Campbell Hall Rehabilitation Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Campbell Hall, New York.
- Location
- 23 Kiernan Rd, Campbell Hall, New York 10916
- CMS Provider Number
- 335657
- Inspections on file
- 35
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 52
Citation history
Health deficiencies cited at Campbell Hall Rehabilitation Center Inc during CMS and state inspections, most recent first.
A resident with impaired mobility and multiple health conditions developed a Stage 2 pressure ulcer that was not properly assessed or monitored for nearly three weeks, resulting in progression to multiple Stage 3 ulcers. Despite physician orders for wound care and facility policy requiring regular RN assessments, there was no documentation of wound monitoring or care plan revision during this period. The resident was eventually hospitalized for worsening pressure ulcers, and staff interviews confirmed lapses in assessment and documentation.
The facility did not maintain adequate nursing staff on multiple shifts, resulting in missed showers, residents being left in bed, and delays in care. Staff, residents, and family members reported that low staffing levels led to incomplete care and long wait times for assistance, especially on weekends and night shifts. Facility leadership confirmed awareness of these staffing shortages.
Surveyors found that the facility failed to ensure a clean, odor-free, and homelike environment, with strong urine odors, soiled floors, garbage in common areas, and clutter in resident rooms. Staff interviews revealed inconsistent cleaning practices, lack of deep cleaning schedules, and insufficient supervision following the departure of the housekeeping supervisor.
Three residents did not receive consistent assistance with ADLs, including scheduled showers and incontinence care, as required by facility policy. One resident dependent on staff for hygiene received only a fraction of scheduled showers, another was kept in bed and missed both showers and social activities due to staffing decisions, and a third was repeatedly observed in soiled clothing and bedding without evidence of refusals or adequate intervention. Staff interviews revealed that care was often deprioritized due to staffing shortages and lack of supervision, and documentation of refusals or alternative care was inconsistent.
Surveyors found multiple instances of unlabeled, undated, and expired food items in kitchen and pantry areas, including open containers of garlic, cheese, perogies, salad dressing, cookies, yogurt, and beverages. Staff interviews revealed confusion and lack of clarity regarding responsibilities for labeling, dating, and discarding food, with dietary, nursing, and maintenance staff each providing different accounts of their roles.
A resident with cognitive impairment and a history of wandering entered another resident's room and physically assaulted them, causing injury and removal of a medical device. Despite known behavioral risks, staff did not implement or document effective monitoring or interventions to prevent the incident or protect other residents, and care plans were not updated accordingly.
A resident with severe cognitive impairment and a history of wandering was not adequately supervised, allowing them to access an alarmed stairwell door and fall down the stairs in their wheelchair, resulting in serious injuries. Despite known risks and prior incidents, staff did not implement increased supervision or effective interventions to prevent the resident from leaving supervised areas, and the alarmed door could be opened after a delay, contributing to the incident.
Two residents experienced significant unplanned weight loss due to inadequate nutrition care, lack of individualized dietary interventions, and inconsistent monitoring of meal intake. One resident with a pressure ulcer did not receive supplemental protein or have food preferences documented, while another resident's dietary supplement was delayed despite ongoing poor intake. Staff interviews confirmed gaps in documentation and care plan updates, contrary to facility policy.
The facility did not consistently ensure that both outgoing and incoming nurses signed the narcotic count sheets at shift changes, resulting in 37 missing signatures over 104 days. Although narcotic counts were reportedly performed and no medication discrepancies were found, the absence of signatures meant there was no documented proof of reconciliation and transfer of responsibility for controlled drugs.
A resident with epilepsy and dementia missed five doses of Lamictal due to unavailability, and multiple LPNs failed to notify the physician or supervisor as required. The resident subsequently experienced a breakthrough seizure and was hospitalized. The facility's policy for reporting medication administration issues was not followed.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with multiple medical conditions was recorded and exposed on social media when a CNA inadvertently live streamed video during care, violating facility policies prohibiting cell phone use and unauthorized recordings. The resident felt violated and humiliated by the incident, which was discovered after a report to the facility.
A resident with a history of anxiety and cognitive intactness reported to staff that they had been raped and was found disoriented on the floor. Although the resident later recanted the allegation, the facility did not report the initial abuse claim to the state health department as required, resulting in a deficiency for failure to immediately report suspected abuse.
A resident who required staff assistance was found disoriented and sitting on the floor in their room after a fall, with the incident initially reported by the resident's relative. Although staff responded and assessed the resident, no incident or accident report was completed or documented as required by facility policy, and no investigation into the cause of the fall was conducted.
Two residents reported ongoing mouse activity in their rooms, but there was no documented evidence that these rooms were inspected or that targeted pest control measures were implemented. Staff interviews revealed inconsistent awareness and documentation of the complaints, and a significant wall hole was observed in one room. The facility's pest control program did not ensure resident rooms were specifically addressed, resulting in a deficiency.
A resident with severe cognitive impairment and dementia was physically struck on the arm by a CNA during care after becoming combative. The CNA had not received abuse prevention training, and the resident's care plan had not been updated. The DON confirmed that staff had not received required abuse or behavioral health education, and both the physician and medical director were not promptly notified of the incident.
A resident with severe cognitive impairment was involved in an incident where a CNA allegedly struck the resident after being hit during care. The facility's investigation was incomplete, lacking review of camera footage, missing required signatures, and failing to notify law enforcement and the medical team in a timely manner, contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses was inaccurately assessed on the MDS as having no behaviors, despite CNA and nursing documentation of physically aggressive incidents during the assessment period. The error resulted from conflicting CNA entries and an oversight by the MDS Coordinator, leading to an incomplete and inaccurate resident assessment.
Two residents with significant behavioral and mental health diagnoses did not have comprehensive care plans in place to address their aggressive behaviors, despite repeated documentation of incidents and physician orders for behavioral monitoring. Gaps in communication and documentation review among staff led to the absence of required care plans, contrary to facility policy and regulatory requirements.
Two residents with dementia and behavioral disturbances did not have individualized care plans addressing their aggressive behaviors, despite repeated incidents and physician orders for behavior documentation and intervention. The care plans were not reviewed or revised to include specific interventions, and the DON could not explain the lack of appropriate updates, even after documented incidents of aggression and abuse.
A nurse aide was not provided with required training in abuse prevention and dementia care, as confirmed by missing documentation and staff interviews. The facility lacked evidence of completed in-services, and the staff educator position was vacant, resulting in no recent training for staff.
The facility failed to supervise residents who smoked, despite being a non-smoking facility. A resident with impaired cognition started a fire on the patio by discarding a cigarette butt into dry leaves, with no staff present. The facility's inconsistent smoking policy and lack of safety assessments or supervision resulted in substandard care and immediate jeopardy.
The facility failed to implement comprehensive care plans for several residents, including those with dementia, diabetes, and smoking habits. A resident with Alzheimer's lacked care plans for dementia and diabetes management, while another at risk for pressure ulcers had no preventive care plan. Additionally, a resident with schizophrenia was observed smoking unsupervised without a care plan addressing smoking. Staff interviews revealed lapses in care plan initiation and updates.
The facility failed to supervise residents who smoked, leading to a fire incident, and did not enforce its non-smoking policy. Staff were not adequately trained in fire procedures, and required fire drills were not conducted. The facility also lacked sufficient nursing staff and did not ensure staff received updated COVID-19 vaccinations. Emergency preparedness plans were outdated, and staff training was insufficient.
The facility failed to supervise and manage smoking activities among residents, leading to a fire incident in a non-smoking facility. Despite being aware of the issue, the facility did not document a Quality Assurance Performance Improvement plan or hold meetings to address the problem. Key staff, including the Administrator, Director of Nursing, and Medical Director, were either unaware or did not communicate the issue effectively, resulting in a deficiency cited under Immediate Jeopardy.
The facility failed to document and offer COVID-19 vaccination to staff, including a RN Supervisor, a Receptionist, several CNAs, a Physical Therapist, and Maintenance staff. The facility's policy required education on the vaccine's benefits and risks, but this was not followed. The Director of Nursing admitted to not tracking or organizing vaccine offerings due to staffing issues, resulting in a lack of declination forms.
