F0580

D

Failure to Notify Resident Representatives of Falls and Resident-to-Resident Altercations

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify resident representatives of significant changes in residents’ status, as required by facility policy and 10 NYCRR 415.3(e)(2)(ii)(a). The facility’s written policy, “Change in a Resident Condition or Status” (revised 12/2019), required licensed nursing staff to promptly notify the resident’s representative whenever the resident was involved in any accident or incident, or when there was a significant change in the resident’s physical, mental, or psychosocial status. Surveyors determined that this notification did not occur for two residents following events that met the facility’s own criteria for required notification.

For one resident with diagnoses including hematuria, overactive bladder, difficulty walking, and moderate cognitive impairment, a nursing progress note documented that on 8/05/2025 the resident self‑reported a fall to a CNA, who informed the nurse. The nurse then notified the nurse practitioner and assessed the resident, identifying a skin tear on the top of the right hand. However, there was no documentation in the nursing progress notes that the resident’s representative was notified of this self‑reported fall with injury. During interview, the assistant administrator confirmed there was no documentation that the family had been notified of the fall.

For another resident with diagnoses including noninfective gastroenteritis and colitis, chronic idiopathic constipation, and slow transit constipation, and with moderate cognitive impairment, a grievance form dated 6/28/2025 documented that a family member reported a complaint that another resident had entered the resident’s room during the night of 6/22/2025–6/23/2025, yelled at the resident, and dumped water from a refillable water bottle onto them. The grievance described that the resident felt shaky, scared, and unsafe when seeing the other resident and requested that the other resident be moved. The grievance form lacked documentation of who received the grievance, whether further investigation was required to rule out abuse/neglect, and any investigation or follow‑up details, although it did note that the complainant was notified of actions taken and was satisfied. There was no documentation in the nursing progress notes that the resident’s representative was notified of the resident‑to‑resident verbal/physical altercation during the night shift, and the family member later stated in interview that no one from the facility had reported the incident to them and that they learned of it directly from the resident.