Failure to oversee water management program and respond to Legionella exposure: The Administrator, DON/IP, and Maintenance Director did not ensure effective oversight of the facility’s water system after a resident was diagnosed with Legionnaires’ Disease and was believed to have been symptomatic during the stay. The facility had non-operational mixing valves, non-functional water heater gauges, an unplugged circulation pump, and water temperatures below the stated target range, while requested water system risk assessment and monitoring records were not provided. The facility also delayed committee action and did not fully implement DOH guidance related to hot water temperature, flushing, and showerhead positioning; later environmental samples from the resident’s room and another room were positive for Legionella pneumophila.
A resident with dementia, schizophrenia, and continuous O2 was observed on the smoking patio with cigarettes and a lighter in a plastic bag in her lap, despite staff stating she was supposed to use a smoking apron and that smoking materials were to be held by staff. Interviews showed the Administrator, DON, and Activity Director knew residents were keeping cigarettes and lighters on their person, that the smoking policy was not being enforced, and that residents with cognitive impairment or on O2 should not have access to smoking materials.
Administration and nursing staff failed to enforce the facility’s Smoking/Vaping policy and control smoking materials for multiple smokers, including oxygen‑dependent residents. A resident with COPD and intact cognition, known to smoke in his room and sometimes while on oxygen, repeatedly retained cigarettes and a lighter despite staff awareness and prior incidents. One evening, a CNA observed this resident smoking in his room with a nasal cannula in place; the cannula ignited, causing facial burns and respiratory distress that required emergency transfer and intubation. Other residents, including two oxygen‑dependent smokers and one non‑oxygen‑dependent smoker, reported routinely keeping cigarettes and lighters on their person, sometimes smoking in their rooms or bathrooms, and refusing to surrender supplies due to fear of theft. Smoking evaluations and care plans often classified these residents as safe smokers, sometimes without supervision, and documentation did not reflect their ongoing noncompliance, while a CNA stated that leadership had long been aware that residents retained smoking materials and smoked in non‑designated areas without effective action.
Failure to implement performance improvement plans and infection control deficiencies. The facility identified problems with PASRR, medication administration and storage, wound care, and infection control, but the related PI documentation lacked required education, competencies, and audits. Staff were also observed with staffing mismatches, delayed resident supervision, missed or delayed care, poor hand hygiene, improper enteral tube syringe handling, an open soiled linen room door, and a CNA entering a resident’s contact isolation room without a gown.
Unsafe resident smoking practices and unsecured ignition devices were found for four residents. Residents with diagnoses including MS, mental health disorders, substance use disorders, COPD, and repeated falls were observed or reported keeping cigarettes and lighters in rooms or on their person, including one resident who produced a visible flame with a lighter. The DON said residents had been educated and the Administrator said the smoking concerns had not been identified until the survey.
Facility administration failed to ensure effective oversight and processes to prevent unsafe wandering and elopement when a cognitively impaired, confused, and frail resident with documented treatment-interfering behaviors and an incapacity determination walked past an unattended front desk, exited through an unlocked front door, and traveled off premises without staff knowledge. Despite prior documentation of moderate cognitive-communication deficits, fluctuating confusion, and dementia-level testing, the resident had been assessed as not at risk for elopement and was not reassessed. After the resident was found offsite and sent to the ER, leadership declined to classify the event as an elopement, did not document the incident or preventive measures in the clinical record, and a nurse reported being instructed not to document, contrary to the facility’s own elopement and documentation policies, resulting in an Immediate Jeopardy finding under F835.
Facility administration failed to ensure that an allegation of neglect involving a medically complex resident left unattended on a smoking patio for over 4.5 hours was promptly investigated, documented, and reported. Security footage reportedly showed the resident receiving no care from the assigned CNA during this period, after which the resident was found unresponsive and a code blue was initiated. The incident was not entered into the abuse log, and key staff, including an RN unit manager, therapy staff, and department heads, denied knowledge of the event or provided vague responses during a complaint survey. Despite policies requiring immediate reporting and investigation of suspected violations, the administration did not effectively implement these processes, and leadership later acknowledged that information about the incident and related concerns had been hidden.
The facility failed to keep the AFSS and fire pump repaired after both systems were red tagged for months, and the Administrator could not provide interim fire safety measures or staff training on fire and evacuation protocols. The facility also did not report a resident's allegation of sexual misconduct by a former therapist; the resident, who had a BIMS of 15 and said she feared retaliation, described inappropriate sexual advances and told the RM she did not want police contacted, but the RM and Administrator decided not to file an abuse report.
The facility failed to enforce its smoking policy and maintain oversight of residents’ ignition devices. Multiple residents were observed smoking while keeping cigarettes and lighters in their possession, including residents with oxygen orders and oxygen equipment at bedside. Records showed incomplete or absent smoking evaluations and missing smoking agreement documentation for some smokers. The DON stated there had been no monitoring or auditing for compliance, and the Administrator acknowledged residents were still keeping smoking supplies despite repeated discussions and resident council meetings.
Facility administration failed to prevent the misappropriation of resident funds by not ensuring proper oversight and documentation. A staff member responsible for managing resident accounts could not account for missing funds, and required receipts and signatures were not obtained for multiple withdrawals, including those made after residents were discharged or deceased. Residents were not adequately informed about their financial statements, and leadership did not fully investigate the discrepancies when they were discovered.
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