Failure to Conduct Comprehensive Risk Assessment for Legionella in Facility Water System
Summary
The facility failed to conduct a thorough risk assessment to determine why opportunistic waterborne Legionella continued to grow and spread in the facility's water system. Despite ongoing positive Legionella test results in multiple rooms since 2023, the facility's actions were limited to periodic flushing, temperature monitoring, and the installation of water filters in affected rooms. Documentation revealed that only three rooms were retested in April, instead of the five recommended by the consultant, and there was no evidence of regular meetings to discuss results or perform comprehensive risk assessments. The Director of Plant Operations acknowledged that the expansion tank had insufficient air pressure, which could contribute to Legionella growth, and that cleaning of the mixing valve was performed without documentation. Interviews with facility staff indicated a lack of clarity and consistency in following the water management plan and consultant recommendations. The administrator was unsure why only three rooms were retested and admitted that positive findings were not reported to the local health authority, as no residents had tested positive for Legionella disease. There was also no documentation that residents' families were notified of the ongoing Legionella issue. The facility experienced a gap in water testing during a change in testing companies, and the water management company had only recommended flushing, with no further interventions until a plumber was called for mechanical inspection after two years of positive results. Water temperature logs showed variable temperatures in the affected rooms, with some readings within the range that supports Legionella growth. Laboratory results documented persistent low to high levels of Legionella in several rooms, with the highest recorded at 30 CFU/mL. The facility's policy stated a commitment to prevention and control of water-borne contaminants, but the lack of comprehensive risk assessment, incomplete testing, and insufficient documentation contributed to the ongoing deficiency affecting all residents in the facility.
Penalty
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In the laundry department, 1 of 2 commercial washers was out of service for more than 8 months, leaving only 1 washer available for resident laundry. Laundry Aides stated they used the working washer for all residents and that keeping up with timely laundry services was sometimes challenging with only 1 machine.
A resident who required a mechanical lift for transfers experienced repeated Hoyer lift battery failures during transfers, including one observed transfer where the lift stopped working while he was being lowered. Staff reported that lift batteries were often not charged, that overnight staff were responsible for charging them, and that they sometimes used the emergency release to lower the resident when the battery died. The DON and other staff confirmed the batteries were not consistently checked or maintained, and the maintenance supervisor said batteries were only replaced occasionally.
Flooring Renovation Started Before Construction Review Approval: The facility removed carpet and installed laminate flooring in resident areas before receiving DOH Construction Review Services approval. The Administrator said the second-floor west unit remodeling had already been completed and residents were moved to another unit during the work. Notices to residents described planned flooring replacement, observation confirmed new wood flooring in the hallway and resident rooms, and a resident said they were relocated for at least two weeks. The Regional Plant Operations Director stated the approval was still pending and that they were unsure of the approval process.
Laundry equipment was not maintained in safe operating condition. A resident with ESRD on dialysis reported that clothes came back stinking, while the Laundry Supervisor said the industrial washer kept breaking down, hot water was not getting hot, the wrong soap was being used for resident clothing, and the department lacked a hopper for washing soiled linens. Observation showed a small washer overfilled with sheets, and staff gave mixed reports about washer breakdowns and linen shortages.
Mechanical lift equipment on the 3rd floor was observed with exposed black and red inner cords from the grey charging cord hanging out. An RN said the lift should not be used if the cords are exposed, and the DON stated such equipment should be reported to maintenance and removed from the floor for safety precautions. The Maintenance Director confirmed the outer grey cord protects the inner cords, and the maintenance log showed no repair report for the lift.
Expired Ambu Bags Found on Two Crash Carts: The facility failed to ensure two crash carts were in safe operating condition when an Ambu bag on the First Floor Crash Cart and an Ambu bag on the Second Floor Crash Cart were both found expired. RN staff confirmed the expired equipment and acknowledged the carts were not maintained as required by the facility's crash cart management process.
Inoperable Commercial Washer in Laundry Department
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for the laundry department. Of the 2 commercial washing machines in the laundry area, only 1 was functioning, and the other washer had been out of service for longer than 8 months. During observations and interviews, Laundry Aides stated they were using the 1 working commercial washer to complete resident laundry and that keeping up with timely laundry services was at times challenging with only 1 washer for all residents. The Administrator stated the facility and Owner were aware that 1 of the 2 commercial washers was not working and that the washer was under the manufacturer's warranty, but the facility had been unsuccessful in securing vendor service for the past 8 months.
