Briarcliff Manor Center For Rehab And Nursing Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Briarcliff Manor, New York.
- Location
- 620 Sleepy Hollow Road, Briarcliff Manor, New York 10510
- CMS Provider Number
- 335005
- Inspections on file
- 21
- Latest survey
- June 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Briarcliff Manor Center For Rehab And Nursing Care during CMS and state inspections, most recent first.
A resident with mild cognitive impairment and a history of depression was physically abused by a CNA, who pushed the resident onto their bed and struck them in the groin. The incident was witnessed by the resident's roommate, and both individuals identified the CNA involved. The resident suffered emotional distress as a result of the abuse, and the facility's investigation confirmed that the event occurred.
The facility failed to maintain the Ansul fire suppression system and K extinguisher in accordance with NFPA standards. The Ansul system's inspection tag was unsigned, and the K extinguisher's pressure gauge was in the recharge zone, indicating improper maintenance.
The facility did not maintain and test its emergency generator as required by NFPA standards. Missing documentation for weekly inspections and monthly load tests was noted during a survey, and the Director of Maintenance confirmed the oversight.
The facility did not ensure annual testing of all fire alarm system devices, specifically omitting the inspection of magnetic door hold open devices and delayed egress devices. This was identified during a documentation review, with the Director of Maintenance acknowledging the oversight.
The facility failed to maintain its sprinkler systems as required by NFPA standards. Missing quarterly reports, corroded sprinklers, and outdated water pressure gauges were observed. The Director of Maintenance acknowledged the issues but had not yet addressed them.
The facility did not ensure fire drills were conducted under varied conditions as required by NFPA 101. During a survey, it was found that attendance sheets for fire drills in the fourth quarter of 2024 were missing, making it impossible to verify staff participation. The Director of Maintenance confirmed the absence of these records.
The facility did not maintain fire doors according to NFPA standards, as fire-rated labels were covered with paint or illegible in the basement and on one resident floor. The Director of Maintenance acknowledged the issue during the survey.
The facility was cited for improper use of power strips, with refrigerators in the recreation and DON offices plugged into power strips instead of wall outlets. Additionally, in a resident room, a power strip was daisy-chained to a multiple adapter, with personal equipment connected. The Director of Maintenance acknowledged the issue.
The facility did not maintain continuous illumination in the Rehab corridor, as required by NFPA 101 standards. During a survey, it was found that turning off the wall-mounted light switches extinguished all lights in the corridor leading to an emergency stairwell exit. The Director of Maintenance confirmed the issue, noting that the lights would be continuous.
A survey identified deficiencies in the facility's sprinkler system, with missing coverage in the alcove area of the soiled utility discharge room, a walk-in box used for storage, and under the first accessible landing in a stairwell. The Director of Maintenance acknowledged the issues.
The facility was found deficient in maintaining a safe environment, with a black mold-like substance in the women's locker room and missing wall tiles in the men's locker room, creating safety hazards.
The facility did not provide privacy curtains around the platform table in the Physical Therapy room, as observed during a Life Safety recertification survey. The Physical Therapy Director confirmed that a privacy curtain was not used, which is a violation of Title 10 regulations.
Two residents requiring assistance with activities of daily living were observed with long, ungroomed fingernails, indicating a deficiency in personal hygiene care. Despite facility policies and staff expectations for regular nail care, observations showed that necessary grooming was not consistently provided, leading to the deficiency.
A resident with a high risk for falls experienced two unwitnessed falls, and the facility failed to update the care plan with new interventions after the first fall. Despite medical assessments indicating high fall risk, the care plan was not revised, leading to a deficiency. Interviews with the DON and an LPN confirmed the oversight.
A resident in an LTC facility, requiring a two-person assist for bed mobility and bathing, fell and sustained injuries due to inadequate supervision. The CNA involved was unaware of the updated care plan requiring two-person assistance, highlighting a communication breakdown within the facility.
The facility failed to offer pneumococcal vaccinations and provide education to two residents, as required. One resident had not been offered the vaccination since 2001, and another since 2012. The lack of documentation was attributed to staffing shortages and turnover, as confirmed by the Administrator and DON.
The facility failed to provide five CNAs with the required 12 hours of annual in-service education, only delivering 10 hours without covering mandatory topics like abuse and residents' rights. This lapse was due to turnover in the Assistant Director of Nursing position, leading to inadequate monitoring of training requirements.
A resident was hit in the face with a bed control while receiving care, but the incident was not properly documented or reported by the LPNs involved. The resident, who was on blood thinners and had severely impaired cognition, was not assessed by an RN as required. Bruising appeared later, but it was not documented, leading to a deficiency in care standards.
A resident with impaired cognition was found with a bruise of unknown origin, which the facility failed to report to the state agency. The DON initially linked the bruise to a previous incident involving bed controls, despite the time gap and lack of documentation. Staff interviews and the Nurse Practitioner confirmed the bruise's unknown origin, highlighting a deficiency in the facility's reporting procedures.
A resident's advance directives were not accurately updated in the facility's records, leading to a discrepancy between the resident's wishes and documented orders. Despite the resident changing their Medical Orders for Life Sustaining Treatment from Do Not Resuscitate to Full Code, the facility failed to update the electronic medical record and physical indicators. Staff interviews revealed a breakdown in communication and procedure adherence, resulting in the facility not honoring the resident's current preferences.
A resident with moderate cognitive impairment was observed multiple times with food residue on their face and clothing after meals, indicating a failure by the facility to provide necessary post-meal care. Staff interviews confirmed that residents should have their face and hands cleaned after meals, but this was not consistently done for the resident, leading to a deficiency in maintaining dignity.
A resident with a physician's order for oxygen at 3 L/min was observed receiving 2.5 L/min, contrary to the order. Additionally, required oxygen use signage was missing from the resident's room. Staff interviews confirmed the discrepancy and the absence of signage, highlighting a failure to follow the facility's policy and physician orders.
The facility failed to provide a clean, comfortable, and homelike environment, with deficiencies observed in several rooms. Room C-19-B had a broken window latch, room C-9-B had a broken radiator cover and stained window shades, and room A-17 had a faulty window unit allowing cold air to enter. The Director of Maintenance was unaware of these issues due to a lack of work order requests, and repairs were delayed pending warranty discussions and weather conditions.
The facility experienced staffing shortages on multiple occasions, with CNA levels falling below the required minimums across various shifts and units. The Director of Human Resources and Staffing cited high turnover and weekend staffing challenges as contributing factors, despite offering incentives and reassigning staff to cover shortages.
A resident was moved multiple times within the facility without receiving the required written notice, violating their rights. The facility's policy did not include the requirement for written notification, and staff relied on verbal communication and documentation in the resident's record. The resident, who was cognitively intact, reported being moved without prior notice or consent, and their questions about the moves were ignored.
A CNA attempted to transfer a resident with severe cognitive and physical impairments from the toilet to a wheelchair without the required two-person assist, resulting in the resident falling. The care plan and Kardex indicated the need for a two-person assist, but the CNA proceeded alone and asked the resident's family member to help, leading to the fall. No injuries were documented.
Resident Physically Abused by CNA During Night Shift
Penalty
Summary
A resident with diagnoses of hydrocephalus and major depressive disorder, and mild cognitive impairment, reported being physically abused by a Certified Nurse Aide (CNA) during the night shift. The incident involved the CNA pushing the resident onto their bed and striking them in the groin. The event was witnessed by the resident's roommate, who corroborated the account. Both the resident and the roommate identified the CNA from a photo lineup, and the facility's investigation found reasonable cause to believe that abuse had occurred. The resident experienced psychosocial harm as a result of the incident, expressing sadness, frustration, and emotional distress during subsequent interviews and psychological evaluation. Although there were no visible physical injuries, the resident became tearful and reported ongoing emotional impact from the event. The resident's care plan included interventions to encourage reporting of threats and feelings of safety, but the incident still occurred, indicating a failure to protect the resident from abuse as required by facility policy and state regulations. The facility's abuse prevention and reporting policy stated that any employee involved in abuse would be disciplined appropriately. Despite ongoing in-services on abuse prevention, the incident took place, and the facility's investigation confirmed the occurrence of abuse. The event was reported to the appropriate authorities, and the CNA was removed from direct care duties pending investigation.
