The facility failed to maintain an effective Legionella water management monitoring program after repeated positive water tests. Environmental samples remained positive in multiple bathroom sink locations over several months, while the facility continued monthly testing instead of the HICPAC-recommended biweekly post-remediation interval. The Administrator and DOPOL acknowledged awareness of the guidance, and the facility did not have a specific Legionella policy, although it did maintain a water management plan with Legionella prevention and control measures.
A resident with dementia and a documented assist-of-1 toileting plan was left alone on a toilet commode without a gait belt, stood up before the aide returned, and fell with wrist pain. Another resident with vertigo and syncope was ambulated at night without the required gait belt, lost balance during a bathroom return, fell, and sustained head and arm injuries requiring ER evaluation and stitches.
Failure to Protect a Resident from Physical Assault: A resident with moderate cognitive impairment was punched multiple times in the face and head by another resident with severe cognitive impairment and psychiatric diagnoses while in a lounge area. The assaulted resident sustained a facial injury, oral laceration, loose tooth, and closed head injury requiring hospital evaluation, and staff interviews confirmed the assault occurred before the residents were separated.
An LPN repeatedly left the unit, was later found unresponsive with suspected drug paraphernalia, and multiple residents then had omitted meds, missing assessments, and inaccurate controlled-substance records. The eMAR showed the LPN later signed off meds she could not verify, while residents with conditions such as DM, AFIB, CHF, seizures, chronic pain, and G-tube dependence had missed insulin, anticoagulants, anticonvulsants, pain meds, supplements, and ordered treatments. One resident also missed time-sensitive meds before a fistulogram, and the event was cited as Immediate Jeopardy.
An LPN became unwell during a shift and was later found lethargic with suspected drug paraphernalia, after which multiple residents were identified with omitted meds and treatments. The facility did not notify the provider immediately for numerous residents with conditions such as DM, CHF, seizures, AFIB, chronic pain, dementia, and tube-feeding dependence. Omitted care included insulin, anticoagulants, antihypertensives, anticonvulsants, pain meds, supplements, and blood sugar checks, and provider notes were not documented until the next day.
Missed Resident Care Conferences After MDS Assessments: The facility did not consistently complete RCCs for multiple residents after MDS assessments, including a resident with dementia and severe cognitive impairment, residents with diabetes, CKD on dialysis, Parkinson's disease, spastic hemiplegia, and psychiatric diagnoses. Records showed no documented RCCs after quarterly, annual, admission, or 72-hour assessments for several residents, and interviews noted social services usually scheduled RCCs but the facility had been without a social worker and was behind on MDSs.
Failure to Provide Timely Social Services After Neglect Incident: An LPN repeatedly left the unit without notifying staff and failed to administer ordered meds and tx, leading to a neglect event with multiple residents affected. Review of records for numerous residents with conditions such as DM, CHF, AFIB, seizures, dementia, chronic pain, and renal dialysis showed no social svc follow-up after the incident. Resident interviews described missed meds, late med pass, increased pain, sleep disruption, and a panic attack after omitted meds and blood sugar checks.
Incomplete investigation after an LPN left the unit multiple times during a shift and was later found lethargic with suspected drug paraphernalia. Twenty-two residents had omitted meds and/or tx, but the facility interviewed only six of the 29 residents on the unit instead of obtaining statements from all residents about whether they received their meds, had symptoms from missed doses, or observed unusual behavior from the LPN.
A resident with cancer and another resident with diabetes had pain-related medication administration and documentation failures. PRN opioid doses were removed from stock but not entered on the MAR, required pain re-evaluations were not completed, and a resident later became unresponsive with respiratory distress. For the second resident, a scheduled pregabalin dose was signed off in the eMAR without matching controlled-substance documentation, and the resident reported not receiving the medication and having pain overnight.
Failure to Protect Residents from Verbal Abuse: Two cognitively intact residents who needed assistance with personal care reported repeated inappropriate comments from an NA during hygiene and incontinence care. One resident described body-shaming remarks about a "big a**" and avoided asking the NA for help afterward; the other reported sexualized comments, unwanted staring through a bathroom door, and threatening remarks that made him/her feel uncomfortable and ashamed.
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