Hoyer Lift Batteries Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to keep patient care equipment in safe operating condition for one resident who used a Hoyer lift for transfers. The resident had intact cognition, chronic respiratory failure with hypoxia, morbid obesity, muscle weakness, bilateral lower extremity impairment, and was dependent on staff for transfers. His care guide and care plan directed that he be transferred with a mechanical lift and multiple staff members. During interview, the resident stated that almost every time he was transferred with the Hoyer lift, the battery would run out in the middle of the transfer, sometimes leaving him hanging in the sling while staff went to get another battery, and that the facility had been recharging the same batteries instead of replacing them. He also stated that the prior night two different batteries were needed to get him into bed. Surveyors observed three nursing assistants transferring the resident from bed to his power mobility device using the Joerns Hoyer lift, and the lift stopped working while the resident was being lowered due to a low battery. Staff then used the manual release button to lower him into the device. Multiple staff members stated that batteries for the lifts were not always charged, that overnight staff were responsible for charging them, and that staff sometimes checked whether the lift would work before entering the room because they expected the battery might be dead. The DON stated staff should check that the battery was charged before transfers and use the emergency release if the lift stopped working. The maintenance supervisor stated batteries were replaced only occasionally and only one lift battery had ever been replaced; no invoices for battery purchases were produced. The manufacturer instructions required batteries to be kept fully charged, charged whenever not in use, and never run completely flat, and the facility policy required staff to verify lift batteries were charged at the start of each shift.
Flooring Renovation Started Before Construction Review Approval
Penalty
Summary
The facility failed to obtain approval from the Department of Health Construction Review Services program before removing carpets and installing laminate flooring in resident areas. The facility’s revised Safe and Homelike Environment policy stated that the facility would provide a safe, clean, comfortable, and homelike environment and that the physical layout would maximize resident independence without posing a safety risk. Staff A, the Administrator, reported that recent renovations had been completed on the second-floor west unit, including patient room remodeling and new flooring replacement, and that residents were moved to another unit while the work was being done. Facility notices showed planned flooring replacement in carpeted hallways and second-floor resident rooms, and observation confirmed that the second-floor west hallway and resident rooms had new wood laminate flooring. Resident 1 stated they were moved to another second-floor unit during the remodeling and remained there for at least two weeks before returning to their room. A state online search showed the flooring project had an initial review and resubmittal review, but the status remained pending approval. Staff A stated they were not aware of the construction review process or that the project was still pending, and Staff B, the Regional Plant Operations Director, stated they were responsible for obtaining approval but were unsure of the approval process and believed they could start the work after signing an acknowledgement of risk.
Laundry Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the laundry room’s mechanical and patient care equipment in safe operating condition. During observation and interview, the Laundry Supervisor stated the industrial washer had been breaking down and the hot water was not getting hot. She also stated the facility was using special soap for resident clothing, but the order had not been placed on time and would not be delivered until 6/1/26. She said the soap used for bed linens and towels would eat resident clothing, that she had not obtained regular soap from petty cash or another facility, and that the laundry department did not have a hopper for washing off bowel movements from linens. The Laundry Supervisor further stated the third washer may or may not clean resident clothing and that laundry staff were doing half loads. Observation showed the smallest washer was overfilled with sheets, with too many sheets for the agitator to move them. Resident #1, a female with ESRD on dialysis and intact cognition, stated her clothes came back stinking and that the facility washed poop linens in the same washer as resident clothes. The Housekeeping Supervisor stated there were three laundry detergents available to order and that she did not know to order the soap from the chemical company. CNA staff gave mixed reports about laundry and linen availability, with one stating the washer broke during the week of 5/11/26 through 5/15/26 and another stating there were sometimes issues with enough linens and that residents sometimes went without showers. Review of repair receipts showed routine maintenance on the washing machine, and the Administrator stated there was no policy for essential equipment.
Mechanical Lift Found With Exposed Charging Cord
Penalty
Summary
The facility failed to ensure a mechanical lift on the 3rd floor was kept in working condition when it was observed with exposed black and red inner cords from the grey charging cord hanging out. On 5/19/26 at 12:15 PM, the lift was seen with the exposed cords. At 12:16 PM, the RN stated she was not sure if the machine worked and said that if the cords were exposed it should not be used because it could be unsafe. At 12:39 PM, the DON stated that machines with exposed cords should be reported to maintenance and removed from the floor for safety precautions. On 5/21/26 at 10:10 AM, the Maintenance Director stated the mechanical lift should be removed from the floor and reported to maintenance if there is a concern, and that the outer grey cord protects the inner cords for safe operating. Review of the 3rd floor maintenance log showed no reports of mechanical lift repair. The facility policy states that mechanical lift equipment shall undergo routine maintenance checks by nursing and maintenance staff to ensure it remains in good working order.
Expired Ambu Bags Found on Two Crash Carts
Penalty
Summary
The facility failed to make certain that equipment was in safe operating condition for two crash carts, identified as the First Floor Crash Cart and the Second Floor Crash Cart. Facility documentation titled Crash Cart Management stated that crash carts must be maintained fully stocked, operational, and secured, and that routine checks must verify medication expiration dates, supply integrity, oxygen pressure levels, suction functionality, cleanliness, full inventory, equipment testing, battery checks, restocking, and infection control review of manufacturer maintenance recommendations. During an observation, the First Floor Crash Cart was found to contain an Ambu bag with an expiration date of 10/18/24. In a separate observation, the Second Floor Crash Cart was also found to contain an Ambu bag with the same expiration date of 10/18/24. RN Employee E4 confirmed the expired Ambu bag on the First Floor Crash Cart and acknowledged the facility failed to make certain the equipment was in safe operating condition. RN Employee E8 similarly confirmed the expired Ambu bag on the Second Floor Crash Cart and acknowledged the same failure.
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