Deficiency in Fire Suppression System Maintenance
Penalty
Summary
The facility failed to ensure that the Ansul fire suppression system and the K extinguisher in the kitchen were inspected and maintained according to the relevant NFPA standards. During a Life Safety recertification survey, it was observed that the monthly inspection tag for the Ansul system was blank, indicating that inspections were not documented as required. This lack of documentation suggests that the necessary monthly inspections may not have been conducted, which is a violation of NFPA 101, NFPA 10, and NFPA 17 A standards. Additionally, the K extinguisher located adjacent to the stove was found with its pressure gauge needle in the recharge zone, rather than the full zone, indicating that it was not in proper working condition. The service tag on the extinguisher showed that it was last recharged in 2024, yet it was not adequately maintained to ensure it remained operational. These deficiencies were identified during a tour of the kitchen, and the Director of Maintenance acknowledged the findings.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K324 I. Immediate Corrective Action: 1. Ansul System Inspection Tag: - On 3/20/25, the Director of Maintenance immediately addressed the issue with the Ansul system inspection tag and signed for the current month. 2. K Extinguisher Pressure Gauge: - The K extinguisher was immediately removed from service and replaced with a fully charged extinguisher, ensuring it was in the full zone (green). - The service company was contacted to inspect and recharge the K extinguisher. The fire extinguisher has been replaced and recharged. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a review of all fire suppression systems and extinguishers in the facility to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's fire safety and inspection procedures. - The policy was updated and reviewed to ensure that all fire suppression system inspection tags are completed and signed monthly. - Maintenance staff were in serviced to consistently monitor and document inspections monthly. A checklist was updated for fire extinguishers, including monthly checks of pressure gauges to ensure that all extinguishers are within the full zone. This checklist will be used by staff during routine inspections. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of monthly fire suppression system inspections and extinguisher checks. 2. Monthly audits will be performed for six months of all ansul systems and fire extinguishers to ensure compliance with NFPA 101, NFPA 10, and NFPA 17 A. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance
Generator Maintenance and Testing Deficiency
Penalty
Summary
The facility failed to maintain and conduct all required tests on its emergency generator in accordance with NFPA 101 and NFPA 110 standards. During a life safety recertification survey, it was observed that the generator logs were missing documentation for weekly visual inspections for the week of the 29th of one month and the first week of the following month in 2024. Additionally, the monthly load tests for two consecutive months were not conducted or documented. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the missing documentation.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K918 I. Immediate Corrective Action: 1. Missing Generator Test Records: - The Administrator educated the Maintenance Director on proper Generator testing as stated in NFPA 110. - To address the missed load and run tests, a load bank test was performed to simulate the expected load on the generator for (MONTH) and (MONTH) 2024. - The generator was started and operated under load for the appropriate duration, as specified by NFPA 110. 2. Review and Verification: - There were no other discrepancies or missing records. The documentation was updated to reflect accurate and complete test results. II. Identification of Others: - All residents have the potential to be affected. - A full audit of the generator maintenance logs was conducted to verify that no other load tests or maintenance records were missing or incomplete. - No additional missing records were identified. III. Systemic Changes: 1. The Director of Maintenance in-serviced all maintenance staff on the updated procedures for documenting generator testing and inspections, emphasizing the importance of timely and complete record-keeping. IV. Quality Assurance: 1. An audit tool was updated to track the completion and documentation of weekly visual inspections and monthly load tests for the generator. - Audits will be conducted monthly for six months to ensure compliance with NFPA 101 and NFPA 110 and verify that all test logs are completed and properly documented. - The results of the audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
Failure to Test Fire Alarm System Devices Annually
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were tested annually, as required by the 2012 NFPA 101 and 2010 NFPA 72 standards. During a documentation review conducted on March 20, 2025, it was observed that the fire alarm system was last serviced on July 10, 2024, and January 6, 2025. However, the service reports did not include the inspection and testing of the magnetic door hold open devices and the delayed egress devices. This deficiency was confirmed through an interview with the Director of Maintenance, who acknowledged the oversight and stated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K345 I. Immediate Corrective Action: 1. Magnetic Door Hold Open Devices & Delayed Egress Devices Testing: - On 3/20/25, the Director of Maintenance immediately contacted the fire alarm service company to schedule an inspection and testing of the magnetic door hold open devices and the delayed egress devices. - The testing was conducted, and a report of the inspection and testing results of these devices has been obtained and placed in the facility’s records. II. Identification of Others: - The Director of Maintenance conducted a full review of all fire alarm service reports from the past 12 months to ensure that all devices, including magnetic door hold open and delayed egress devices, were properly tested and documented. - Any gaps in documentation were corrected, and the necessary reports were obtained. - All residents have the potential to be affected. III. Systemic Changes: 1. The Director of Maintenance updated and reviewed the facility’s fire alarm maintenance policy to ensure that all components, including magnetic door hold open devices and delayed egress devices, are tested semiannually in accordance with NFPA 101. 2. The Director of Maintenance in-serviced the maintenance staff on the updated protocols for fire alarm system testing and documentation, emphasizing the importance of comprehensive record-keeping and compliance with NFPA 101. IV. Quality Assurance: 1. An audit tool was updated to track the completion and accuracy of fire alarm system testing, ensuring that all devices are tested annually, and reports are properly documented. 2. Monthly audits for six months will begin to ensure that all devices are properly tested and documented in the annual service reports. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its automatic sprinkler and standpipe systems in accordance with NFPA 101 and NFPA 25 standards. During a life safety recertification survey, it was observed that the quarterly sprinkler report for the third quarter of 2024 was missing. Additionally, several sprinklers in the laundry room, dishwashing room, and family lounge area exhibited signs of corrosion and were missing escutcheon plates. Water pressure gauges on the sprinkler system were outdated, and documentation of their re-calibration or replacement was not provided. An unknown substance was also found on the sprinklers in the Beauty Salon. Interviews with the Director of Maintenance revealed that the facility had not yet addressed these issues, although the Director stated that a vendor would be contacted to assess the sprinklers. These deficiencies were noted in the basement and on one of the two resident floors, indicating a widespread issue with the maintenance of the facility's fire protection systems.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K353 I. Immediate Corrective Action: 1. Quarterly Sprinkler Report for 2024: - On 3/19/25, the Director of Maintenance contacted the sprinkler service vendor to request the missing third-quarter report for 2024. - The report was obtained on 3/20/25 and placed in the facility’s records to ensure compliance with NFPA 101 and NFPA 25. 2. Sprinkler Corrosion and Missing Escutcheon Plates: - On 3/19/25, the Director of Maintenance immediately contacted a certified sprinkler contractor to assess and address the corrosion and missing escutcheon plates on sprinklers in the laundry room, dishwashing room, family lounge area, and Beauty Salon. - The vendor inspected and replaced corroded sprinklers and installed missing escutcheon plates on 3/20/25. 3. Water Pressure Gauges: - On 3/19/25, the Director of Maintenance arranged for the recalibration or replacement of outdated water pressure gauges. - The water pressure gauges have been replaced by a certified vendor. 4. Substance on Sprinklers (Beauty Salon): - On 3/19/25, the Director of Maintenance immediately arranged for the cleaning and inspection of the sprinklers in the Beauty Salon, where an unknown substance was found. - The sprinklers were replaced on 3/20/25. II. Identification of Others: - The Director of Maintenance conducted a full inspection of all sprinkler systems in the facility, including those in other common areas, to ensure no additional sprinklers were corroded or missing escutcheon plates. - All residents have the potential to be affected. - No additional issues were found, but ongoing checks will be implemented to prevent future occurrences. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility’s sprinkler maintenance policy to ensure all quarterly sprinkler inspections are properly documented and provided in a timely manner. - Maintenance staff will now inspect all sprinklers monthly for six months to ensure no corrosion or damage is present. IV. Quality Assurance: 1. A new audit tool was created by the Director of Maintenance to track the status of sprinkler system maintenance, including quarterly inspections and repairs. 2. The results of monthly audits will be reported to QAPI quarterly, with any corrective actions taken promptly. V. Person Responsible: - Director of Maintenance
