Inspection Reports for
Lemy Avenue Health and Rehab Facility

The facility failed to maintain an effective infection prevention and control program on two of eight units, including failure to disinfect vital signs machines after use in COVID-19 positive rooms and between residents, and failure of housekeeping staff to properly doff PPE and seal trash bags inside COVID-19 positive rooms.

The facility failed to maintain an effective infection control program on two of eight units, including failure to disinfect vital signs machines after use in COVID-19 positive rooms and between residents, and failure of housekeeping staff to properly doff PPE and seal trash bags inside COVID-19 positive rooms.

The complaint investigation involved three residents (#13, #11, and #12) who reported long call light wait times ranging from 40 minutes to one and a half hours. Residents reported incidents of soiling themselves while waiting and staff turning off call lights without returning. The grievance reports lacked documentation on resident satisfaction or appeal processes. Staff interviews acknowledged the issues and agreed call lights should remain on until needs are addressed.

The facility failed to promptly resolve grievances for three residents who reported long call light wait times, resulting in negative impacts such as residents soiling themselves and feeling degraded. Staff interviews confirmed occasional long wait times and improper call light handling.

The complaint investigation involved grievances from Residents #13, #11, and #12 about long call light response times. The grievances were not resolved promptly, and the reports lacked documentation on resident satisfaction or appeal processes. Residents reported negative outcomes including incontinence and a fall. Staff interviews confirmed occasional long wait times and improper call light handling.

The facility failed to promptly resolve grievances related to long call light wait times for three residents. Interviews and grievance reports confirmed residents experienced excessive delays, sometimes up to one and a half hours, and staff sometimes turned off call lights without returning.

The facility failed to maintain proper infection prevention and control practices, including inadequate hand hygiene during medication administration and meal service, improper handling of resident drink glasses and silverware, and failure to sanitize meal trays between uses. Additionally, the facility was unable to provide documentation of monitoring or control measures for Legionella as required by their Water Management Plan.

The facility failed to maintain proper infection control practices, including inadequate hand hygiene during medication pass and meal service, improper handling of resident drink glasses and silverware, and unsanitized meal trays. Additionally, the facility lacked documentation of monitoring and control measures for Legionella in recently vacated rooms and ice machines as required by their Water Management Plan.

The investigation was complaint-driven due to a fall incident on 5/27/2023 involving Resident #1. The fall was substantiated as an accident caused by human error and equipment malfunction. The nurse aide transferred the resident alone despite the care plan requiring two-person assistance, and the ceiling lift remote was malfunctioning. The resident sustained multiple fractures and a subdural hematoma and died on 5/28/2023.

The facility failed to ensure adequate supervision and safe use of mechanical lifts, resulting in Resident #1 falling from a ceiling lift due to improper transfer by a single nurse aide without assistance, malfunctioning lift equipment, and failure to follow facility policies. The resident sustained multiple fractures and a subdural hematoma and later died. The facility identified equipment malfunctions, policy noncompliance, and human error as causes and implemented corrective actions including staff education, equipment audits, and policy changes requiring two-person assistance for all lifts.

The investigation was complaint-driven following a resident fall from a ceiling lift on 5/27/23. The fall was substantiated as the resident sustained serious injuries and died. The facility failed to follow transfer policies and did not properly maintain equipment.

The facility failed to ensure adequate supervision and safe use of mechanical lifts, resulting in a resident falling from a ceiling lift due to improper transfer by a nurse aide without required assistance and malfunctioning equipment. The resident sustained multiple fractures and a subdural hematoma and later died. The facility's policies and safety interventions were not followed, and multiple ceiling lifts had maintenance issues.

The complaint investigation was substantiated by observations, interviews, and record reviews confirming the resident eloped unsupervised, medication cart security lapses, and infection control deficiencies during wound care.

The facility failed to prevent a cognitively impaired resident from exiting the secure unit unsupervised, left a medication cart unlocked and unattended, and failed to maintain proper infection control practices during wound care, including improper glove use and failure to clean equipment between wounds.

The complaint investigation substantiated that Resident #36 eloped from the secure unit unsupervised on 06/09/2022. The facility confirmed the incident and implemented corrective actions including increased monitoring and use of a WanderGuard. Additional findings related to medication cart security and infection control were also identified.

The facility failed to prevent Resident #36 from exiting the secure unit unsupervised, left a medication cart unlocked and unattended, and failed to maintain proper infection control practices during wound care for Resident #62. No injuries resulted from the elopement, and corrective measures such as placing a WanderGuard were implemented.