State Findings:
Based on observations, staff interviews, interview with the Legionella Consultant, record reviews, review of the Certificate of Death, review of the water sample report, review of the facility’s water management policy, review of the facility’s Legionella water management program, and review of the facility’s Legionella written plan, the facility failed to adhere to their policy and water management program to prevent the spread of Legionella. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death on [DATE] when one resident (Resident #100) was found lethargic, with a reddened rash, cool skin, unable to answer or follow commands, and was going in and out of consciousness. Resident #100 was sent to the emergency room for evaluation. On [DATE], Resident #100 tested positive for legionella at the hospital, and expired on [DATE]. This affected one (Resident #100) of three residents reviewed for exposure to Legionella and placed all other residents residing in the facility at risk for potential negative health outcomes as the facility was not implementing their water management program to detect and prevent the spread of Legionella. The facility census was 51.
On [DATE] at 4:16 P.M., the Administrator, Director of Nursing (DON), and Corporate Nurse #300 were notified that Immediate Jeopardy began on [DATE] when Resident #100 was found lethargic, with a reddened rash, cool skin, unable to answer or follow commands, and was going in and out of consciousness before being transported to the hospital. The resident was subsequently diagnosed with Legionella on [DATE] and expired on [DATE]. Additionally, the facility was not implementing their water management program in accordance with their Water Management Policy by not obtaining quarterly water testing to detect and prevent the spread of Legionella and not maintaining their holding tank at the required temperature of 140 degrees Fahrenheit or above.
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If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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