The facility failed to support resident self-determination by not providing a designated smoking area or offering smoking cessation programs after changing its policy to prohibit smoking. This affected five residents who were known smokers at admission, with no evidence of cessation support or staff training provided. The facility's administrator admitted that the needs and preferences of these residents were not considered.
During a survey, several maintenance and cleanliness issues were identified, including dusty fans, stained fixtures, and nonfunctional fans in nurse station toilets. Additionally, a janitor's room door did not close properly, compromising the safety and comfort of the environment.
The facility failed to update Comprehensive Care Plans for four residents, leading to deficiencies in care planning. A resident involved in a fire incident did not have their Smoking Care Plan updated. Another resident's Respiratory Care Plan lacked interventions for oxygen use, and their Psychotropic Medication Care Plan was incomplete. A third resident was discharged without an updated Discharge Care Plan, with no documentation of discharge planning.
The facility failed to maintain sufficient staffing levels, as evidenced by a review of staffing from 11/20/2024 to 12/20/2024, resulting in a 1-star rating. Residents experienced delays in call bell responses, with some waiting up to two hours. Despite recruitment efforts and using agency staff, the facility struggled to meet required staffing levels, impacting resident care.
The facility failed to maintain infection control practices, lacking a Water Management Plan for Legionella and not conducting required testing in 2024. Additionally, there was no effective tracking of infections among residents, and staff immunization records for influenza and pneumococcal vaccines were incomplete. The DON admitted to not knowing the current infection status and falling behind on immunization documentation due to staffing issues.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during hospital transfers. Despite requests, documentation could not be provided, and interviews with the Director of Social Work and DON confirmed the notifications were not given.
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident with severe cognitive impairment and diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Schizophrenia. The facility's policy requires the Social Worker to complete the PASARR before admission, but there was no documented evidence of this being done. The Director of Social Services confirmed the absence of the required screening form.
A resident with a suprapubic catheter did not receive appropriate care due to the facility's failure to develop a care plan or obtain necessary physician orders. The resident's catheter management lacked documentation, including diagnosis, catheter size, and care instructions. Interviews with staff revealed an absence of proper orders and care planning, leading to the deficiency.
A resident experienced a significant weight loss of 28.12% over four months due to inadequate nutritional intake and lack of effective communication with the physician. Despite the facility's policy, there was no assessment by the physician, and staff failed to provide necessary assistance during meals. The facility's documentation and communication processes were inadequate, contributing to the deficiency.
Two residents received inappropriate respiratory care in an LTC facility. One resident was given oxygen without a physician's order, while another received oxygen at a higher rate than prescribed, despite their oxygen saturation being above the threshold. Staff interviews confirmed these discrepancies, which were inconsistent with facility policies.
A resident experienced a significant weight loss of 41 pounds over sixteen weeks without adequate physician supervision or intervention. Despite the facility's policy, there was no documented assessment or action by the physician regarding the weight loss. Observations showed the resident not consuming meals with little staff assistance, and interviews revealed a lack of communication between dietary staff and the physician, contributing to the deficiency.
The facility did not ensure proper labeling and storage of drugs and biologicals, as expired antibiotics and intravenous fluids were found in a medication storage room. The policy requires removal and disposal of expired medications, but they were still present. Staff interviews indicated that the night nurse was responsible for checking expiration dates, and the DON confirmed expired medications should be returned to the pharmacy.
A facility failed to document that a resident with severe cognitive impairment and multiple health conditions was offered or educated about the pneumococcal vaccine. The facility's policy required that all residents receive education and be offered the vaccine, but this was not followed. The DON admitted to disorganization in vaccination records, focusing only on influenza vaccines.
The facility did not ensure that pharmacy consultant recommendations from monthly drug regimen reviews were consistently reviewed, acted upon, and documented by physicians or nurse practitioners. For multiple residents with complex medical and psychiatric conditions, recommendations regarding medication indications and discontinuations were not addressed in a timely manner, and there was no evidence of a clear policy or process to ensure follow-up. Interviews with the DON and nurse practitioners revealed gaps in communication and oversight, resulting in missed or delayed responses to pharmacy recommendations.
A resident with a history of wandering and elopement risk was injured when an LPN inadvertently pushed a door against them, causing a fall. The resident, who has multiple diagnoses including Alzheimer's, was attempting to exit the facility for fresh air due to dizziness from low oxygen. Despite known risks, the facility lacked documented elopement interventions, and the resident's care plan was not updated post-incident.
The facility failed to conduct timely and thorough investigations of incidents involving residents, including a resident being knocked down by an LPN and a resident-to-resident altercation resulting in scratches. The facility did not report these incidents to the DON or the state health department promptly, and incident reports were incomplete or missing.
The facility did not conduct performance evaluations for CNAs at least once every 12 months, as required. Evaluations for two CNAs were last completed in 2018 and 2019, with no documented evidence of evaluations from May 2022 to July 2024. Interviews confirmed that evaluations had not been conducted since 2022, and there was no policy in place for performance reviews.
The facility failed to provide adequate behavioral health care for two residents, resulting in deficiencies in their care plans. One resident, identified as an elopement risk, attempted to exit the facility unsupervised, yet their care plan lacked specific interventions. Another resident with severe cognitive impairment exhibited aggressive behavior, but their care plan was not updated to address these issues. The facility lacked a Behavioral Health Policy and specific training for staff, contributing to these deficiencies.
The facility did not ensure staff were trained to meet residents' behavioral health needs, lacking documented evidence of education from January to July 2024. Despite a facility assessment indicating required training, interviews revealed no behavioral health training since May 2024. A plan was created, but training had not started by the survey's end.
The facility failed to update its Assessment for nearly three years, and the Administrator was unfamiliar with the document. During a system outage, the Administrator did not know the emergency plan to access medical records. Additionally, the facility did not report investigation results of an abuse allegation and an injury of unknown origin to the state health department within the required timeframe.
The facility did not conduct or document a facility-wide assessment to determine necessary resources for resident care during daily operations and emergencies. The assessment was not available for review during a survey, and it had not been updated since 2021. The Administrator was unfamiliar with the document and only located it after consulting a colleague, providing it two days later.
A facility failed to ensure the Minimum Data Set (MDS) accurately reflected a resident's status, missing documentation on care refusals, a pressure ulcer, and mild pain. Interviews revealed flaws in the MDS updating process and lack of safeguards for accuracy.
The facility failed to ensure comprehensive care plans were reviewed and updated quarterly and as needed for a resident. The care plans for pain, osteomyelitis, lymphedema, pressure ulcer, and behavior were not updated timely, despite system alerts indicating they were due or overdue. Staffing issues contributed to this deficiency.
Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
A resident with multiple comorbidities, including diabetes, acute kidney failure, and impaired mobility, was identified as being at risk for pressure ulcers and was dependent on staff for bed mobility. The resident was initially assessed as having no pressure ulcers and was placed on a care plan that included regular skin assessments, use of pressure-reducing devices, and frequent repositioning. On a later date, a Stage 2 pressure ulcer was identified on the resident's sacrum, along with deep tissue injuries to the upper posterior thighs. Physician orders were obtained for wound care, including cleansing, foam dressing, turning every two hours, and use of a gel cushion. However, there was no documented evidence of wound assessments or monitoring from the time the ulcer was first identified until nearly three weeks later, despite facility policy requiring regular RN wound assessments. During this period, the resident's condition was not adequately monitored or reassessed by a registered nurse, and the wound care team did not evaluate the resident until a significant delay had occurred. Progress notes from nurse practitioners documented visits for unrelated issues, but did not mention the resident's skin condition or pressure ulcers. When the wound care physician finally assessed the resident, two Stage 3 pressure ulcers were identified, indicating a progression of the wounds. There was also a lack of documentation regarding wound progression for an additional week, and no evidence that the care plan was reviewed or revised in response to the resident's deteriorating skin condition. The resident was eventually hospitalized for worsening pressure ulcers, with hospital records describing extensive wounds with both partial and full thickness ulcerations, necrotic tissue, and a large affected area. Interviews with facility staff revealed uncertainty about wound assessment responsibilities, frequency, and documentation requirements. Staff acknowledged that wound assessments were not performed as required and that the wound care team visit was delayed, in part due to a COVID-19 outbreak. The delay in assessment and lack of documentation resulted in actual harm to the resident, as the pressure ulcers progressed in severity before appropriate interventions were implemented.
