Failure to Investigate Resident-to-Staff Violence Incident
Summary
The facility failed to comply with applicable Federal, State, and local laws, regulations, and codes by not investigating an incident involving resident-to-staff violence. The incident involved a resident who was cognitively intact and had a history of violent behavior, including bipolar disorder and anxiety disorder. On the night of the incident, the resident was observed yelling and using profanity in the hallway. When approached by an LPN, the resident pushed the LPN and slammed the door. Despite this, the facility did not complete an incident report or conduct an investigation as required by their Workplace Aggression/Violence Policy. The facility's policy mandates that all employees report any threats or violent acts, which include verbal or physical harassment and threats, to the appropriate supervisor or HR Director. However, the Director of Nursing (DON) did not consider it necessary to write an incident report after seeing the progress note in the resident's medical record. Additionally, the facility's Administrator did not review the camera recording of the incident, and the recording was no longer available. This lack of action and documentation indicates a failure to adhere to the facility's policy and ensure a safe environment for both staff and residents. Interviews with staff revealed that the incident was not reported to the facility's Corporate Compliance Officer, as it was not considered an incident but rather a behavior. The resident's behavior was notably above baseline, and the resident was later transferred to a Behavioral hospital with police assistance. The facility's failure to investigate and report the incident demonstrates non-compliance with their own policies and regulatory requirements, compromising the safety and well-being of both staff and residents.
Penalty
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Surveyors found that the facility failed to comply with state requirements that resident beds be kept at least three feet from radiators, resulting in harm to a resident whose bed had been placed too close to a radiator. During an abbreviated survey triggered by this incident, interviews and room measurements showed that multiple beds in sampled rooms were positioned less than 36 inches from radiators, confirming that resident equipment was not consistently maintained at the required distance.
A resident with neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure was admitted directly into a conference room and remained there for six weeks, even though this area was not approved for patient housing and lacked a sink and bathroom. The care plan documented that the resident was housed in the conference room and required staff to bring water and soap for handwashing, and observations showed the resident using a bedside commode behind an improvised curtain with the door sometimes left open during care. Staff reported that the family requested a private room and chose the conference room after being told it had been used previously for residents, and leadership cited past COVID-19-related flexibility but could not provide current authorization, while state regulations and CDPH guidance reviewed by surveyors did not support using the conference room as a resident room.
Facility staff did not meet the State-required minimum average of 4.1 hours of direct nursing care per resident per day, providing only 4.0 hours on a day when the census was 117. On that same day, a resident with a tracheostomy was found in the doorway of their room with the trach dislodged during the early morning hours, and an IJ related to CPR requirements was later identified. The staffing coordinator confirmed that the required staffing level was not achieved and attributed this, in part, to an inability to obtain replacements for staff who called out.
Surveyors found that facility leadership failed to provide access to an investigation into narcotic diversion and misappropriation of resident property. During a complaint survey, the NHA and DON were informed that multiple complaints would be investigated, and staff disclosed that a nurse had taken narcotics and police had been notified. When the SA requested the complete investigation, the DON initially stated it was in his office and could be copied, but later admitted that no investigation existed for the misappropriation incidents involving five residents. The NHA and DON acknowledged that the absence of an investigation and the time surveyors spent waiting for it caused a delay in the survey.
The facility used its van with an expired vehicle registration to transport residents to physician appointments several times a week, despite having a policy requiring safe, compliant transportation and the availability of other transportation services. Emails between facility administration and the parent company showed ongoing awareness that the van’s registration had expired and that the title was needed to renew it. Observation confirmed the expired plate sticker, and review of transportation logs showed repeated use of the van for resident appointments while some residents were transported by outside companies. In interviews, the van driver, an LPN, and the Administrator all acknowledged that the van’s license had expired the previous year, that administration knew about it, and that the van continued to be used for resident transport during this period.
The facility failed to ensure LPNs practiced within their professional standards and defined scope when one LPN independently assessed, measured, and staged pressure ulcers for two residents with significant cognitive and physical impairments, including heel and sacral pressure injuries. This LPN regularly performed wound assessments and staging when the wound NP was unavailable, yet facility job descriptions for treatment and unit nurse roles did not include pressure ulcer assessment or staging responsibilities, and no LPN job description was available to support this practice.