Missing Attendance Sheets for Fire Drills
Penalty
Summary
The facility failed to ensure that fire drills were conducted under varied conditions as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the fire drill logs for the fourth quarter of 2024 were missing attendance sheets for the Day, Evening, and Night shifts. This omission made it impossible to verify staff participation in the drills. The Director of Maintenance confirmed in an interview that the fire drills are conducted by an outside vendor and acknowledged the absence of the attendance sheets.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K712 Completion Date: (No later than 60 days from exit date 03/20/2025) (05/19/2025). I. Immediate Corrective Action: 1. Fire Drill Attendance Sheets for Fourth Quarter of 2024: - On 3/20/25, the Director of Maintenance contacted the outside vendor responsible for conducting the fire drills to request the missing attendance sheets for the Day, Evening, and Night shifts from the fourth quarter of 2024. - The vendor provided the missing attendance sheets on 3/20/25, which were then added to the facility's fire drill records for the appropriate quarter. 2. Fire Drill Documentation Review: - The Director of Maintenance immediately reviewed the fire drill documentation for all prior quarters to ensure that attendance sheets for all shifts were present and complete. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a review of the fire drill logs for the entire year 2024 to ensure that all attendance sheets were accounted for. III. Systemic Changes: 1. An in-service was conducted by the Director of Maintenance for all maintenance staff on the importance of verifying and maintaining complete fire drill records, including attendance sheets. - A reminder was also issued to the outside vendor to ensure that all necessary documentation is submitted following each drill. IV. Quality Assurance: 1. The Director of Maintenance established a monthly internal audit to ensure that fire drill logs, including attendance sheets, are complete and accurate. - The audit will be conducted monthly for six months, and findings will be reviewed to ensure full compliance with NFPA 101. 2. The results of the audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
Fire Door Labeling Deficiency
Penalty
Summary
The facility failed to maintain fire doors in accordance with NFPA 101 and NFPA 80 standards. During a Life Safety survey, it was observed that the fire-rated labels on several fire doors were either covered with paint or illegible. This issue was identified in the basement and on one of the two resident floors. Specifically, the fire-rated label on the center stairwell door in the basement was covered with paint, as were the labels on the fire door to the soiled utility room, the storage room in corridor D, the stairwell door in Corridor 3, and the door to the clean linen room on the B even side. The Director of Maintenance acknowledged the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K761 I. Immediate Corrective Action: 1. Fire Door Labels Covered with Paint/Illegible: - On 3/19/25, the Director of Maintenance conducted an immediate inspection of all fire doors with illegible or covered fire-rated labels. - The paint was removed from the labels on the center stairwell door, soiled utility room door, storage room door in corridor D, stairwell door in corridor 3, and the clean linen room door on the B even side by 3/20/25. All of the above referenced fire rated labels are now legible. II. Identification of Others: - All residents have the potential to be affected. - A thorough inspection of all fire doors within the facility was conducted to ensure no other fire-rated labels were covered or illegible. - No other issues were found, but the Director of Maintenance has implemented a regular inspection schedule for fire doors to prevent the recurrence of this issue. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's policy on fire door maintenance to ensure that all fire-rated labels are always clearly visible and legible. 2. The Director of Maintenance in-serviced all maintenance staff on the importance of maintaining clear and legible fire-rated labels and ensuring fire doors remain in compliance with NFPA 101 and NFPA 80. IV. Quality Assurance: 1. The Director of Maintenance created an audit tool to track the status of fire door label visibility. - Monthly audits will be conducted for six months with findings reviewed to ensure that all fire door labels are visible and legible. 2. The results of monthly audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
Improper Use of Power Strips for Refrigerators and Resident Equipment
Penalty
Summary
The facility was found to be non-compliant with the 2011 NFPA 70 National Electrical Code Article 400.8, which prohibits the use of flexible cords and cables as a substitute for fixed wiring unless specifically permitted. During a Life Safety recertification survey, it was observed that refrigerators in the recreation office and the Director of Nursing office were plugged into power strips instead of directly into wall outlets. Additionally, in a resident room, a power strip was daisy-chained to a multiple adapter, which was then plugged into a wall outlet, with the resident's personal equipment connected to the power strip. These findings were noted on one of two resident floors and in the basement. The Director of Maintenance acknowledged the issue during an interview and stated that corrective action would be taken.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 K920 I. Immediate Corrective Action: 1. Refrigerators Plugged into Power Strips: - On 3/19/25, the Director of Maintenance immediately disconnected the refrigerators in the Recreation Office and the Director of Nursing Office from the power strips. - The refrigerators were plugged directly into wall outlets to comply with NFPA 70 standards. 2. Daisy-Chained Power Strips in Resident Room: - On 3/19/25, the Director of Maintenance immediately addressed the issue in Resident Room B-27 by disconnecting the daisy-chained power strip and multiple adapters. - The equipment was properly reconfigured with a single, correctly rated power strip, plugged directly into a wall outlet. - The resident's personal equipment was safely reconnected. II. Identification of Others: - All residents have the potential to be affected. - A facility-wide audit of all power strips and adapters in resident rooms, offices, and common areas was conducted on 3/19/25. The audit identified no additional instances of daisy-chaining or refrigerators plugged into power strips. - NO further issues were noted. III. Systemic Changes: 1. The Director of Maintenance updated the facility's Electrical Safety Policy to ensure all electrical devices, including refrigerators and personal equipment, are directly connected to wall outlets unless explicitly approved by an electrical engineer or licensed contractor. - The policy now includes strict guidelines on the proper use of power strips and prohibits daisy-chaining of power strips or adapters. 2. All staff, including maintenance and housekeeping, received an in-service on NFPA 70 electrical safety standards, focusing on proper usage of power strips, avoiding daisy-chaining, and ensuring that appliances are plugged directly into outlets where applicable. 3. The facility will ensure that all residents and or family members will be informed of the proper use of power strips in the facility by the following methods: - Maintenance Director will hang up signage around the facility and discuss by monthly resident council the appropriate methods to use power strips. - Additionally, the Maintenance Director will draft a policy/notice that will be placed at the front desk for all families to see as well as mailing/emailing to all family members this notice on the appropriate usage of power strips. IV. Quality Assurance: 1. The Director of Maintenance created an audit tool to track compliance with NFPA 70 regarding power strips, adapters, and appliance connections. - The facility will conduct monthly audits for six months of all areas to ensure that no power strips are used inappropriately or daisy chained. - The results of these audits will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
Failure to Ensure Continuous Illumination in Egress Pathway
Penalty
Summary