Insufficient Nursing Staff Resulting in Missed Care and Delays
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by staffing levels falling below the facility's own assessment of desired staffing on eleven out of ninety shifts during the review period. Documentation from daily staffing sheets showed multiple instances where the number of certified nurse aides and nurses on duty was significantly less than what was outlined in the facility assessment. As a result, residents did not receive showers as scheduled, were left in bed for extended periods, and were not able to participate in planned activities. Staff, residents, and family members consistently reported that low staffing led to delays in care, with some residents waiting up to two hours for assistance, and staff being unable to take breaks due to the workload. Interviews further confirmed the impact of inadequate staffing, with residents stating they missed showers and were left in bed because staff were too busy. Staff members reported that on certain shifts, especially weekends and nights, the number of aides was insufficient to provide care for all residents, sometimes leaving only three aides to care for forty residents. The Human Resource Director and Administrator acknowledged awareness of staffing shortages, particularly on weekends, and confirmed that the daily staffing sheets accurately reflected these deficiencies.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents. Observations revealed persistent strong urine odors in various areas of Unit 2, including hallways, a specific resident room, and the dining room, with the smell extending into surrounding areas. Floors in Unit 2 hallways and dining room were visibly soiled or stained, and garbage was found on the floors in the shower room, dining room, and hallways. The Unit 1 dining room cabinet drawer contained garbage, and clutter was observed in resident rooms, including an unused oxygen concentrator and boxes of supplies stored on the floor. The Unit 2 shower room had used linens left on shower chairs, bagged linens outside of receptacles, and other items left out of place. Interviews with staff indicated a lack of routine deep cleaning schedules and inconsistent supervision, especially following the recent absence of a housekeeping supervisor. Housekeeping aides reported cleaning shared spaces and resident rooms daily, but there was no established schedule for deep cleaning or for providing additional attention to rooms with persistent odors. The facility's provided cleaning policy addressed only terminal cleaning, not routine cleaning. The Administrator confirmed that rooms and floors should be cleaned daily and that clutter and unused equipment should not remain in resident rooms, but acknowledged that deep cleaning had not occurred recently and that oversight of housekeeping rounds was lacking.
Failure to Provide Consistent ADL Assistance and Hygiene Care
Penalty
Summary
Surveyors identified that the facility failed to provide necessary assistance with activities of daily living (ADLs) for three out of six residents reviewed. One resident, who was dependent on staff for showering and transfers due to physical and cognitive limitations, did not receive scheduled showers as required by facility policy. Documentation showed that out of 20 scheduled opportunities, only five showers were provided, with most other instances recorded as bed baths and no consistent documentation of refusals. The resident expressed a preference for showers and dissatisfaction with the inconsistency, noting that staff found it burdensome due to the need for a mechanical lift and two-person assistance. Staff interviews confirmed that showers were often missed due to staffing challenges and that the resident required regular hygiene due to incontinence. Another resident with severe cognitive impairment and extensive ADL needs was observed in bed throughout multiple days, missing scheduled social activities and not receiving showers as scheduled. Staff interviews revealed that decisions to keep the resident in bed and forego showers were made by CNAs based on staffing levels and workload, without consultation with nursing staff. Documentation indicated that showers were frequently replaced with bed baths, and refusals were not consistently documented. Nursing staff acknowledged that supervision of CNAs was lacking due to competing responsibilities, such as medication administration, and that communication between CNAs and nurses regarding care delivery was insufficient. A third resident, who had self-care deficits and was occasionally incontinent, was repeatedly observed in soiled clothing and bedding with a strong odor of urine present in their room and on their person. Despite care plans indicating the need for regular incontinence care and hygiene assistance, there was no documented evidence of refusals, education, or social work support related to hygiene. Staff interviews confirmed that the resident did not consistently refuse care and that soiled conditions persisted for extended periods. Supervisory staff were aware of the ongoing hygiene issues but could not provide evidence of recent interventions or consistent follow-up to address the resident's needs.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. During the recertification survey, multiple instances of unlabeled and undated food items were found in both the kitchen and unit pantries, including open jars of chopped garlic and ricotta cheese, a defrosted turkey breast, and an open bag of perogies. Expired food items, such as salad dressing, cookies, and yogurt, were also found in various storage areas and pantries. Additionally, an unlabeled open vanilla pudding with mold and a jar containing an unknown substance were observed. Open and undated beverages, including thickened liquids and milk, were present in the second-floor pantry refrigerator. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for labeling, dating, and discarding food items. The Maintenance Director, Certified Nurse Aide, DON, and Food Service Director each provided differing accounts of who was responsible for monitoring and maintaining food safety in the pantries and refrigerators. The Food Service Director acknowledged that dietary staff were responsible for labeling and discarding food after three days but admitted that some items may have been missed. There was also uncertainty about who stocked certain cabinets and who was responsible for discarding liquids used for medication pass if they were undated or expired.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, diabetes, and major depressive disorder, who was assessed as having intact cognition and at risk for abuse, was subjected to physical abuse by another resident. The incident involved a second resident with severe cognitive impairment, dementia, schizophrenia, and a history of wandering and resistance to care. This resident entered the first resident's room, struck them with a Reacher, scratched their arm causing a Dexcom sensor to be dislodged, and threatened them with scissors. The incident resulted in visible red scratch marks and the removal of the glucose monitoring device. Prior to the incident, the resident who committed the abuse had documented behaviors of wandering and resistance to care, with care plans indicating the need for monitoring while up in their wheelchair. However, there was no evidence that interventions were implemented to address these behaviors or to protect other residents from potential harm. Staff interviews revealed a lack of awareness regarding specific monitoring interventions for the resident after the incident, and care plans were not updated to reflect new risks or necessary precautions. Facility video footage confirmed that the resident continued to wander unsupervised after the incident, including moving through exit doors undetected. Multiple staff members, including nurses and certified nurse aides, reported being unaware of any additional interventions or monitoring put in place following the altercation. The failure to implement and document appropriate interventions to prevent further incidents contributed to the deficiency in protecting residents from abuse.
Failure to Prevent Resident Accident Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, schizophrenia, falls, and wandering was not adequately supervised, resulting in the resident accessing an alarmed stairwell door and falling down the stairs in their wheelchair. The resident sustained two fractured vertebrae and a scalp hematoma. The resident's care plan documented wandering and elopement risk, and interventions included monitoring while in a wheelchair. However, after a prior incident involving resident-to-resident aggression and documented wandering, there was no evidence that increased supervision or additional interventions were implemented to address the resident's ongoing wandering behavior. On the day of the incident, the resident was placed in the Day Room by staff to be monitored but was observed multiple times moving independently in the hallway. Despite being redirected once, the resident was able to access the stairwell door, which was alarmed but could be opened after a period of continuous pressure. Staff were providing care in another room when the alarm sounded, and there was a delay in responding to the alarm. Video surveillance confirmed that the resident was able to open the stairwell door and enter the stairwell unaccompanied, leading to the fall. Interviews with staff revealed that they were aware the resident had a tendency to wander and approach doors, requiring redirection. The alarm system on the stairwell door was known to allow the door to open after a certain period, even while sounding. There was no evidence of additional visual cues or barriers, such as stop signs, on the stairwell doors as planned. The lack of timely supervision and effective interventions to prevent the resident from accessing the stairwell resulted in the resident's fall and injuries.
