Failure to Notify Department of Health of Incident
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for serious harm. The resident, who was cognitively impaired and had a history of stroke, was found on the floor beside their bed. Following this incident, neurological checks were initiated. Later, the resident's daughter requested that the resident be sent to the emergency room for evaluation, and the resident was subsequently admitted to the hospital with a diagnosis of a stroke. Despite these events, there was no documented evidence that the incident was reported to the Department of Health until after Adult Protective Services contacted the facility, confirming the delay in notification.
Plan Of Correction
Resident 1 has had an incident reported to the Department of Health. A review of the last 30 days incidents were audited to find any resident who were sent for treatment to verify they had been reported to the Department of Health. Education provided to Director of Nursing regarding the process to report resident admissions to the hospital when they are due to an incident that occurred in the facility. Nursing Home Administrator or designee will audit 3 random resident incident reports for transfer to hospital x 4 weeks, then 3 random records monthly for documentation of Event Report submitted to the Department of Health when appropriate. These audits will be forwarded to Quality Assurance for review.
Penalty
Surveyors found that the facility failed to notify the Department of Health when two of three nursing units experienced a disruption in hot water service. The NHA acknowledged that a boiler malfunction resulted in running water that was not warm enough and that the issue was not reported because the water was not completely shut off and did not affect the entire building. A maintenance employee reported that two units lacked readily available hot water in resident rooms for a period of time, that no water temperatures were taken, and that one boiler was replaced, requiring a 30-minute shutdown of water service. The facility did not report these hot water service disruptions to the State Agency.
A facility failed to notify the Department of Health about an incident involving a resident with dementia, whose spouse attempted to take her from the facility. The situation escalated, requiring police presence and crisis intervention. The resident remained safe at the facility, but the Department of Health was not informed, as confirmed by the DON.
Failure to Notify State Agency of Hot Water Service Disruption
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the Department of Health of a disruption in hot water service affecting two of three nursing units (North Unit and South Unit). During an interview, the Nursing Home Administrator (NHA) reported that one hot water boiler had issues and was repaired, stating that there was always running water but it was not warm enough and that the problem was not building-wide. When asked, the NHA acknowledged that the issue was not reported to the State Agency because the water was not completely shut off and did not affect the entire building. In a separate interview, a maintenance employee stated that two of the three units did not have readily available hot water in resident rooms a few weeks prior, that no water temperatures were taken and the water felt cool, and that one boiler was replaced. The maintenance employee also confirmed that to connect the new boiler, the water was shut down for about 30 minutes, and that the facility did not notify the Department of Health of this disruption of hot water service for the two affected units. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Plan Of Correction
1.The hot-water boiler system malfunctioning was reported to the DOH via ERS system. 2.The unit's affected still had access to water on their units and hot water on the subacute unit. 3.The regional NHA, educated the NHA on the topics that need to be reported to the DOH. 4.The NHA or designee will audit all events within the facility for 4 weeks to ensure that all events are reported appropriately. The findings will be reported to QAPI.
Failure to Notify Department of Health of Incident
Penalty
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for harm. The incident involved a resident who was cognitively intact but required extensive assistance with daily care needs and had a diagnosis of dementia. On a specific date, the resident's spouse attempted to take her from the facility, but she was unable to stand to get into the car. This led to the spouse becoming extremely frustrated with both the resident and the staff. The situation escalated to the point where police presence was required, and the police had to contact crisis services due to a comment made by the spouse. After the situation was de-escalated, the resident remained safe at the facility, and her daughter was informed and agreed that the facility was the safest place for her. However, the Director of Nursing confirmed that the Department of Health was not notified of this incident, which constitutes a failure to meet the regulatory requirement for notification.
Plan Of Correction
Unable to retroactively notify the Department of Health of incident that had the potential for harm to a resident. Residents who receive care and services at the facility have the potential to be affected. Director of Nursing was educated by the Administrator on reporting incidents that have the potential for harm to a resident to the Department of Health. The Director of Nursing will review questionable incidents with the Administrator to ensure compliance in reporting. The Administrator or designee will audit and review incident reports to ensure the necessary reporting is completed. Audits will be conducted as follows: 3.) Up to 5 records will be reviewed daily for 4 weeks. 4.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