The facility failed to ensure continuous illumination in the means of egress as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the wall-mounted light switches in the Rehab corridor, when turned off, extinguished all the lights in the corridor leading to an emergency stairwell exit. This issue was identified on one of the two resident floors. The Director of Maintenance acknowledged the finding during an interview, stating that the corridor lights would be continuous.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K281 I. Immediate Corrective Action: 1. Rehab Corridor Lighting: - The Maintenance director immediately contacted an electrician to address the lighting issue in the Rehab corridor, powering every other light for clear illumination of egress. - The wall-mounted light switches that were controlling the lights leading to the emergency stairwell exit have been re-wired to ensure that the illumination in the means of egress is continuous, even when the light switches are turned off. II. Identification of Others: - All residents have the potential to be affected. However, none were. - All other egress routes were found to be compliant. - The Director of Maintenance conducted a review of all light switches and emergency exit routes on both residents’ floors to ensure compliance with NFPA 101, identifying and addressing any similar concerns. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility's Life Safety procedures, ensuring maintenance staff are trained in NFPA 101 requirements for the illumination of means of egress. The training included instructions on how to ensure continuous illumination for safe exits. - Maintenance staff were re-educated on the importance of maintaining proper lighting on all exit routes, with an emphasis on the emergency stairwell. 2. Regular checks on all emergency lighting systems during routine inspection were added to the routine maintenance checklist ensuring all corridors and exits are properly illuminated and compliant with NFPA 101. IV. Quality Assurance: 1. A tracking tool was developed by the Director of Maintenance to ensure ongoing compliance with lighting and means of egress standards. 2. Monthly audits of all exit routes will begin to ensure that lighting remains compliant with NFPA 101, and any identified issues will be corrected promptly. 3. The results of the monthly audits will be reviewed during QAPI and reported quarterly. V. Person Responsible: - Director of Maintenance
Deficient Sprinkler Coverage in Key Areas
Penalty
Summary
During a life safety recertification survey, several deficiencies were identified in the facility's sprinkler system coverage, which did not comply with NFPA 101 and NFPA 13 standards. Specifically, the survey revealed that sprinkler coverage was missing in the alcove area of the soiled utility discharge linen chute room. Additionally, the walk-in box used for dry storage in the storage room on corridor D lacked sprinkler coverage. Furthermore, in one of the emergency exit stairwells, sprinkler coverage was not observed under the first accessible landing, affecting two resident floors and the basement. These deficiencies were noted during a survey conducted between 9:30 AM and 3:30 PM. At approximately 11:40 AM, the absence of sprinkler coverage in the alcove area was observed. By 12:00 PM, the lack of sprinkler coverage in the walk-in box was identified, and at 12:50 PM, the deficiency in the stairwell was noted. The Director of Maintenance acknowledged these findings during an interview and mentioned that a vendor would be contacted to address the issues.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 K351 I. Immediate Corrective Action: 1. Soiled Utility Discharge Linen Chute Room (Alcove Area): - On 3/19/25, the Director of Maintenance immediately arranged for an inspection and installation of sprinkler coverage in the alcove area adjacent to the discharge chute in the soiled utility room. - Sprinkler coverage was installed and tested by a certified sprinkler contractor on 3/19/25, ensuring compliance with NFPA 101 and NFPA 13 standards. 2. Walk-In Storage Box: - On 3/19/25, the Director of Maintenance contacted a certified contractor to install the missing dry sprinkler coverage in the walk-in box used for storage in the storage room on corridor D. - Sprinkler coverage was installed and tested by the contractor on 3/19/25, ensuring full compliance with NFPA 101 and NFPA 13. 3. Stairwell Landing (Basement): - A sprinkler contractor was contacted to install sprinkler coverage under the first accessible landing in the emergency exit stairwell located in corridor 4 in the basement. - The missing sprinkler coverage was installed and tested ensuring compliance with NFPA 101 and NFPA 13. II. Identification of Others: - All residents have the potential to be affected. - The Director of Maintenance conducted a thorough inspection of all other stairwells, utility rooms, and storage areas on the premises to ensure there are no further gaps in sprinkler coverage. - Additional checks were made to verify compliance in all areas, and no further issues were found. III. Systemic Changes: 1. The Director of Maintenance reviewed the facility’s sprinkler system installation policy to ensure that all areas, including utility rooms, storage spaces, and stairwells, are covered in accordance with NFPA 101 and NFPA 13. - A new protocol was implemented for regular, detailed inspections of sprinkler coverage during routine maintenance rounds to ensure no areas are missed in the future. 2. A review of all floor plans was conducted to verify that sprinkler coverage is properly indicated and confirmed for all spaces. 3. The Director of Maintenance in-serviced to understand the importance of compliance with sprinkler installation standards and the process for identifying and addressing gaps in coverage. IV. Quality Assurance: 1. A new audit tool was created by the Director of Maintenance to track the status of sprinkler system coverage throughout the facility, ensuring ongoing compliance with NFPA 101 and NFPA 13. - Monthly inspections and audits of all sprinkler systems, including utility rooms, storage areas, and stairwells, will be conducted with findings documented for review. 2. The results of the audits and any corrective actions will be reported to QAPI quarterly. V. Person Responsible: - Director of Maintenance
Deficiency in Facility Maintenance and Safety
Penalty
Summary
The facility failed to maintain a safe and healthy environment as required by regulations. During a life safety recertification survey, a black mold-like substance was observed on one of the walls in the women's locker room located in the basement. This was attributed to a leak from the floor above, as confirmed by the Director of Maintenance. Additionally, in the men's locker room, several wall tiles were missing, resulting in a large opening in one of the walls. These conditions indicate that the facility did not adequately maintain the building to prevent fire and other hazards to personal safety.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 I. Immediate Corrective Action: 1. Black Mold in Women's Locker Room: - On 3/19/25, the Director of Maintenance immediately initiated remediation of the black mold-like substance in the women's locker room. The affected wall was cleaned. - The wall was dried, and mold remediation procedures were followed as per environmental safety standards. 2. Opening in Men's Locker Room Wall: - On 3/19/25, the Director of Maintenance immediately secured the area with a safety barrier around the large opening in the men's locker room wall to prevent any safety hazards. - The hole in the men’s locker room was repaired. II. Identification of Others: - All residents have the potential to be affected. - A thorough inspection of all locker rooms, bathrooms, and other areas within the facility was conducted to identify potential mold growth or structural integrity issues. - No additional issues were identified. However, the facility will continue to monitor for any future concerns. III. Systemic Changes: 1. The Director of Maintenance reviewed and updated the Facility Maintenance Policy to include regular checks for signs of moisture, mold, and structural integrity, particularly in high-risk areas such as bathrooms, locker rooms, and ceilings. - A bi-monthly inspection schedule was established to identify and address any potential issues before they become major hazards. 2. The Director of Maintenance scheduled monthly inspections for six months to monitor moisture damage, mold growth, and structural issues throughout the facility, including in areas previously identified as high-risk, such as locker rooms and bathrooms. IV. Quality Assurance: 1. An audit tool was developed to monitor and track the facility's compliance with moisture control, mold prevention, and structural integrity standards. - Quarterly audits of locker rooms, bathrooms, and other high-risk areas will be conducted for six months. The findings will be reported to QAPI. V. Person Responsible: - Director of Maintenance
Lack of Privacy Curtains in Physical Therapy Room
Penalty
Summary
The facility failed to ensure privacy curtains were provided around each individual treatment area in the Physical Therapy room, as required by Title 10 regulations. During a Life Safety recertification survey, it was observed that the platform table in the new Physical Therapy room lacked a privacy curtain. In an interview conducted at the time of the finding, the Physical Therapy Director confirmed that a privacy curtain was not used.