Failure to Provide Adequate Nutrition and Monitor Intake
Penalty
Summary
The facility failed to ensure adequate nutrition care and services for two residents, resulting in significant unplanned weight loss and insufficient monitoring of nutritional intake. One resident experienced a 12% weight loss over five months and had a Stage 3 pressure ulcer, yet their care plan lacked documentation of food preferences and did not include any nutritional interventions. Despite a history of poor appetite and refusal of supplements, meal intake was not consistently documented, with 13 out of 24 meals left unrecorded during the survey period. The resident frequently ordered take-out food due to dissatisfaction with facility meals, and there was no evidence of supplemental protein being provided to support wound healing, as would be expected for a non-healing wound. Another resident experienced a 9.8% weight loss in six weeks and consistently consumed less than 50% of meals during the survey period. The care plan for this resident included general interventions such as offering food preferences and between-meal nourishment, but did not specify a particular nutrition supplement. Although a dietary supplement (Magic Cup) was recommended and ordered by the dietitian, there was a delay of several days before the supplement was actually started. Intake documentation showed that the resident continued to eat poorly, and observations revealed difficulty with meal consumption, including spitting out food despite being served a preferred diet texture. Interviews with staff, including the registered dietitian, speech therapist, and LPN, confirmed gaps in documentation of food preferences and inconsistent implementation of dietary interventions. The facility's policies required daily intake monitoring and immediate care plan updates for weight changes, but these procedures were not consistently followed for the affected residents. The lack of timely and individualized nutritional interventions contributed to ongoing weight loss and inadequate support for residents with complex medical needs.
Missing Nurse Signatures on Narcotic Count Logs
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled, as required by policy. Specifically, over a 104-day period, there were 37 instances where nurse signatures were missing from the change of shift narcotic count log out of 624 opportunities. The facility's policy mandates that a complete count of all narcotics must occur at every change of personnel, with both the outgoing and incoming nurses signing the narcotic count sheet to indicate agreement with the count and transfer of responsibility. Review of narcotic count sheets revealed missing signatures, indicating that the narcotic count was not always completed before the transfer of narcotic keys. Observations and interviews confirmed that the count process was generally followed, with nurses stating that the count was performed between shifts and that they could not leave until it was completed. However, the missing signatures were attributed to nurses forgetting, being rushed, or needing to return to the floor quickly. Despite the absence of medication count discrepancies, the lack of signatures meant there was no documented proof that reconciliation and transfer of responsibility had occurred as required by policy.
Significant Medication Error: Missed Anti-Seizure Medication Doses
Penalty
Summary
A resident with diagnoses including epilepsy, dementia, and headaches had a physician's order for Lamictal, an anti-seizure medication, to be administered twice daily. Over several days, five doses of Lamictal were missed due to the medication not being available. Multiple LPNs involved in the resident's care did not administer the medication as ordered, signed the Medication Administration Record as if it had been given, and failed to notify the physician or nursing supervisor about the missed doses. The pharmacy delivered only a partial supply of Lamictal due to concerns about drug interactions, but this information was not effectively communicated to the clinical team responsible for the resident's care. As a result of the missed doses, the resident experienced a breakthrough seizure and required transfer to the hospital. Documentation and interviews confirmed that the facility's policy required all medication administration issues to be reported to supervisory staff before the end of the shift, but this was not done. The facility's investigation did not address all missed doses, and the physician was not notified of the medication errors at the time they occurred.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Resident Exposed on Social Media Due to Unauthorized Live Streaming by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) used a personal cell phone to live stream video while providing care to a resident, resulting in the resident being recorded and exposed on social media without consent. The CNA entered the resident's room and performed care while the phone, carried in their pocket, inadvertently activated a live stream, capturing the resident's head, chest, and legs while they were wearing only a brief. The incident was discovered after the facility received a call about the live stream, and the CNA stopped recording when approached by the nursing supervisor. The resident, who had diagnoses including atrial fibrillation, major depressive disorder, and hemiplegia, was cognitively intact and later expressed feeling violated and humiliated by the event. Facility policies strictly prohibited the use of cell phones in resident care areas and the unauthorized capture or dissemination of photos or videos of residents. Despite in-service training and clear policies, the CNA admitted to carrying the phone in violation of these rules and was unaware that live streaming was occurring. Staff interviews confirmed that monitoring cell phone use during care was challenging, but efforts were made to intervene when observed. The administrator acknowledged that the staff member's actions constituted abuse, regardless of intent, as the resident's privacy and dignity were compromised.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an allegation of abuse, specifically rape, to the New York State Department of Health as required. The incident involved a resident with diagnoses including asthma, osteoarthritis, and anxiety, who was assessed as cognitively intact and requiring assistance with activities of daily living. On the morning in question, the resident's relative contacted the facility after the resident reported being on the floor and having been raped. Facility staff, including the Registered Nurse Supervisor, responded and found the resident disoriented and confused, expressing that they had been raped and needed help. The resident was alert but required repeated orientation to their surroundings. Despite the resident's later recantation of the rape allegation and clarification that no rape had occurred, the initial allegation was not reported to the state health department as mandated. The Registered Nurse Supervisor informed the Nurse Practitioner, DON, and physician about the incident, but the Administrator confirmed that the allegation was not reported to the authorities. The failure to report the alleged abuse immediately, regardless of the subsequent recantation, constituted a violation of reporting requirements.
Failure to Document and Investigate Resident Fall Incident
Penalty
Summary
A resident with diagnoses including asthma, osteoarthritis, and anxiety, who was cognitively intact and required staff assistance for activities of daily living, was found sitting on the floor of their room. The incident was initially reported by the resident's relative, who received a call from the resident stating they were on the floor, naked, and needed help. Facility staff, including a Registered Nurse Supervisor and floor nurses, responded and found the resident alert but disoriented, expressing confusion about their surroundings and alleging rape. Subsequent medical assessment found no injuries or changes in the resident's baseline condition. Despite facility policy requiring documentation and investigation of all accidents and incidents, there was no documented evidence that an incident/accident report or investigation was completed for the resident's fall. Interviews with facility staff confirmed that while the incident was verbally reported to supervisory staff and medical providers, no written report or investigation could be located. The Administrator stated that the allegation of rape took precedence over the fall, resulting in the lack of documentation for the accident as required by policy.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent and address the presence of mice in resident rooms, as evidenced by complaints from two residents about mice in their rooms. Despite the facility's pest control policy requiring findings of pest activity to be reported and addressed, there was no documented evidence that the affected resident rooms were inspected or that specific pest control measures were implemented in response to these complaints. Observations revealed a cluttered room and a significant hole in the wall behind a resident's bed, which could facilitate rodent entry. Staff interviews confirmed that while pest control services were utilized for the facility overall, resident rooms were not specifically inspected by pest control professionals, and reports of mice were not consistently documented or addressed. Multiple staff members, including maintenance and nursing staff, were either unaware of the ongoing mouse issues in the specific resident rooms or did not have documentation of the complaints. The maintenance log book contained reports of mice in other areas but lacked entries for one of the affected rooms, despite resident complaints. The Director of Maintenance acknowledged the presence of a hole in the wall and the need for food storage precautions but was not aware of all resident-specific pest issues. The lack of targeted inspection and intervention in response to resident reports led to the deficiency in maintaining a pest-free environment as required by regulation.
Resident Subjected to Physical Abuse by CNA During Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia, encephalopathy, and Parkinson's Disease was subjected to physical abuse by a Certified Nurse Aide (CNA) during care. The incident took place while two CNAs were assisting the resident, who became combative and struck one of the aides. In response, the other CNA hit the resident on the arm. Documentation and staff statements confirmed the occurrence of the physical altercation, and the involved CNA was subsequently removed from the schedule. The resident's care plan identified them as being at risk for abuse due to dementia, but there had been no review or revision of the care plan since its creation. Further review revealed that the CNA involved in the incident had not received any abuse prevention training during their employment at the facility. Additionally, the Director of Nursing acknowledged that abuse and behavioral health education had not been provided to staff, and there was no staff educator in place to conduct such training. Both the attending physician and the medical director were not informed of the incident in a timely manner, despite expectations to be notified of all abuse allegations and incidents to ensure proper assessment and intervention.