Noncompliant Bed Placement Near Radiators Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to comply with N.Y. Comp. Codes R. & Regs. Tit. 10 § 713-1.3(h)(1), which requires that resident beds be placed so they can be approached from at least one side and one end and that no bed be closer than three feet to a window, radiator, or an adjacent bed. During an abbreviated survey conducted in response to an incident, surveyors determined that at least one resident’s bed had been positioned less than three feet from a radiator. This improper placement of the resident’s bed resulted in harm to that resident. The report identifies this as a failure to ensure compliance with applicable State and local laws governing the design and equipment of resident bedrooms for adequate nursing care, comfort, and privacy. Interviews and record review during the survey confirmed that the facility had not consistently maintained the required minimum three-foot distance between resident beds and radiators prior to the incident. The Maintenance Director reported that the bed in the involved room had been moved away from the radiator after the incident, preventing assessment of the original distance from the radiator. A sample of rooms measured by surveyors showed several beds with distances from the radiator to the mattress of less than 36 inches, including measurements of 32, 34, and 35 inches, indicating that the deficiency was not isolated to a single room. These findings support that the facility did not ensure resident equipment (beds) was kept at the minimum required distance from radiators, leading to the cited harm to a resident.
Resident Housed in Unapproved Conference Room Without Sink or Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to comply with state regulations requiring that residents be housed only in areas approved for patient housing. One resident was admitted directly into a conference room and remained there from admission through discharge, a total of six weeks. The conference room was located behind the reception desk at the facility entrance, had advertising brochures on the walls, and was separated primarily by a curtain, with the door left open during care at times. The resident’s care plan specifically documented housing in the conference room and noted that staff needed to bring in water and soap for handwashing because there was no sink in the room. The resident had multiple medical diagnoses, including neutropenia, hemiplegia, hemiparesis, functional diarrhea, and heart failure, and had an intact cognitive status based on a BIMS score of 13. Observations showed the resident in a patient bed in the conference room with a bedside commode and bedside table, and the resident reported using a bell to call for help. A CNA confirmed there was no bathroom or sink in the room, that the resident used the commode for bowel movements, and that privacy was difficult to maintain because the room was primarily separated by a curtain and the door was not fully closed during care. Interviews with staff revealed that the resident’s family requested a private room and selected the conference room after being informed it had been used in the past for resident housing. The Admissions Coordinator stated the census listed the resident in a standard room number, but the resident was always physically located in the conference room. The DON acknowledged the conference room was not ideal for patient care due to the lack of a toilet and sink. The current Administrator and former administrator referenced prior CDPH authorization during the COVID-19 pandemic to use the conference room for residents, but neither could provide dates or documentation, and a review of CDPH waivers and AFLs showed no current authorization and confirmed that temporary COVID-19 waivers had been discontinued, while state regulations prohibit housing patients in non-approved areas without temporary permission in an emergency.
Failure to Meet State Minimum Direct Care Staffing Requirement
Penalty
Summary
Facility staff failed to meet the State requirement of providing a minimum daily average of 4.1 hours of direct nursing care per resident per day on 02/22/26, when the census was 117 residents and the facility’s total direct care staffing level was 4.0 hours. On that same date, a facility reported incident documented that at approximately 3:00 AM, Resident #5 was found in the doorway of his room with his tracheostomy dislodged. An Immediate Jeopardy was identified at 42 CFR 483.24, F678, related to cardiopulmonary resuscitation on 02/25/26 at 3:40 PM. During a face-to-face interview on 03/03/26, the staffing coordinator calculated the total direct care staff, acknowledged that the 4.1-hour requirement was not met on 02/22/26, and stated that staffing had generally been good but that on some days replacements could not be obtained for staff who called out. The deficiency centers on the facility’s failure to comply with State minimum direct care staffing requirements on 02/22/26, in the context of an incident where a resident with a tracheostomy was found with the trach dislodged during the early morning hours, and the subsequent identification of Immediate Jeopardy related to cardiopulmonary resuscitation requirements.
