Failure in Administrative Oversight and Resident Protection
Penalty
Summary
The facility failed to administer its resources effectively and provide adequate administrative oversight, resulting in multiple deficiencies affecting resident care and safety. Specifically, the administration did not ensure residents were protected from verbal abuse and involuntary seclusion, and failed to notify the State Agency in a timely manner about reportable events. There were also failures to investigate allegations of abuse promptly and thoroughly, and staff accused of abuse were not removed from the schedule in a timely fashion. Additionally, the facility did not manage resident personal needs accounts according to requirements, did not provide individualized activities for bedbound or dependent residents, and did not update activity calendars to reflect actual activities provided. Further deficiencies included not following physician's orders, failing to maintain a safe environment due to high water temperatures, and not ensuring adequate pest control. These failures were identified through observation, clinical record review, facility documentation, policy review, and interviews. Actual harm occurred in the area of Freedom from Abuse, Neglect, and Exploitation. The administrator's job description outlined responsibilities for overall facility operations, compliance with laws and regulations, and protection of resident rights, but these duties were not fulfilled as required.