Failure to Thoroughly Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of staff-to-resident abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia, encephalopathy, and Parkinson's disease. The incident occurred when two certified nurse aides were providing care and the resident became combative, resulting in one aide allegedly hitting the resident in response to being struck. The facility's investigation did not include a review of available camera footage, and the internal investigative documentation was incomplete, missing required signatures from the Administrator, the medical provider, and the nurse manager. Additionally, the facility did not provide documented evidence that law enforcement was notified regarding the alleged abuse, as required by policy. The Administrator stated that law enforcement was not contacted because the resident did not wish to press charges, and a referral to the Certified Nursing Aide Registry was not made for the staff member involved. The Director of Nursing was not involved in initiating the investigation, and the medical director, as well as the primary physician, were not notified of the incident until several days after it occurred. Facility policy required that all elements of an abuse investigation be completed within 48 hours and that completed investigations be reviewed and signed off by the Administrator, Medical Director, Director of Nursing, and Social Services. In this case, the investigation was not coordinated as per policy, and key personnel were not informed or involved in a timely manner. The lack of a nurse manager and staff educator contributed to the incomplete documentation and review process.
Inaccurate MDS Assessment of Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessment accurately reflected a resident's status at the time of assessment. Specifically, the MDS documented that the resident had no behaviors, despite Certified Nurse Aide (CNA) documentation and nursing progress notes indicating multiple physically aggressive behaviors, such as kicking and hitting, during the assessment period. The resident in question had diagnoses including dementia, encephalopathy, and Parkinson's disease, and was noted to have severely impaired cognition. The MDS Coordinator confirmed that the assessment was completed using a 7-day look-back period, during which CNA documentation showed conflicting entries for the same day—one indicating no behaviors and another documenting aggressive behavior. The oversight occurred when the MDS Coordinator failed to capture the documented behaviors in the MDS, resulting in an inaccurate assessment. This discrepancy was identified during the survey through record review and staff interviews.
Failure to Develop and Implement Comprehensive Behavior Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address behavioral needs for two residents with significant mental health diagnoses. One resident, admitted with dementia with behavioral disturbances, Parkinson's disease, and major depressive disorder, exhibited multiple documented incidents of aggressive behaviors such as kicking, hitting, pinching, scratching, spitting, biting, and abusive language. Despite repeated documentation of these behaviors by Certified Nurse Aides and nursing staff, there was no behavior care plan in place until after a resident-to-staff incident occurred. Physician orders required behavior notes and interventions to be documented each shift, but the care plan was not initiated on admission, and the abuse care plan was not updated following a subsequent incident. Another resident, admitted with schizoaffective disorder, Alzheimer's disease, and major depressive disorder, also demonstrated verbal and physical aggression, including an incident where the resident attempted to throw a television at another resident. This resident had physician orders for behavior documentation each shift, and multiple behavioral incidents were recorded in nursing notes. However, there was no documented evidence of a behavior or abuse care plan in the electronic medical record. Staff interviews revealed that interventions such as redirection and reapproach were used, but these were not formalized in a care plan, and communication gaps between nursing and Certified Nurse Aides contributed to incomplete documentation and lack of care plan initiation. The facility's policy required comprehensive care plans to be developed by the 21st day of admission and updated with any significant change in condition. However, failures in communication, documentation review, and interdisciplinary coordination led to the absence of required care plans for residents with documented behavioral issues. This resulted in the facility not meeting regulatory requirements to maintain residents' highest practicable physical, mental, and psychosocial well-being.
Failure to Individualize Dementia Care Plans for Residents with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that residents diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, two residents with dementia and behavioral disturbances did not have individualized care plans with interventions to address their verbal and physically aggressive behaviors. For one resident with severe cognitive impairment and a history of behaviors such as kicking, hitting, biting, abusive language, and threatening actions, there was no documented evidence that the care plan was reviewed or revised to include specific approaches for managing these behaviors, despite multiple documented incidents and a physician order requiring behavior notes and interventions each shift. Another resident, diagnosed with Alzheimer's disease and schizoaffective disorder, also exhibited verbal and physical aggression, as well as rejection of care. Although this resident had a general cognitive/dementia care plan, it did not include individualized interventions to address the aggressive behaviors. Multiple behavior incidents were documented in nursing notes, and a physician order was in place for behavior documentation and intervention, but the care plan was not updated to reflect these needs. Interviews with the Director of Nursing revealed that care plans are expected to be initiated and updated by the appropriate discipline, and that staff documentation should prompt the initiation of behavior management care plans. However, the Director of Nursing was unable to explain why behavior care plans were not initiated or updated for these residents, even after incidents of aggression and abuse were reported and documented.
Failure to Provide Required Abuse and Dementia Training to Nurse Aide
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide received required training in dementia management and abuse prevention, as mandated by facility policy and state regulations. Record review and staff interviews revealed that there was no documented evidence of such training for the aide in question. The only training record provided was for behavioral health, but the aide did not work on the date listed, and the in-service sign-in sheet lacked essential details such as the date, duration, and instructor's name. The Human Resources Director was unable to locate the aide's training folder, and both the Director of Nursing and the Administrator confirmed that the staff educator position was vacant, with no one currently performing the function. Further interviews indicated that the aide had not received in-services on abuse, behavioral health, or dementia care, only on fire safety. The Director of Nursing acknowledged that no in-services had been conducted since assuming responsibility for staff education, due to the absence of a staff educator. The facility's policy requires all staff to be trained on abuse identification and dementia care at hire and annually, but this was not met for the aide in question.
Inadequate Supervision of Smoking Residents Leads to Fire Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents related to smoking for six residents identified as smokers. Despite being a non-smoking facility, the facility did not complete safety assessments or develop and implement a plan of care to ensure the safety of these residents. Resident #41, a known smoker with moderately impaired cognition, was involved in an incident where a fire was started on the outside patio after they threw a cigarette butt into dry leaves. There was no staff supervision during this smoking activity, and the fire was only noticed by the Director of Human Resources from their office window. The facility's smoking policy was inconsistent and did not address how to accommodate residents who smoked prior to the policy change. Residents were observed smoking on the patio without supervision, and there were no ashtrays or cigarette receptacles available. Resident #54 was found with cigarettes and lighters in their room, and a strong odor of cigarette smoke was present. The facility was aware of the residents' continued smoking but did not complete safety assessments or provide supervision, resulting in substandard quality of care with immediate jeopardy. Interviews with staff and residents revealed that the facility was aware of the smoking activities but did not have a formal list of smokers or a system to supervise them. The facility's administration acknowledged the issue but did not implement new systematic interventions to prevent unsupervised smoking. The lack of supervision and failure to update care plans after the fire incident contributed to the deficiency, posing a likelihood for serious adverse outcomes to all residents in the facility.
Removal Plan
- The Smoking Policy was reviewed and updated to include that residents admitted to the facility prior to the implementation of the nonsmoking policy would be given smoking privileges. These residents who desired to smoke would be permitted to do so if the facility Interdisciplinary Team determined that the practice was safe for the residents, and they do so in the facility designated area.
- A nursing assessment by a Registered Nurse was done for all smokers. They examined the residents and clothing for any burns.
- All residents that currently smoke were assessed to determine if they were safe to smoke or require supervision and or assistance.
- Safe smoking contracts were established for residents that smoke.
- A safe smoking area 30 feet from the building was established.
- Appropriate receptacle for cigarettes butts was installed. A small metal step-on garbage can that self-closed was installed.
- Sign for supervised smoking area was posted.
- Smoking aprons were placed by exit to patio for those residents assessed to need an apron. Two smoking aprons were observed stored in two tier plastic storage bins by the [NAME] room door.
- A standard size all-purpose fire extinguisher was located near the patio door.
- Smoking materials for all residents were removed from resident rooms and placed in a locked medication cart.
- Supervised smoking times were assigned for 10:00 AM, 2:00 PM and 6:30 PM; doors were locked when smoking was not in session.
- Schedule of staff supervision was completed.
- Care plans for all 6 smokers were completed for safe smoking.