Plan Of Correction
Plan of Correction: Approved April 10, 2025 I. Immediate Corrective Action: 1. Privacy Curtain in Physical Therapy Room: - The Director of Maintenance immediately ordered and installed a privacy curtain around the platform table in the Physical Therapy room to ensure compliance with Title 10 standards. II. Identification of Others: - All residents have the potential to be affected. - No additional privacy curtain issues were identified. However, all treatment areas will be monitored for compliance going forward. III. Systemic Changes: 1. The Director of Maintenance reviewed the Facility Construction and Maintenance Policy to ensure all treatment areas are properly equipped with the necessary privacy measures, including privacy curtains or partitions where applicable. - A quarterly inspection schedule for six months will be implemented to ensure privacy curtains are installed and maintained in compliance. IV. Quality Assurance: 1. A monthly audit for six months will be conducted by the Director of Maintenance to ensure privacy curtains remain in place and compliant in all treatment areas. Any corrective actions will be implemented immediately. 2. Results from the monthly audits will be reviewed during the quarterly QAPI meetings. V. Person Responsible: - Director of Maintenance
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene. Specifically, two residents who required dependent assistance with activities of daily living were observed with long and ungroomed fingernails during multiple observations. Resident #52, who was cognitively intact and dependent on staff for personal hygiene, was observed with long and ungroomed fingernails on several occasions. The resident reported that their fingernails were rarely cut and that they had to wait frequently for nail care. Similarly, Resident #57, who had moderately impaired cognition and required assistance for hygiene, was also observed with long and ungroomed fingernails during multiple observations. Interviews with facility staff revealed that Certified Nurse Aides were responsible for providing personal hygiene care, including nail care, for non-diabetic residents. The Registered Nurse Unit Manager and the Director of Nursing both stated that residents' nails should be kept short and well-groomed, and that nail care should be completed as needed during care routines. Despite these expectations, the observations indicated that the facility did not consistently provide the necessary nail care for the residents, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) F677: I. Immediate Corrective Actions: Resident # 52 1. The licensed nurse provided nail care for Resident # 52. 2. OT reassessed residents right hand contracture to determine if Resident # 52 would benefit from any devices for bilat hand contractures. 3. The resident verbalized satisfaction with nail care provided. 4. The ADL CCP and CNAAR for Resident # 52 was updated by the RN regarding bilat hand contractures and provision of nail care. Resident # 57 1. The assigned CNA provided nail care for Resident # 57. 2. The resident verbalized satisfaction with nail care provided. 3. The ADL CCP and CNAAR for Resident # 57 was updated by the RN regarding the provision of nail care. II. Identification of Others: 1. The DON, in conjunction with the RNS, conducted Facility rounds to ascertain if any other residents were not provided with nail care. There were no additional issues found. III. Systemic Changes: 1. The DON/Administrator reviewed the PP for the provision of nail care for residents and it was determined to be in compliance. This PP will be in serviced to all licensed nurses and CNAs by the Designee. The lesson plan will focus on: - Reviewing the regulatory requirement (F677) that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; - The responsibility of Nursing staff to ensure nail care is provided to all residents as needed; - The specific responsibility of the licensed nurse to provide nail care to residents with hand contractures; - The responsibility of the CNA to communicate to the Unit Nurse and/or RNS when nail care cannot be provided to a resident. IV. Quality Assurance: 1. The DON developed an audit tool to ensure residents are provided with nail care as needed. This audit will be completed by the RNS for 4 residents weekly x 4 weeks followed by 4 residents monthly for 11 months. 2. Findings from the audit requiring immediate corrective action will be rectified immediately. 3. Results from the audit will be brought to the quarterly QA meeting. V. Person Responsible: Director of Nursing
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and updated in a timely manner following a fall, leading to a deficiency. Resident #164, who was admitted with a high risk for falls due to multiple diagnoses including balance problems and decreased muscular coordination, experienced a fall on 12/2/24. Despite a medical assessment on 11/29/24 that highlighted the resident's deficits in mobility and activities of daily living, and the high risk of falls, the care plan was not revised to include new interventions after the fall. The resident was sent to the hospital for examination, but no fractures were found. Subsequently, the resident experienced another unwitnessed fall on 12/08/24, resulting in a head laceration and bruises on both knees, necessitating another hospital visit. Interviews with the Director of Nursing and a Licensed Practical Nurse revealed that the care plan should have been reviewed and updated with new interventions after the initial fall, but this was not done. The failure to update the care plan after the fall on 12/2/24 was a key factor in the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) F657 I. Immediate Corrective Action: 1) Resident #164 is no longer in the facility and was discharged with no outward or obvious issues. II. Identification of Others: 1) All residents could potentially be affected. 2) A list of residents who are potential for fall risk will be generated from the medical record. The comprehensive care plan was reviewed to ensure that all residents who are at risk were updated to reflect current status and contained new interventions to enhance communication. Any identified issues were addressed. 3) All residents who have had falls in the past 30 days will have their CCP’s reviewed and updated to include any necessary safety, supervision, and resident-specific precautions and interventions. 4) Education was provided to all RN’s tasked with updating Care Plans with respect to updating the plan of care for residents every time there is a fall; specifically that a new intervention must be in place post each fall and/or after a change in condition. III. Systemic Changes: 1) The DNS and Administrator reviewed the Policy and Procedure for CCP and found same to be in compliance. 2) All Registered Nurses responsible for care planning will receive Inservice Education given by the Inservice Educator/DON/ADON on updating the CCP with quarterly MDS assessments and when any episodic event happens including falls, other incidents, or change in conditions. Highlights of the lesson plan include: - The care planning process to include Assessment Planning, Goals/Interventions, Monitoring/Evaluation. - The responsibility of the RNs to review the CCP after each MDS assessment, fall, incident, and/or change in condition and revise, based on changing goals, preferences, needs of the resident. - The responsibility of the RNs to revise and update the plan of care when an episodic event occurs. IV. Quality Assurance: 1) The DNS developed an audit tool to monitor the facility’s compliance with updating the Fall CCP with interventions after each fall any resident experiences. 2) All residents that have had falls or change in conditions within the last 30 days or who are on the list of “potential to fall” will be reviewed by the DON/ADNS to ensure that the CCP has been updated to reflect any new interventions if need be. This audit will start as weekly x 4 weeks and monthly x 11 months. 3) Any findings that require interventions will be addressed immediately and discussed in the next QA. V. Person Responsible for F Tag: DNS
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident, resulting in the resident rolling off the bed and sustaining injuries. The resident, who was admitted with multiple diagnoses, was documented to require a two-person assist for bed mobility and bathing according to the care plan. However, the Certified Nurse Aide (CNA) instructions were inconsistent, initially indicating a one-person assist, which was later changed to a two-person assist without a documented date. During an incident, the resident was being cared for by a CNA who turned away to get a washcloth, during which the resident rolled off the bed and fell to the floor, sustaining a laceration and abrasions. The incident report concluded that the fall was witnessed and caused by the resident's intent or behavior. The resident was sent to the hospital for a CAT scan and returned in stable condition. Interviews with the CNA involved revealed a lack of communication regarding changes in the resident's care requirements, as the CNA was unaware of the need for a two-person assist. The physical therapist confirmed that the resident required extensive two-person assistance. The facility's failure to ensure proper communication and adherence to the care plan led to the resident's fall and subsequent injuries.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 689 P(NAME) Description: I. Immediate Corrective Action: Resident #165 is no longer at the facility. II. Identification of others: All residents will be reviewed to ensure the following: (1) Supervision status is accurately reflected in the CCP and CNAAR. (2) If care plan or CNAAR is not updated appropriately, it will be immediately rectified. All resident charts were reviewed to ensure the appropriate supervision status. None others were identified. III. Systemic Changes: a. The Director of Nursing and Administrator reviewed the policy and procedure regarding Supervision. It was found to be in compliance. b. The Director of Nursing and Administrator reviewed the policy and procedure for accidents and incidents and found to be in compliance. c. All Nursing staff will be inserviced by ADNS, DON on the importance of checking the CNAAR for the final determinant of a resident's supervision status. All C.N.A.s will receive education on checking the CNAAR for appropriate supervision status. IV. QA monitoring: a. An audit tool was created to monitor all residents' supervision status to ensure its accuracy. b. Audits will be conducted weekly for 4 weeks for all residents, then monthly for 11 months. c. All negative findings will be reported to the Director of Nursing and the administrator and will be corrected immediately. d. All results of the audits will be brought to the QAPI committee quarterly for a year. V. Person Responsible: Director of Nursing.
