Federal inspectors found that Infection Preventionist 1 at Park Avenue Healthcare & Wellness Center documented false conversations with responsible parties throughout January 2025, admitting she was "stressed out" and "trying to get through the resident list as fast as possible."
The consequences were immediate and severe. Resident 4 developed a fever of 102.3 degrees and oxygen saturation of just 83 percent on Christmas Day, requiring emergency transport to the hospital. Hospital records show the resident tested positive for Influenza A and developed sepsis.
Resident 1, who had immunodeficiency and a history of COVID-19, was hospitalized December 28 with vomiting, dropping oxygen levels, and fever. Hospital tests confirmed Influenza A, and the resident required IV fluids and antibiotics for sepsis.
Resident 2, also with immunodeficiency, was rushed to the hospital December 26 with oxygen saturation of 79 percent and a fever of 102.1 degrees. Hospital records documented Influenza A and pneumonia.
The infection preventionist's deception was systematic. She documented speaking with Resident 4's responsible party about declining the flu vaccine due to "fear of side effects." But when inspectors called the family member, they said no one from the facility had contacted them about the flu vaccine for the current season. The family member said they would not have declined the vaccine.
The same pattern emerged for multiple residents. The infection preventionist claimed she spoke to Resident 1's responsible party, who declined due to "personal reasons." The family member told inspectors no one had called them. They would not have declined the vaccine.
For Resident 9, she documented the responsible party declined because they "don't want at this time." She admitted to inspectors she had only left a voicemail and documented the conversation because she was "stressed."
The infection preventionist told inspectors she knew documenting conversations that never happened was "willful falsification of medical records." She said she was "not supposed to document that I spoke to a resident or their RP when I did not because it was not correct documentation."
Director of Nursing confirmed that falsifying such records was "a patient safety issue." The facility's policy required two licensed nurses to be present during consent calls to validate the conversation, but this protocol was ignored.
Seven residents ultimately contracted influenza during the outbreak. Six were hospitalized with sepsis and pneumonia. Resident 7 had consented to receive the flu vaccine on December 18, 2024, but never received it despite the documented consent.
The facility's tracking system had completely broken down. The infection preventionists provided inspectors with an incomplete flu outbreak line list missing information for multiple residents. Infection Preventionist 1 admitted "all residents were more susceptible to catching the flu because the IPs did not know what residents were vaccinated and what residents were not vaccinated."
Resident 4, who had atherosclerotic heart disease and immunodeficiency, became critically ill on Christmas. The change-in-condition report noted the resident was tachycardic at 117 beats per minute. The attending physician recommended immediate emergency transport. Hospital records show the resident needed admission for treatment of Influenza A, pneumonia, and sepsis.
The resident had moderately impaired cognition, making family consent essential. The facility's records showed the last flu vaccine offer was November 8, 2023 — over a year earlier. But the infection preventionist documented a January 2025 conversation that never occurred.
Resident 1's case was equally severe. The resident with severely impaired cognition developed increased fatigue December 27, then vomiting and dropping oxygen levels the next day. Hospital records show the resident arrived febrile, tachycardic, and septic, requiring IV fluids and antibiotics under sepsis protocol.
The facility's policy required offering flu vaccines to all residents each season unless medically contraindicated or previously immunized. The policy mandated documentation showing residents or their representatives received education about risks, benefits, and side effects.
None of this happened for the seven affected residents.
Infection Preventionist 1 told inspectors the flu season ran from October 1, 2024, through March 31, 2025. Staff should have begun offering vaccines in late September and administering them by October 1. She said it was "important to offer the flu vaccine at the beginning of each flu season to prevent residents from getting sick from the flu, or for the symptoms to be minimized."
Instead, the facility was "not organized" and "not following the facility's process for vaccinating residents."
Federal inspectors called immediate jeopardy January 15, 2025, finding the facility's failures had caused or were likely to cause serious injury, harm, or death. The designation was removed the next day after the facility implemented emergency measures.
The facility immediately suspended both infection preventionists pending investigation. They promoted a licensed vocational nurse with infection prevention training to serve as interim infection preventionist, with the director of nursing conducting weekly compliance audits.
Emergency vaccination efforts began immediately. Residents 1, 3, 4, and 6 received flu vaccines after proper consent was obtained. Resident 2's family actually declined when contacted properly. Resident 5's family consented, but the resident physically prevented nurses from administering the vaccine.
The outbreak had exposed fundamental failures in the facility's infection control program. As the director of nursing explained, "when there was no tracking system or log in place, residents who were medically eligible to receive the flu vaccine would not be offered the vaccine because of the facility's disorganization."
Resident 7 remained hospitalized as inspectors completed their review.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Avenue Healthcare & Wellness Center from 2025-01-16 including all violations, facility responses, and corrective action plans.
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