- Physician orders for each smoker documented residents were care planned to smoke in facility designated area only.
- The facility employs 109 staff members. Of these, 102 completed the in-service training, including supervisors. A sample of staff members from Nursing, Rehabilitation, Administration, and Recreation were interviewed and verified they received the education.
- All supervisor staff were educated on facility procedures particularly their role to call 911 in the event of a fire.
- An hourly smoking monitoring log was maintained to check resident rooms for signs of smoking.
- The patio door was locked and remained locked except during the smoking times. Staff was observed supervising the smokers, unlocking the door to allow the residents into the smoking area and locking the door when smoking was completed.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #15, who was admitted with diagnoses including traumatic brain injury, diabetes, and Alzheimer's, did not have care plans for dementia care, psychotropic drug use, or diabetes management. Despite receiving medications such as Lorazepam, Seroquel, and insulin, the care plans lacked documented goals or interventions. Interviews with staff revealed a lack of awareness and completion of necessary care plans for residents with dementia or Alzheimer's. Resident #84, admitted with dementia, hip fracture, and respiratory failure, was at risk for pressure ulcers but did not have an appropriate care plan in place. Observations noted the resident's feet were not offloaded, and there was no care plan for pressure ulcer prevention despite a Braden Score indicating risk. The Director of Nursing and other staff acknowledged the oversight, noting that the care plan was not reactivated upon the resident's readmission from the hospital, and protocols for skin breakdown prevention were not implemented. Resident #29, diagnosed with schizophrenia, diabetes, and anxiety disorder, was observed smoking unsupervised on the facility's patio, yet had no care plan addressing smoking or non-compliance. The resident's electronic health record lacked a smoking assessment, and staff interviews indicated that care plans should be initiated and updated routinely, but this was not done. The facility's failure to develop and implement these care plans resulted in deficiencies in providing adequate care and supervision for the residents involved.
Deficiencies in Supervision, Fire Safety, Staffing, and COVID-19 Protocols
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents related to smoking for residents identified as smokers. Specifically, a resident known to smoke in a non-smoking facility was not properly assessed or provided with a care plan to ensure their safety. This oversight led to a fire incident on the outside patio when the resident discarded a cigarette butt into dry leaves, with no staff present to supervise the activity. Additionally, the facility did not enforce its non-smoking policy, as smoking was observed during the survey. The facility also failed to ensure that employees were periodically instructed and followed general fire procedures according to the facility's Fire Emergency Plan. During a fire emergency, staff did not activate the fire alarm or contact the fire department. Furthermore, the facility did not conduct the required number of fire drills per quarter, and records did not include details of simulated emergency conditions, violating the NFPA 101: Life Safety Code. Moreover, the facility did not maintain adequate nursing staffing levels to meet resident needs, as documented in their facility assessments. This was evident in 17 out of 90 shifts reviewed, resulting in a 1-star rating in the payroll-based journal report. Additionally, the facility did not ensure that staff were offered updated COVID-19 vaccinations, with no documented evidence of immunization records for several staff members. The facility's emergency preparedness plans were not updated, and staff were not trained annually, further compromising resident safety and care.
Inadequate Supervision of Smoking Activities in Non-Smoking Facility
Penalty
Summary
The facility was found to have a deficiency related to inadequate supervision and management of smoking activities among residents, despite being a non-smoking facility. During the survey, it was observed that residents were smoking on the patio and gazebo, which are unsupervised areas, leading to a fire incident caused by a discarded cigarette butt. The facility failed to establish and implement a process for the Administrator to report to the governing body, and there was no documented evidence of a Quality Assurance Performance Improvement (QAPI) plan or meetings to address the smoking issue. The Administrator acknowledged the non-compliance with the facility's smoking policy and identified six residents as smokers, but no actions were taken to address the issue through the QAPI committee. Interviews with the Director of Nursing, Medical Director, and the facility owner revealed a lack of awareness and communication regarding the smoking activities and the fire incident. The Director of Nursing was unaware of residents smoking in their rooms, and the Medical Director was not informed about the smoking-related fire. The facility owner admitted awareness of the smoking issue but stated it was not brought to the QAPI committee's attention. The deficiency was cited under Tag F 689 at Immediate Jeopardy scope and severity J, indicating a serious lapse in ensuring resident safety and compliance with facility policies.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with the vaccine. During the recertification survey, it was found that there was no documented evidence of immunization records for COVID-19 vaccines for ten staff members, including a Registered Nurse Supervisor, a Receptionist, several Certified Nurse Aides, a Physical Therapist, and Maintenance staff. The facility's policy, dated May 15, 2021, required that all staff be educated about the COVID-19 vaccine before it was offered, but this was not adhered to. Additionally, a Dear Administrator Letter dated September 13, 2023, reminded nursing homes of the expectation to ensure all eligible residents and staff remain up to date with CDC-recommended COVID-19 vaccine doses. The facility did not have documentation of screening, education offering, current COVID-19 vaccine booster status, or signed declination forms for the staff members in question. The Director of Nursing, who is also the Infection Preventionist, admitted during an interview that they had not been offering or keeping track of COVID-19 vaccines for staff due to staffing issues and had not organized the offering of vaccines, resulting in a lack of declination forms for the COVID-19 vaccine.
Failure to Support Resident Smoking Preferences
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice by not providing a designated smoking area or offering a smoking cessation program when it changed its policy to prohibit smoking. This deficiency affected five residents who were known smokers at the time of their admission. The facility's policy initially allowed smoking in designated areas, but a subsequent policy change prohibited smoking entirely without considering the needs and preferences of the residents who smoked. There was no documented evidence that these residents were offered smoking cessation counseling, nicotine replacement options, or that staff received training on smoking cessation programs. Resident #29, who was cognitively intact and admitted with diagnoses including schizophrenia, diabetes, and anxiety, was not assessed for smoking habits or offered cessation support. Similarly, Resident #41, also cognitively intact and admitted with paraplegia, borderline personality disorder, and schizophrenia, reported that no accommodations were made for smokers after the policy change. Resident #54, with quadriplegia and major depressive disorder, had care plans that mentioned smoking but lacked evidence of cessation support being offered. The facility administrator acknowledged that the needs and preferences of residents who smoked were not considered when the policy changed.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
During the recertification survey conducted from December 15 to December 22, 2024, several deficiencies were observed in the facility's maintenance and cleanliness, compromising the safety and comfort of the environment for residents, personnel, and the public. On December 17, 2024, a dusty fan was found in the soiled room on the second floor. In a resident's room, the tub had a brown stain around the drain, and a green-colored substance was present around the sink faucet. Stained ceiling tiles were noted in the second-floor corridor. Additionally, the toilets in the nurse stations on both the first and second floors had nonfunctional fans, and another resident's room had a toilet with a dusty fan. Furthermore, the janitor's room door in the service corridor on the second floor did not close properly. These observations were made in the presence of the Director of Maintenance.
Deficiencies in Comprehensive Care Plan Revisions
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were revised for four residents, leading to deficiencies in care planning. Resident #41, who had diagnoses including Paraplegia and Schizoaffective Disorder, was involved in a fire incident after extinguishing a cigarette in dry leaves. Despite this incident, the Smoking Care Plan was not updated to include new interventions for safe smoking practices. The resident had previously been counseled on the facility's non-smoking policy, but there was no documented evidence of updates to the care plan following the fire incident. Resident #89, diagnosed with conditions such as Unspecified Atrial Fibrillation and Chronic Obstructive Pulmonary Disease, had a physician's order for oxygen use as needed, but this was not reflected in their Respiratory Care Plan. Observations noted the resident using oxygen at 3 liters, yet the care plan lacked interventions or goals related to oxygen therapy. Additionally, the Psychotropic Medication Care Plan for this resident did not include interventions or goals for monitoring behavior or the effectiveness of psychotropic medications, despite the resident's severely impaired cognition and ongoing medication adjustments. Resident #48, with diagnoses including Unspecified Dementia and Generalized Anxiety Disorder, was discharged without an updated Discharge Care Plan. The care plan still indicated the resident as a long-term care resident, and there were no documented notes or goals related to discharge planning. Despite the resident being discharged home, there was no evidence of nursing or social services documentation regarding the discharge process. Interviews with staff revealed a lack of documentation and communication regarding the discharge planning for this resident.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by a review of staffing levels from 11/20/2024 to 12/20/2024. During this period, the facility did not meet the minimum staffing levels outlined in their Facility Assessment for 17 out of 90 shifts. Specifically, the facility was short on Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) during various shifts, which contributed to a 1-star rating in the payroll-based journal report. Observations and interviews with residents revealed that the lack of adequate staffing resulted in delayed responses to call bells, with some residents waiting up to two hours for assistance. Interviews with the Human Resource Director and the Administrator highlighted the challenges the facility faced in maintaining adequate staffing levels. Despite efforts to recruit staff through bonuses and the use of agency staff, the facility struggled to meet the required staffing levels. Agency staff often did not have set schedules, and the management team frequently had to assist on the units to ensure residents received care. The resident council also expressed concerns about staffing, noting that staff often did not return after turning off call bells, further indicating the impact of insufficient staffing on resident care.