Failure to Offer Pneumococcal Vaccinations and Education
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal immunizations and provided with education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey, where it was found that two residents did not have documented evidence of being offered the pneumococcal vaccination, nor did they receive education about it. Resident #1, who had intact cognition, had not been offered the vaccination since their last recorded dose in 2001. Similarly, Resident #24, admitted with specific diagnoses, had not been offered the vaccination since their last recorded dose in 2012. Interviews with facility staff revealed that there was no documentation available for these residents regarding the offer and education of the pneumococcal vaccination. The Administrator acknowledged the lack of documentation and attributed it to nursing staffing shortages and turnover. The Director of Nursing confirmed that a declination form should be signed and uploaded to the electronic medical record if a resident refused a vaccination, and that the pneumococcal vaccination should be offered to all eligible residents at admission and/or every five years.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F883 P(NAME) Description: I. Immediate Corrective Action Resident #1 and resident #24 were immediately offered education regarding the risks and benefits of the pneumococcal vaccine as well as offered the vaccine itself. II. Identification of others All residents have the potential to be affected by the deficient practice. All Resident Charts will be audited to determine if they received their pneumococcal vaccine, declined, and received education. All negative findings were rectified immediately. III. Systematic Changes The Policy and procedure regarding pneumococcal vaccines was reviewed and determined to be in compliance. An in-service will be provided to all LPNs and RNs to educate them that the resident and/or representative has a right to receive education, receive or decline the pneumococcal vaccine as well as documented in the resident CCP. All consents and/or declinations will also be uploaded to the document section of Sigma. IV. QA monitoring a. An audit tool was developed to ensure that all residents and/or representatives receive education, receive or decline the pneumococcal vaccine. Audits will be conducted weekly for 4 weeks and monthly for 11 months. Any negative findings from the audits will be corrected immediately. b. Audits will be brought to QA meeting. V. Title Responsible a. Director of Nursing
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that five randomly selected Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service education. Specifically, CNAs #17, 18, 19, 20, and 21 only received 10 hours of training, which did not include mandatory topics such as abuse and residents' rights. This deficiency was identified during a recertification survey conducted from March 5 to March 12, 2025. The Director of Nursing confirmed the shortfall in training hours during an interview on March 11, 2025. The Administrator acknowledged the deficiency, attributing it to a lapse in monitoring due to turnover in the Assistant Director of Nursing position. The facility had two Assistant Directors of Nursing who did not remain employed, leading to a failure in ensuring the CNAs met the 12-hour in-service requirement. Both the Administrator and the Director of Nursing were aware of the deficiency by the end of the survey, recognizing that the CNAs had not completed the necessary training hours or covered the required topics.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F730 P(NAME) Description: I. Immediate Corrective Action All C.N.A’s will be educated via in-service on resident abuse and resident rights. All 5 CNAs reviewed have been provided with additional in-services to equal the required 12 hours/annually. II. Identification of others A. All residents have the potential to be affected. The DNS/designee will review all CNA records to ensure that all CNA’s have received the mandatory in-services within the past year as well as 12 hours of in-service/year. Those found not to have these in-services will immediately be scheduled for in-services which will be provided by the DNS/designee. III. Systematic Changes The DNS/administrator reviewed the policy and procedure on C.N.A. yearly in-service and found it to be in compliance. IV. QA monitoring a. An audit tool was developed by the DON to ensure that all C.N.A’s are receiving the 12 hours of in-service annually specifically abuse and resident rights. b. Audits will be conducted weekly for 4 weeks on randomly selected CNAs and then monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. d. Audits shall be brought to QA meeting. V. Title Responsible a. Director of Nursing.
Failure to Document and Assess Resident After Incident
Penalty
Summary
The facility failed to ensure appropriate care in accordance with professional standards of practice for a resident with skin conditions. On a specific date, a resident was hit in the face with a bed control while being cared for by a Certified Nurse Aide. The incident was reported to a Licensed Practical Nurse (LPN), who observed no immediate injury and did not document the incident or report it to a nursing supervisor. The resident, who was on blood thinners and had severely impaired cognition, was not assessed by a Registered Nurse as required. Subsequently, another LPN was informed of the incident during a shift change but also failed to document the occurrence or report it to a supervisor. Although no immediate bruising was noted, bruising appeared in the following weeks, which was not documented. The Director of Nursing confirmed that the incident was not reported to the nursing supervisor and acknowledged that a Registered Nurse should have assessed the resident. The lack of documentation and failure to follow proper reporting and assessment protocols led to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F684 I. Immediate Corrective Action: 1) Resident # 10 was assessed by the MD and no untoward persisting effects of the bruise on the resident’s face were noted. 2) A full body assessment was done for Resident # 10 by the RN Supervisor to assess for any unknown bruises. None were found. 3) Resident # 10 was assessed by the SWD and no signs of psychosocial distress were noted. 4) The IDT Team reviewed Resident # 10 CCP and CNAAR for specific interventions. The Resident is determined to have all interventions in place needed. II. Identification of Others 1) The Facility respectfully states that all residents were potentially affected. 2) The DON will review all accidents/incidents for the past 30 days to ascertain if there were any injuries of unknown origin that required further investigation: No issues were identified. III. Systemic Changes 1) The DON in conjunction with the Administrator reviewed the facility’s policy titled Accident/Incident Reporting and Investigation and found same to be compliant. 2) The policy and procedure will be re-in serviced to all registered nurses, licensed practical nurses, and certified nurse assistants by the Designee. The lesson plan will focus on: - The responsibility of all direct care staff to report any incident involving or during resident care to the Unit Charge Nurse and/or RNS - The responsibility of all direct care staff to report any injuries of unknown origin including bruising, redness, or skin changes - The chain of command for reporting events involving residents includes: the CNA will report to the unit LPN, then the unit LPN will report to the unit charge nurse and/or RN Supervisor. - Immediate assessment of the resident by the RN Supervisor and initiation of A/I report. - RN Supervisor to inform the physician and carry out any orders. - MD/NP will also assess resident and document any findings. - RN Supervisor to inform the designated health care representative of incident/change in condition and plan of care. - Licensed nurse to document in the resident’s medical record as well as the 24-hour report. - The responsibility of the DON and Administrator to investigate and report to NYSDOH any injuries of unknown origin. IV. Quality Assurance: 1) The DON developed an audit tool to monitor the facility’s compliance with ensuring an RN assessment and investigation is conducted for all incidents/accidents involving residents. 2) 4 Randomly selected incidents will be audited weekly for 4 weeks and monthly for 11 months. 3) All findings will be brought up at the QA Meeting for input and correction as needed. V. Person Responsible: Director of Nursing
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with severely impaired cognition and a history of erratic movements. On 3/4/25, an Accident/Incident Report documented that the resident was observed with discoloration on the right side of their face. This was not reported to the state agency as required. The resident had a previous incident on 2/18/25 where the bed controls swung into their face, but no injury was noted at that time. The Director of Nursing initially attributed the bruising to this earlier incident, despite the time lapse and lack of documented evidence of bruising between the two dates. Interviews with staff revealed that the bruise was first noticed on 3/4/25, and the Nurse Practitioner confirmed it was of unknown origin. The Director of Nursing acknowledged that the incident should have been reported within two hours and admitted that Incident Reporting In-Service had not been conducted. The failure to report the injury of unknown origin was a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F609 I. Immediate Correction: 1) Resident # 10 was assessed by the MD and no untoward persisting effects of the bruise on the resident’s face were noted. 2) Resident # 10 was assessed by the SWD and no signs of psychosocial distress were noted. 3) The IDT Team reviewed and updated Resident # 10 CCP and CNAAR for specific interventions - The Placement of the bed, TV remote are all secure and don’t pose a risk to the resident or environmental hazard. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) All incidents and accidents for the preceding 30 days will be reviewed to ensure that any incidents of unknown origin were reported to NYSDOH. No other issues were identified. III. Systemic Changes: 1) The Policy and Procedure for Abuse Prevention was reviewed by the Administrator in conjunction with the DON and is in compliance. 2) Inservice education will be provided for all nursing staff on reporting requirements related to reporting violations involving abuse to the NYS DOH. 3) Highlights of the Lesson Plan include: - The facility staff must report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property, immediately to the Administrator/DNS. - Upon notification the DON/Administrator must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYS DOH. - As per CMS 42CRF 483.12(c) the reporting definition “immediately” is defined as: 1) 2 hours if the alleged violation involves abuse or results in serious bodily injury. 2) 24 hours if the alleged violation does not involve abuse and does not result in serious injury. - As per Federal regulation 483.12(b)(5) all reasonable suspicions of crimes and/or suspicious incidents resulting in serious bodily injury must be reported to the local law enforcement within two hours. - Any reasonable suspicion of a crime not resulting in serious injury must be reported to law enforcement within 24 hours. - The Facility procedure for Staff to notify Administrator/DON immediately of any incidents involving alleged abuse or serious injuries immediately 24hrs day/7 days weekly and the responsibility of the DON or Administrator/designee to report to NYS DOH to comply with reporting requirements. IV. Quality Assurance: 1) An audit tool was developed to monitor the facility’s compliance with ensuring that all incidents and accidents are investigated, and injuries of unknown origin are reported timely as per NYS DOH and Federal reporting guidelines. 2) 5 Random Accident and Incidents will be audited by DON/Designee weekly for 4 weeks and monthly for 11 months. Any identified issues will be immediately corrected. 3) Findings will be reviewed at QA Meeting to monitor sustainability. Responsible for this FTag: DON
