Widespread Administrative Failures Lead to Harm, Repeat Citations, and Immediate Jeopardy
Penalty
Summary
Facility administration failed to effectively utilize resources to maintain compliance with federal regulatory requirements, resulting in multiple deficiencies. Specifically, administration did not identify, report, or assess a pattern of abuse related to resident-to-resident altercations, particularly involving one resident, and failed to implement interventions for potential abuse incidents involving several other residents. There was also a lack of adequate supervision and nursing staff, which led to falls and substantial injuries for multiple residents. Additionally, the administration did not provide necessary behavioral or mental health services for some residents, and failed to ensure medications were administered as prescribed, resulting in harm to at least one resident. The facility's infection control program was not implemented according to acceptable standards, leading to illness among a significant number of residents and staff. The administration also failed to utilize the Quality Assurance and Improvement Program (QAPI) to address and follow up on identified concerns in a timely manner. Several of these deficiencies were repeat citations, indicating that previous corrective measures were not maintained or sustained. During interviews, facility leadership acknowledged awareness of some issues but were not fully informed of the extent of the problems until notified by the survey team.