Inadequate Infection Control and Immunization Documentation
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by the absence of a Water Management Plan to prevent and control Legionella. There was no documented evidence of Legionella testing or completion of an Environmental Risk Assessment within the last year. The last recorded Legionella test was conducted in February 2023, with no subsequent testing in 2024. The facility's policy required annual Legionella culture sampling and analysis, but this was not adhered to. The Administrator confirmed the lack of testing in 2024, and the owner was unable to provide the necessary documentation for review. Additionally, the facility did not effectively track and monitor infections and outbreaks among residents. The Director of Nursing, who was responsible for the Infection Control Program, admitted to not knowing the current infection status within the facility. There was no documented tool to track infections, symptoms, lab results, or isolation precautions. Furthermore, the facility failed to maintain proper documentation of staff immunization records for influenza and pneumococcal vaccines. The Director of Nursing acknowledged falling behind on tracking immunization records due to staffing issues, resulting in incomplete records for several staff members.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers. This deficiency was identified during a recertification survey conducted from December 15 to December 22, 2024. Specifically, two residents, identified as Resident #49 and Resident #93, were transferred to the hospital, and the facility could not provide evidence that written notice of the bed hold policy was given to them or their representatives. The facility's policy, revised in June 2019, requires notification to the private insurance carrier when a resident is transferred to the hospital or is on therapeutic leave. Resident #49, who was admitted with diagnoses including Sepsis, Dementia, and Bipolar Disorder, was discharged to the hospital on September 27, 2024, and admitted with Septic Shock on September 28, 2024. Resident #93, with diagnoses of Non-Alzheimer's Dementia, Huntington's Disease, and Parkinson's Disease, experienced hospitalizations on December 4-5, 2024, and November 29 to December 2, 2024. Despite requests for documentation on December 22, 2024, the facility could not verify that written notifications were provided. Interviews with the Director of Social Work and the Director of Nursing confirmed that the notifications were not given, and they were unable to provide copies of the notifications.
Failure to Complete PASARR for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) was completed for one of the residents reviewed during the recertification survey. Specifically, the facility did not complete the required Screen form (DOH-695) for a resident with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Schizophrenia. The facility's policy, dated May 26, 2022, mandates that the Social Worker, designated as the Qualified Screener, is responsible for completing the PASARR as per New York State Department of Health Regulations. The policy also states that no resident should be admitted without a completed PASARR to determine the appropriate level of care required. The resident in question had documented severe cognitive impairment in both the Annual and Quarterly Minimum Data Set Assessments conducted in April and September 2024, respectively. However, there was no documented evidence of a completed PASARR for this resident. During an interview, the Director of Social Services confirmed the absence of the Screen form, indicating that it could not be verified if the screening had been completed. This oversight represents a failure to comply with the regulatory requirements for preadmission screening, as outlined in NYCRR 415.11(a)(5).
Inadequate Care for Suprapubic Catheter
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a suprapubic catheter. The resident, who had a size 16 French suprapubic catheter surgically inserted for urinary incontinence, did not have a care plan developed that included a diagnosis, catheter size, or directions for care. Additionally, there were no physician orders specifying the care of the suprapubic catheter or instructions on when it should be changed. Observations and interviews revealed that the resident had the catheter attached to a urinary drainage system, but the facility lacked documentation and orders for its management. The resident's medical records indicated that the suprapubic tube was replaced during a urology consult, but the facility did not have a current order for the catheter. Interviews with the Director of Nursing and a Licensed Practical Nurse confirmed the absence of a proper order and care plan for the suprapubic catheter. The resident was unaware of the diagnosis or the reason for the catheter, and the facility staff could not confirm when the catheter was last changed within the facility. This lack of documentation and care planning led to the deficiency identified during the survey.
Failure to Maintain Nutritional Status and Communicate Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, resulting in a significant weight loss of 28.12% over four months. The resident, who had diagnoses including Huntington's Disease, Parkinson's Disease, and Gastritis, experienced a decrease in appetite and oral intake following a recent hospitalization. Despite the facility's policy requiring monitoring and communication of significant weight changes to the physician, there was no effective communication or assessment by the physician regarding the resident's weight loss. Observations revealed that the resident was often left without assistance or encouragement to eat during meals, contributing to their inadequate nutritional intake. The resident was observed lying in bed with meal trays set up but not consuming the food, and staff did not consistently provide the necessary assistance or encouragement. Interviews with staff indicated a lack of awareness and communication regarding the resident's weight loss and nutritional needs, with some staff uncertain about the frequency of weight monitoring and the resident's dietary requirements. The facility's documentation and communication processes were inadequate, as evidenced by the absence of dietary progress notes between August and December and the lack of formal discussion with the physician about the resident's weight loss. The Registered Dietician acknowledged the significant weight loss and the need for improved weight tracking, but there was no evidence of effective communication with the physician or implementation of appropriate interventions. The failure to address the resident's nutritional needs and communicate effectively with the physician contributed to the deficiency.
Inappropriate Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in care. Resident #75, who had diagnoses including unspecified atrial fibrillation and bacterial pneumonia, was observed receiving oxygen therapy at 2.5 liters via nasal cannula without a physician's order. Despite multiple observations over several days, there was no documented order for this oxygen therapy, and staff, including a Licensed Practical Nurse and a Unit Manager, confirmed the absence of such an order. The facility's policy requires a physician's order for oxygen therapy, and in emergencies, a licensed nurse may start oxygen therapy but must obtain an order as soon as possible. However, this protocol was not followed for Resident #75. Resident #89, diagnosed with conditions such as unspecified atrial fibrillation and chronic obstructive pulmonary disease, had a physician's order for oxygen at 2 liters as needed for oxygen saturation below 90%. Despite this, the resident was observed receiving oxygen at 3 liters via nasal cannula, even when their oxygen saturation was above 90%. Staff interviews revealed that the oxygen was often left on for the resident's comfort, despite not being medically indicated. This practice was inconsistent with the physician's order and the facility's policy, which requires monitoring and adjusting oxygen therapy based on the resident's current needs and physician's directives.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure adequate physician supervision of medical care for a resident who experienced a significant weight loss of 41 pounds, or 28.12%, over a period of sixteen weeks. Despite the facility's policy requiring that significant weight changes be monitored and addressed by the interdisciplinary team, including notification to the attending physician, there was no documented assessment or intervention by the physician regarding the resident's weight loss. The resident, diagnosed with Huntington's Disease, Parkinson's Disease, and Gastritis, required assistance with eating and had a history of poor intake, yet the physician did not document any medical note or implement appropriate interventions in response to the weight loss. Observations and interviews revealed that the resident's weight was not consistently documented in physician or nurse practitioner progress notes, and there was a lack of communication between the dietary staff and the physician regarding the resident's nutritional status. The registered dietician noted the resident's malnourished status and poor intake but had not formally discussed the weight loss with the physician. The nurse practitioner and director of nursing were unaware of the resident's significant weight loss, indicating a breakdown in communication and monitoring processes within the facility. The resident was observed multiple times not consuming meals, with little to no staff assistance or encouragement provided during mealtimes. Despite the resident's poor intake and significant weight loss, the facility's staff did not adequately address the issue or implement effective interventions to prevent further decline. The lack of physician involvement and oversight, combined with insufficient staff support during meals, contributed to the deficiency in care for the resident.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals in one of two medication storage areas were labeled and stored according to professional standards. During a recertification survey, it was observed that antibiotics and intravenous fluids with expiration dates of October 2024 were found in the medication storage room on the first floor. The facility's policy, revised in September 2017, requires that discontinued drug containers be removed from the medication cart and marked to indicate discontinuation, with expired medications being disposed of. However, during an observation, Piperacillin and Tazobactam, along with intravenous fluids, were identified as expired. Interviews with staff revealed that the night nurse was responsible for checking expiration dates and removing expired medications, while the Director of Nursing confirmed that expired medications should be sent back to the pharmacy and not remain in the storage room.