Failure to Update Resident's Advance Directives
Penalty
Summary
The facility failed to ensure the accuracy of a resident's advance directives, specifically for a resident who had changed their Medical Orders for Life Sustaining Treatment (MOLST) from Do Not Resuscitate (DNR) to Full Code. Despite the resident being cognitively intact and having updated their MOLST during a quarterly care plan meeting, the facility did not update the electronic medical record or the physical indicators, such as the red sticker on the resident's door, to reflect this change. The physician signed the updated MOLST, but the physician orders were not updated accordingly, leading to a discrepancy between the resident's wishes and the documented orders. Interviews with facility staff revealed a breakdown in communication and procedure adherence. The Social Work Director was unaware of why the physician orders were not updated, and Licensed Practical Nurse #1 was not informed of the change in the resident's code status. The Director of Nursing indicated that social workers were responsible for notifying nursing staff of changes, but this did not occur in this instance. This lack of communication and failure to update records resulted in the facility not honoring the resident's current advance directive preferences.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** P(NAME) F578: I. Immediate Corrective Actions: Resident # 82 1) The Primary Physician reviewed the Medical Orders for Life Sustaining Treatment (MOLST) and ensured it was revoked and the physician DNR order in the medical record was discontinued. 2) The RNS with the SW ensured DNR identifiers were removed for Resident # 82. 3) The IDT Team met with Resident # 82 and updated the Care Plan updating to Full Code status and documented in the Medical Record. II. Identification of Others: 1) The facility respectfully states that all residents had the potential to be affected. 2) The DON and Director of Social Work obtained a list of all Advanced Directives. This list will be utilized by SW and RNS to review all residents orders for Advanced Directives including MOLST forms to ensure all Advanced Directives are accurate and current. No issues were noted. III. Systemic Changes: 1) The Administrator, Medical Director, DON, and Director of SW reviewed the Facility PP for Advanced Directives and found same to be compliant. All Physicians, NPs, Licensed nurses, Social workers, and IDT Team members will be in serviced by the Designee: - Topic of Inservice is as follows: - On admission the SW or admission RN will provide information on Advanced Directives and document the education in the medical record. - The admitting RN will ascertain if the resident has an existing Advanced Directive and inform physician for follow up orders as needed. - If the resident is unable to discuss advanced directives on admission the SW in conjunction with the physician and IDT Team will discuss advanced directives with the resident representative/surrogate and/or Health Care Proxy (HCP) as indicated. - All established Advanced Directives will be documented on the Medical Orders for Life Sustaining Treatment (MOLST) form signed by the physician/NP. - The SW will be responsible for ensuring all accurate Facility identifiers for DNR are in place. - The Advanced directives will also be documented in the physician order [REDACTED]. - In cases where advanced directives are changed by the resident or HCP the SW will immediately inform the physician and document in Medical Record. - Any prior MOLST form will be revoked and a new MOLST form signed by the physician will be completed as needed. - The RN will be informed and ensure physician orders [REDACTED]. IV. Quality Assurance: 1) The Administrator developed an audit tool to monitor the Facility compliance with ensuring all residents’ Advanced Directives are accurate. This audit will be done by the Director of SW for 4 randomly selected residents weekly x 4 weeks followed by 4 residents monthly x 11 months. 2) All audit findings will be discussed at Morning Meeting and presented at the Quarterly QA meeting for input and follow up as needed. V. Person Responsible: Director of Social Work
Failure to Maintain Resident Dignity Post-Meals
Penalty
Summary
The facility failed to ensure a dignified experience for a resident, identified as Resident #24, who was observed multiple times with food and crumbs on their chin and gown after meals. Resident #24 had a history of moderate cognitive impairment and required supervision or touching assistance for eating and personal hygiene. Despite these needs, the resident was repeatedly observed with food residue on their face and clothing, indicating a lack of appropriate post-meal care. Interviews with facility staff, including a Certified Nurse Aide and the Director of Nursing, revealed that the expectation was for residents to have their face and hands cleaned after meals if needed. However, observations showed that this standard was not consistently met for Resident #24, as they were left with food remains on their clothing and face after meals. This failure to provide necessary assistance and maintain the resident's dignity was a deficiency identified during the recertification survey.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) F 550 I. Immediate Corrective Action: 1) Resident # 24 has been provided with assistance during all meals. The resident’s CCP was revised to reflect her preferences. Nursing Instructions related to this were carried over to the CNAAR. 2) Resident # 24 CCP and CNAAR were reviewed to ensure the correct ADL care was being provided. 3) The SW interviewed resident #24 to identify the presence of any negative psychosocial outcomes related to the incident and none were noted or reported. II. Identification of Others: 1) The facility maintains the position that all residents were potentially affected. 2) All residents CCP’s and CNAAR’s will be reviewed by the Nursing Department to determine if assistance was needed during meals. All residents who have been determined to need assistance with ADL’s during meals will be placed on the CNA’s assignment sheets moving forward. III. Systemic Changes: 1) The DNS reviewed the Policy and Procedure for Residents Rights and found same to be in compliance. 2) All Nursing Staff received Inservice on the Resident Rights specific to residents right to respect and dignity. Highlights of the lesson plan include: - Residents have the right to a dignified experience. Ensuring a resident has an Apron or is given the appropriate assistance in line with the CNAAR. - The Responsibility of the Nursing Aides to routinely check if residents on their assignments are well maintained and free of an undignified experience. - The Responsibility of the Nursing Aides to ensure that all residents including independent residents are cleaned up after meals. IV. Quality Assurance: 1) An audit tool to monitor compliance ensuring that residents are well maintained and free of an undignified experience. 2) Residents will be audited by the RN Managers weekly x 4 weeks followed by monthly x 11 months. 3) Any findings will be corrected by the auditor immediately and brought to the quarterly QAPI meeting. V. Person Responsible: Director of Nursing
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident, who had a physician's order for oxygen to be administered via nasal cannula at 3 liters per minute. Observations during the recertification survey revealed that the resident was receiving oxygen at a rate of 2.5 liters per minute, which was not in accordance with the physician's order. Additionally, there was no signage indicating oxygen use on the door of the resident's room, as required by the facility's policy. Interviews with facility staff, including a Licensed Practical Nurse and a Registered Nurse Supervisor, confirmed the discrepancy in oxygen administration and the absence of required signage. The LPN acknowledged the fluctuation in the oxygen rate and the RN Supervisor confirmed that signage should have been posted. The Director of Nursing stated that physician orders for oxygen use were mandatory, except in emergencies, and that signage should be present when oxygen is in use. The deficiency was identified as a failure to adhere to the physician's order and facility policy regarding oxygen administration and signage.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 695 P(NAME) Description: I. Immediate Corrective Action Resident #34 was assessed by MD to ensure there were no negative effects. Resident #34 was provided with a new concentrator; one that has the liter flow consistently matching the doctor's order. II. Resident #34 now has a sign outside the room with the appropriate oxygen signage. III. Identification of others a. All residents on O2 were evaluated to ensure that oxygen delivery was consistent with MD order. No other residents were noted with this deficiency. b. All rooms with residents receiving oxygen were audited to ensure they have the proper signage. No other resident rooms were found to be lacking proper signage. IV. Systematic Changes a. Policy and procedure regarding obtaining a MD order for oxygen usage was reviewed and found to be in compliance. An in-service was provided to all RNs and LPNs on ensuring that oxygen delivery is in accordance with doctor's orders. V. QA monitoring a. An audit tool was developed to ensure that all residents on oxygen are being given the prescribed setting. b. Audit will be conducted by RNs on residents receiving oxygen weekly for 4 weeks and monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. c. Audits shall be brought to QA meeting to review with the team. VI. Title Responsible a. Director of Nursing.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a recertification survey. In room C-19-B, a broken window latch was noted, with a hand-written sign instructing not to open the window, indicating a lack of awareness and action from the maintenance staff. Room C-9-B had a broken radiator cover, stained window shades, and black scuff marks on the wall, with the Director of Maintenance unaware of these issues due to the absence of work order requests. Additionally, room A-17 had a faulty window unit and a Packaged Terminal Air Conditioner unit that allowed cold air to enter, with the Director of Maintenance acknowledging the problem but citing pending warranty discussions and weather conditions as reasons for the delay in repairs. The Director of Maintenance admitted to not being informed about the environmental concerns in rooms C-19-B and C-9-B, as no work orders were submitted. The facility's policy requires staff to report such issues to their unit manager, who should then enter a work order into the maintenance software. Despite a complaint from a resident in room A-17 about cold air entering through the air conditioner unit, the facility had not yet resolved the issue, pending warranty discussions and warmer weather for repairs. These deficiencies highlight a breakdown in communication and maintenance processes, leading to an environment that does not meet the required standards for resident comfort and safety.