Failure to Timely Report Neglect Allegation and HVAC System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. A resident reported to the RN Unit Manager, with a Social Worker Assistant present, that a GNA had failed to change the resident’s brief after the resident requested assistance, instead covering the resident with a blanket and leaving. This interview occurred on 10/27/2025, and the resident indicated the incident had occurred approximately three weeks earlier, though the exact date was not recalled. The RN Unit Manager acknowledged that the resident reported the aide did not change him and that she spoke with the ADON after the interview. Despite this, the Administrator and ADON later stated they were not aware of the 10/27/2025 interview or the resident’s allegation at that time. The Administrator reported that he first became aware of the concern when he received a letter from the resident’s family member on 10/29/2025. Based on that letter, the Administrator submitted an allegation of abuse/neglect to OHCQ on 10/29/2025 at 1:39 PM. As a result, the allegation communicated by the resident on 10/27/2025 was not reported to OHCQ within two hours of the facility becoming aware of it, and the required initial report was delayed until two days later, after the family’s written complaint. A second deficiency concerns the facility’s failure to timely report a malfunction of the HVAC heating system to OHCQ. On survey entry, staff informed the survey team that the usual survey room (the B-wing solarium) did not have heat, and the team was relocated. Review of a Facility Reported Incident showed the HVAC failure in the B-wing solariums on two floors was not reported to OHCQ until the evening of the same day the survey team arrived. The NHA later stated that the HVAC system had malfunctioned in early November 2025 and that an estimate for repair had been obtained on 11/14/2025, but no additional estimates had been secured and the malfunction had not been reported to OHCQ at the time it occurred. The NHA acknowledged both the delay in obtaining required repair estimates and the delay in reporting the heating system malfunction to the State Agency.
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