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F0684
E

Failure to Ensure Timely RN Assessment and Documentation After Resident Incidents

Staatsburg, New York Survey Completed on 11-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received treatment and care in accordance with professional standards of quality, as evidenced by the lack of timely assessment by a registered nurse (RN) following significant incidents involving three residents. In the first case, a resident with paranoid schizophrenia and neurocognitive disorder was found with three open wounds on the left hip, reportedly caused by a coffee burn. There was no documented evidence that an RN assessed the wounds in a timely manner after discovery, and staffing records confirmed that no RN was present in the facility for over 36 hours during the period when the wounds were identified and reported. Communication about the incident occurred via group text, but no RN assessment was documented until after the wound care physician evaluated the resident days later. In the second case, a resident with metabolic encephalopathy, dysphagia, and lupus experienced an unwitnessed fall and complained of hip pain. The incident was documented by an LPN, and the physician was notified with x-rays ordered. However, there was no documentation of an RN assessment following the fall, and staffing records indicated that no RN was on duty at the time. Interviews with staff revealed uncertainty about whether an RN assessment occurred, and the Director of Nursing could not recall the event or confirm that an RN had evaluated the resident prior to their transfer from the floor to the bed. The third case involved a resident with dementia, depression, and anxiety who was found on the floor with a bloody nose after an unwitnessed fall. The resident was assisted back to bed by LPNs without documented RN assessment prior to the move. There was also no evidence of 72-hour post-fall monitoring or treatment for the bloody nose. Staffing records again showed no RN on duty at the time, and interviews with staff and the Director of Nursing confirmed that the expected process of RN assessment and documentation was not followed. The Director of Nursing acknowledged being the backup when no RN was present but did not come to the facility or document any assessment.

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