units were physically secured, blocking access to the outside. Multiple staff members, including nurses and aides, were unaware that the emergency exit doors were secured shut. Interviews revealed that the doors would frequently alarm due to high winds, which may have led to the use of zip ties and gauze to prevent the alarms from sounding. Despite this, there was no documentation or communication among staff or management regarding the application of these obstructions, and maintenance staff were also unaware of the situation. The Nursing Home Administrator and DON confirmed they were not aware that the emergency exit doors had been secured in this manner. The deficiency was identified during the survey, and it was determined that the facility's failure to ensure unobstructed emergency exits placed residents in immediate jeopardy of serious harm, as it would have prevented safe egress during an emergency.
Failure to Prevent Accident Hazard Due to Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.
Failure to Provide Timely and Effective BLS/CPR to Full Code Resident
Penalty
Summary
Facility staff failed to provide proper and effective Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code when found unresponsive, pulseless, and not breathing. Multiple staff members, including CNAs, RNs, and LVNs, did not immediately call a code blue or initiate CPR upon discovering the resident's condition. Instead, staff delayed action while attempting to verify the resident's code status, and there was confusion and lack of clarity among staff regarding the resident's code status and the location of this information in the medical record. Chest compressions were not started until approximately 12 minutes after the resident was found unresponsive. When CPR was eventually initiated, it was performed on the resident's bed without first placing the resident on a firm, flat surface or using a backboard, which was available in the facility. Staff did not consistently perform continuous and uninterrupted CPR, and there were inconsistencies in the rate and quality of chest compressions. Additionally, staff failed to use the Ambu-bag for rescue breathing, instead placing a non-rebreather mask on the resident, which is not appropriate during CPR. EMS personnel arriving at the scene observed these deficiencies and had to move the resident to the floor to continue CPR. Interviews and record reviews revealed that some staff members lacked current BLS/CPR certification, and there were discrepancies in staff knowledge regarding proper CPR procedures, including compression rates and the use of equipment. Documentation and staff statements indicated that the emergency cart was not properly checked or restocked, resulting in missing essential equipment such as the Ambu-bag. These failures resulted in the resident not receiving timely and effective life-saving measures as required by their full code status.
Failure to Monitor and Investigate Resident Illicit Drug Use
Penalty
Summary
The facility failed to implement an effective system to monitor and investigate how a resident with a known history of substance abuse was able to obtain and use illicit drugs while residing in the facility. Despite the resident being cognitively intact and having no independent outside pass privileges, there were multiple documented incidents where the resident was found in possession of illicit substances and drug paraphernalia, and subsequently tested positive for cocaine, fentanyl, and opiates. Staff discovered a white powdered substance and a crack pipe in the resident's room on more than one occasion, and hospital records confirmed the resident's admission of drug use within the facility. There was a lack of consistent documentation and follow-through regarding the monitoring and supervision of the resident after each incident. Although the resident's care plan and behavior contract addressed substance abuse, there were no additional interventions documented after repeated hospitalizations for drug use. The facility's own policies required immediate assessment, drug screening, and restriction of passes, but there was no evidence of a thorough investigation into how the drugs were obtained or brought into the facility. Staff interviews revealed uncertainty about the process for handling contraband, inconsistent communication, and a lack of clarity regarding the involvement of law enforcement or addiction specialists. Furthermore, there was insufficient documentation of frequent monitoring and supervision of the resident following each incident, as required by facility policy. Staff did not consistently document monitoring on various shifts, and there was no evidence of a substance abuse assessment, psychiatric evaluation, or referral for addiction treatment after the resident's repeated positive drug screens and hospitalizations. The facility's failure to investigate the source of the drugs and to implement effective interventions contributed to the ongoing risk and ultimately resulted in the resident requiring multiple hospital transfers due to drug use while in the facility.
Failure to Implement Effective Infection Control and Water Management Program
Penalty
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria. The deficiency was identified after a resident, who was bedbound, ventilator-dependent, and had not left the facility for over two weeks, became unresponsive and was hospitalized with septic shock and pneumonia. The resident subsequently tested positive for legionella pneumophila antigen and died in the hospital. Review of the facility's water management documentation revealed significant gaps, including the absence of updated control measures for areas affected by flooding and closure, lack of detailed plumbing schematics, and insufficient documentation of water system maintenance, flushing, and monitoring. There was no evidence that the water management plan had been revised to address changes in the physical plant, such as the closure of the Somerset unit after flooding, nor was there a written description of how water was supplied, heated, stored, or circulated throughout the building. Observations and interviews further revealed that water stagnation and potential sources of contamination were not adequately addressed. For example, the Somerset unit, which had been closed after flooding, still had water running to certain areas, and there were no logs or documentation to confirm that water lines were being flushed to prevent stagnation. In addition, the attic area above the affected resident's room showed signs of mold, water damage, a decomposed animal carcass, and leaking pipes, all of which were verified by maintenance staff. These environmental conditions, combined with the lack of clear signage and communication to staff regarding water restrictions and infection control measures, contributed to the risk of legionella exposure. The facility's infection control practices were also found lacking in other areas. For instance, a respiratory therapist was observed providing suctioning and tracheostomy care to a resident in contact isolation for Clostridium difficile infection without wearing appropriate personal protective equipment. This failure to adhere to standard infection control protocols had the potential to affect multiple residents on the same unit. Overall, the facility's inaction and insufficient oversight in both water management and general infection control practices led to the identified deficiencies.
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