Failure to Provide Investigation of Narcotic Diversion and Misappropriation to Surveyors
Penalty
Summary
The deficiency involves the facility’s failure to provide the State Agency (SA) with access to a facility investigation related to narcotic diversion and misappropriation of resident property, which caused a delay in the survey process. During a complaint survey, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed that the SA team would be investigating five complaints. Later that day, the SA was informed that a nurse over the weekend had been taking narcotics and that the police had been notified. In an interview, the DON confirmed that a nurse had taken narcotics and that law enforcement had been contacted several days earlier. When the SA requested the facility’s complete investigation of this incident, the DON stated that the investigation was in his office and that he could retrieve it, and the SA requested a copy of the full investigation at that time. Subsequent interviews with the Interim Assistant DON and the NHA documented that they were made aware the SA was waiting for the DON’s complete investigation. Later that afternoon, the DON confirmed that he did not have an investigation for the misappropriation of resident belongings that included narcotic diversion involving five residents. When questioned by the SA about his earlier statement that the investigation was in his office and would be copied for review, the DON admitted that no such investigation existed. The NHA and DON then confirmed that the facility did not have an investigation for five instances of misappropriation of resident property involving narcotic diversion, and they were made aware that the extended time the SA spent waiting for an investigation that did not exist resulted in a delay in the survey. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility for licensee and 28 Pa. Code 201.18(d)(e)(1) Management.
Use of Facility Van with Expired Registration for Resident Transportation
Penalty
Summary
The facility failed to ensure its transportation van was properly licensed in accordance with State law while continuing to use it to transport residents to medical appointments. Review of the facility’s transportation policy showed it committed to providing safe, non-emergency transportation with a well-maintained van and appropriate liability and insurance coverage. Emails between the facility’s administrative team and the parent company documented ongoing awareness that the van’s registration had expired and that the title was needed to complete registration, with multiple communications about tracking down or obtaining duplicate titles and identifying facilities with expired registrations. Observation of the van showed a license plate sticker indicating expiration in 2025, and review of the transportation log showed multiple instances over several days in which residents were transported to physician appointments using the facility van, while some residents were transported by outside transportation companies. During interviews, the van driver stated that the van was used several times a week to transport residents, confirmed the license had expired the previous year, and reported being told the facility would pay any ticket if the van was pulled over, adding that other transportation services were available and that they would not drive their personal vehicle with expired tags. An LPN similarly reported that the van’s license had expired the previous year, that administration was aware, that the van was used a couple of times a week for resident appointments, and that administration was responsible for keeping the license current and probably should not have been driving it with expired tags. The Administrator acknowledged that the van’s license had expired the previous year after the new company purchased the facility, that the parent company was having difficulty obtaining the title from the previous owner and had referred the matter to its legal department, and that the van continued to be used several times a week for resident transportation despite the expired license, even though other transportation companies were available.
LPNs Performed Pressure Ulcer Staging Outside Defined Scope and Job Descriptions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that LPNs practiced within their professional standards and scope of training regarding pressure ulcer assessment and staging, as required by applicable laws and accepted professional standards. For Resident #20, who had Alzheimer’s disease, depression, spinal stenosis, osteoarthritis, severe cognitive impairment, dependence for most ADLs, incontinence, and was at risk for pressure ulcers, multiple skin issue assessments were completed by LPN #1500. These assessments documented an in-house acquired right heel unstageable pressure ulcer with specific measurements and tissue composition, followed by subsequent documentation of the same right heel wound as a stage 3 pressure ulcer on later dates, with changing measurements and wound bed composition. On observation and interview, LPN #1500 confirmed that she personally measured and staged the right heel pressure ulcer and would document the assessment in the chart. The DON verified that LPN #1500 was the one who staged and measured this resident’s right heel pressure ulcer on three specific dates. For Resident #30, who was admitted with diagnoses including severe protein calorie malnutrition, hemiplegia and hemiparesis after cerebral infarction, muscle weakness, and a stage 4 sacral pressure ulcer, LPN #1500 also completed skin issue assessments. These assessments documented a sacral stage 4 pressure ulcer with detailed measurements and wound bed composition on two separate dates. The DON confirmed that LPN #1500 assessed, staged, and measured this resident’s sacral stage 4 pressure ulcer on those dates. Review of the facility job descriptions for the Treatment Nurse and Unit Manager positions showed no inclusion of pressure ulcer wound assessments, including measuring, staging, and assessments, in their essential functions. The facility was unable to provide any job description for LPNs, and thus there was no documented authorization or role definition for LPNs to perform pressure ulcer wound assessments and staging, despite LPN #1500 performing these functions for at least two residents.
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