Failure to Correct Hazards and Supervision Deficiencies Through QAPI
Penalty
Summary
The facility failed to establish and implement effective policies to correct identified deficiencies, as evidenced by repeated areas of non-compliance and failure to detect or address immediate jeopardy situations through the QAPI process. Specifically, for 12 out of 61 sampled residents, the environment was not maintained free of accident hazards, and residents did not consistently receive adequate supervision or assistive devices to prevent accidents. Hot water temperatures in resident rooms were observed to range from 121.7 to 145.5 degrees Fahrenheit, significantly exceeding safe limits. However, facility water temperature logs for the same period recorded much lower temperatures, indicating a lack of accurate monitoring or reporting. Additionally, residents assessed as requiring supervision while smoking were observed smoking unsupervised, and some residents were not evaluated for smoking safety at all. There were also incidents of residents with a history of wandering eloping from the facility without staff awareness. Despite previous QAPI plans addressing supervised smoking and elopement risks, the facility did not maintain updated lists of residents requiring supervision, failed to assess residents for smoking safety, and did not ensure interventions for elopement risks were consistently in place. Repeat deficiencies from a prior survey were cited again, including those related to accident hazards, resident rights, medication management, and infection control. The Administrator confirmed that QAPI meetings were held monthly and that action plans had been created for some issues, but hot water concerns had not been identified or addressed through the QAPI process.