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 I. Immediate Corrective Action: 1. Room C-19-B: - On 3/6/25, Maintenance staff inspected the window in Room C-19-B. The broken window latch was repaired, and the Do not open sign was removed. 2. Room C-9-B: - On 3/6/25, Maintenance repaired the broken radiator cover and secured it properly. - On 3/6/25, Housekeeping cleaned the stained window shade and replaced it. - On 3/6/25, Maintenance cleaned the black scuff marks on the wall between the dresser and window/radiator area. 3. Room A-17: - On 3/11/25, Maintenance identified the faulty PTAC. Temporary sealing was applied to prevent outside air from entering. Maintenance placed a temporary seal on the Packaged Terminal Air Conditioner (PTAC) unit to minimize the cold air entering the room. - The facility will complete permanent repair of the window and PTAC unit as soon as the weather permits, with a target completion date of 4/30/25. II. Identification of Others: - All residents in the facility could potentially be affected by similar environmental issues. - The Director of Maintenance conducted a thorough environmental round in all resident rooms to identify any additional issues like those found in Rooms C-19-B, C-9-B, and A-17. All identified concerns will be fixed. III. Systemic Changes: 1. The Director of Maintenance reviewed the Maintenance/Engineering policy and incorporated a procedure for Sequra (Maintenance Tracking Software) emphasizing staff responsibility for reporting environmental concerns via the work order system. Maintenance staff now follow up daily to ensure timely resolution. 2. All Management staff were educated on the updated policy and how to effectively use Sequra to track maintenance requests. IV. Quality Assurance: - An audit tool was created by the Director of Maintenance to track environmental concerns. - Weekly audits of all rooms will be conducted for 4 weeks by the Maintenance Director and findings will be discussed at daily meetings. A monthly audit will continue for 11 months. - The results of audits and any corrective actions will be reported to QA. V. Person Responsible: - Director of Maintenance
Staffing Shortages in Facility
Penalty
Summary
The facility was found to have insufficient staffing levels during a recertification survey conducted from March 5 to March 12, 2025. The survey revealed that on multiple occasions, the number of Certified Nurse Aides (CNAs) on duty fell below the minimum required levels across various shifts and units. Specifically, the staffing shortages were noted on several dates in February and March 2025, affecting all three units (A, B, and C) during different shifts. The minimum staffing requirements were not met, with instances of only one CNA present when two or more were required, particularly during the night shifts. During an interview, the Director of Human Resources and Staffing acknowledged the staffing shortages and attributed them to high turnover rates and challenges in filling weekend shifts. The Director mentioned that they sometimes had to reassign CNAs from units with lower census to cover shortages and offered overtime and incentives to encourage staffing. Despite these efforts, the facility experienced staffing shortages on the specified dates, although the Director could not confirm if these shortages directly impacted resident care.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 P(NAME) Tag-F725 I. Immediate Corrective Action: The Administrator, DON and HR Coordinator furthered Facility recruitment efforts including: 1) contacted CNA Training program(s) LIST 2) contacted 1199 SEIU Hiring division 3) contacted additional Staffing agencies. 4) The facility posted ads for recruitment for all open positions in the facility with Apploy and Indeed. II. Identification of Others: 1) The facility respectfully states that all residents were potentially affected. 2) The Social Service Department conducted an audit with randomly selected alert residents on each unit to identify any issues related to staffing concerns and resident care issues. There were no identified issues. III. Systemic Changes: 1) The DNS and Administrator reviewed and revised the Facility Assessment to document sufficient staffing needs for each unit based on: Acuity level and Census including special care needs of residents on individual units, and any other pertinent information about the resident needs. 2) An evaluation of diseases, conditions, physical, functional, or cognitive limitations of the resident population Specific skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. The number of Nursing staff to provide services to residents and assist and monitor aides. 3) The DNS provided all Nurse manager staff with education on measures to be taken when staffing is below par levels. Highlights of the Inservice include: The responsibility of the RNS to check staff at the beginning of each shift. The need to have a contact list of available staff and agencies to be called in as needed. The responsibility of the Charge Nurse on each unit to complete an assignment sheet and update as needed for any staffing changes. The responsibility of all Nursing Staff to report to Charge Nurse/RNS when any care or services cannot be provided to residents during the shift. The responsibility of the RNS to ensure resident medications, treatments and care are provided in accordance with resident plan of care. The need for ancillary staff to assist with responding to call bells and informing direct caregivers of resident needs/requests. The responsibility of the DON/Designee to contact the NYSDOH Surge and Flex if the facility implements crisis staffing plan. IV. Quality Assurance: 1) The Administrator, in conjunction with the DNS developed an audit tool to ensure that staffing levels are monitored, and all residents receive required services in accordance with resident plan of care. This audit will be done for each unit weekly x 4 weeks and monthly for 11 months. 2) The HR designee will audit the Staffing to identify date, shift and unit that had less than sufficient staffing weekly x 4 weeks followed by monthly x 11 months. 3) Findings will be reported quarterly to QA Committee to track compliance and monitor sustainability. V. Person Responsible: DON
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to honor a resident's right to receive written notice before a room change, as required by regulations. This deficiency was identified during an abbreviated survey, where it was found that a resident was moved multiple times without receiving any written notification. The facility's policy on room changes did not include the requirement for written notification, which contributed to the oversight. The resident, who was cognitively intact with a BIMS score of 15/15, reported that they were moved several times without prior notice or consent, and their inquiries about the reasons for the moves were ignored by staff. Interviews with facility staff revealed that the social worker typically communicated room changes verbally to residents or their families and documented the changes in the resident's record. However, there was no evidence of written notices being provided. The social worker and the Director of Nursing both confirmed that the process involved verbal communication and documentation in the resident's record, but not written notification. The social worker also mentioned that if a resident or family disagreed with a move, the issue would be brought to the interdisciplinary team for further discussion, although this did not occur in the case of the resident in question.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 Resident #1 is no longer in the facility and was discharged home. The Social Worker who was present at the time of this deficiency is no longer employed at the facility. The current Director of Social Services was reeducated on the proper process for completing room changes. Specifically, that the resident has the right to receive written notice prior to the room being changed. An audit was completed for all residents in the past 30 days to ensure that a written Notice was provided prior to executing a room change. All negative findings were brought to the Administrator’s attention immediately. All residents have the potential of being affected. The Policy and Procedure titled Room Change Policy and Procedure was reviewed and updated. Specifically, that the resident has the right to receive written notice prior to the room being changed. The Social Worker was educated by the Administrator to ensure that notice in writing is provided prior to making a room change, and room change is documented in the medical record. Additionally, the DON, ADON, and all Nurse Supervisors will be educated as well. Audits will be conducted by the Social Worker to ensure that written notices are present for each room change prior to the change being executed. Audits will be conducted weekly for 4 weeks and monthly for 2 months. All negative findings will be brought to the attention of the Administrator immediately. The results of all audits will be brought to the QAPI committee. Person responsible: Director of Social Work
Failure to Provide Adequate Assistance During Resident Transfer
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for a resident who required substantial assistance with transfers. Specifically, a certified nursing assistant (CNA) attempted to transfer a resident from the toilet to a wheelchair without the required assistance of another staff member. The resident, who had severely impaired cognition and physical impairments, fell to the floor during the transfer. The resident's care plan and Kardex both indicated that a two-person assist was necessary for toileting and transfers. Despite this, the CNA proceeded with the transfer alone and asked the resident's family member to assist, which led to the fall. No injuries were documented upon assessment post-fall. Interviews with the resident's representative and the Assistant Director of Nursing confirmed that the CNA did not follow the care plan's instructions for a two-person assist. The resident's representative stated that they informed the CNA of the need for another staff member, but the CNA still proceeded with the transfer, resulting in the resident becoming unsteady and falling. The Assistant Director of Nursing reiterated that staff should request assistance from another staff member if a resident requires more than one person for transfers. Attempts to contact the CNA involved were unsuccessful as they no longer work at the facility.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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