Failure to Document Pneumococcal Vaccination Offer and Education
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. Specifically, for one resident reviewed, there was no documented evidence that the resident was offered, declined, or educated about the pneumococcal immunization. The facility's policy stated that the Pneumovax vaccine should be available to all residents to control and spread pneumonia, and that residents should receive education about the vaccine before it is offered. However, this policy was not followed for the resident in question. The resident involved had severe cognitive impairment and diagnoses including Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus, and Malignant Neoplasm of the kidney. Despite these conditions, there was no documentation of the resident or their representative receiving education or being offered the pneumococcal vaccine. During an interview, the Director of Nursing acknowledged the oversight, stating that they were in the process of training a new Infection Preventionist and had only managed to organize influenza vaccines, leaving pneumococcal vaccination records disorganized and without records of declinations.
Failure to Act on Pharmacy Consultant Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review was properly conducted, documented, and acted upon for several residents. Specifically, the facility did not have or provide a policy outlining the process for the Pharmacy Consultant’s review, the communication of recommendations, and the required physician or nurse practitioner response. For three of five residents reviewed for unnecessary medications, there was no evidence that the attending physician, medical director, or DON received, reviewed, or responded to the Pharmacy Consultant’s recommendations in a timely manner, nor was there documentation in the medical record regarding the review and actions taken. For one resident with severe cognitive impairment and multiple psychiatric and neurological diagnoses, the Pharmacy Consultant identified incorrect indications for Montelukast and recommended evaluation of long-term Miconazole use. The facility was unable to provide documentation of physician or nurse practitioner acknowledgment or response to these recommendations. Another resident with chronic respiratory failure and psychiatric diagnoses had recommendations to correct medication indications for Eliquis and Lyrica, but there was no evidence of physician review or changes made to the orders. A third resident with severe cognitive impairment and multiple comorbidities had a recommendation to discontinue Clonazepam after the order expired, but the medication remained active and was administered beyond the intended period, with no timely physician response documented. Interviews with the DON and nurse practitioners revealed that the process for reviewing and acting on Pharmacy Consultant recommendations was inconsistent and lacked oversight. The DON acknowledged that some recommendations were being missed and that there was no tracking of which recommendations were reviewed or when. The nurse practitioners and nurses described a process where recommendations were reviewed and signed off, but there was uncertainty and lack of clarity regarding responsibility for ensuring all recommendations were addressed and documented.
Resident Injury Due to Inadequate Supervision and Accident Hazard
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident. On the morning of April 28, 2024, a resident with a history of wandering and elopement risk was seen on video surveillance attempting to exit the facility through the lobby doors. The resident, who was ambulating with a cane, managed to slightly open the inner lobby door. A Licensed Practical Nurse (LPN) returning from a break outside the facility ran through the outer lobby door and pushed the inner door against the resident, causing them to fall. This incident resulted in the resident sustaining a bloody nose, a black eye, and a bruised ankle. The resident involved had multiple diagnoses, including Chronic Obstructive Pulmonary Disease, schizoaffective disorder, and Alzheimer's disease. Despite having intact cognition as per a recent assessment, the resident exhibited behaviors such as verbal aggression, wandering, and incontinence. The facility's records indicated a history of wandering and attempts to leave the building, yet there was no documented evidence of specific elopement measures or interventions in place. The resident's care plan did not identify wandering as a behavior, and the fall care plan was not updated following the incident. Interviews with facility staff revealed that the resident had previously attempted to exit the building and had even broken the glass of the front door. The LPN involved in the incident stated they were unaware of the resident's proximity to the door due to their haste and adrenaline. The Director of Nursing and the Administrator acknowledged the resident's frequent attempts to leave the building and the challenges in providing constant supervision. The resident themselves reported feeling dizzy and seeking fresh air due to running out of oxygen, which contributed to their attempt to exit the facility.
Failure to Investigate and Report Incidents Timely
Penalty
Summary
The facility failed to ensure timely and thorough investigations of incidents involving residents, as required by state and federal regulations. In one instance, a resident attempted to exit the facility and was inadvertently knocked down by an LPN rushing through the door. The incident was not reported to the Director of Nursing (DON) until the following day, and the investigation was delayed. The DON was not immediately informed, and the incident was not reported to the New York State Department of Health in a timely manner. In another case, the facility did not conduct a thorough investigation into a resident-to-resident altercation. A resident with severe cognitive impairment was involved in an incident where they were found with scratches and food stains in their room. The facility failed to determine the root cause of the altercation and did not provide a completed incident report for a previous similar incident. The investigation was incomplete, and the residents involved were not adequately questioned until days later. Additionally, the facility did not provide incident reports for other altercations involving residents, including an incident where a resident spilled juice on their roommate. The facility's failure to document and investigate these incidents properly indicates a lack of adherence to their abuse identification program and state regulations, which require immediate reporting and investigation of potential abuse or neglect.
Failure to Conduct Timely Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete performance evaluations for Certified Nurse Assistants (CNAs) at least once every 12 months, as required. Specifically, the performance evaluations for CNA #1 and CNA #2 were last completed in 2018 and 2019, respectively. A review of their employee files during an onsite visit revealed no documented evidence of performance evaluations from May 2022 to July 2024. Interviews with the Human Resources Director/Scheduling Coordinator and the Director of Nursing confirmed that performance evaluations had not been conducted since 2022, and there was no policy in place for performance reviews. The Director of Nursing mentioned that evaluations had not been completed due to a lack of opportunity to do so.
Deficiencies in Behavioral Health Care Plans for Residents
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents, leading to deficiencies in their care plans. Resident #1, who was identified as an elopement risk and a wanderer, was observed attempting to exit the facility unsupervised. Despite being recognized as high risk for elopement, the resident's Behavioral Symptom Care Plan lacked specific goals and interventions to address these behaviors and ensure safety. The Director of Nursing acknowledged the oversight, stating that the elopement risk assessment was a mistake and attributed the resident's behavior to attention-seeking, despite the resident refusing psychiatric medications. Resident #2, with severe cognitive impairment and a history of aggressive behavior, also lacked a comprehensive care plan to address unsafe behaviors. The resident had incidents of throwing food and engaging in verbal and physical altercations with roommates. Despite these occurrences, the care plan was not updated with goals or interventions to manage the resident's behavior. The facility's Staff Educator admitted that there was no specific training for behavioral health, and care plans were not adequately updated following significant changes in residents' conditions. The facility was unable to provide a Behavioral Health Policy during the survey, indicating a lack of structured guidance for managing residents with behavioral health needs. The absence of documented goals and interventions in the care plans for both residents highlights a deficiency in the facility's approach to behavioral health care, as required by regulatory standards.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that all staff members were adequately trained to meet the behavioral health needs of residents. During an abbreviated and extended survey, it was found that the facility could not provide documented evidence of staff education on behavioral health from January to July 2024. The facility's assessment indicated a total bed capacity of 134 residents, with common diagnoses including psychiatric and mood disorders, and stated that all staff receive training and competencies upon hire, annually, and on an ongoing basis for mental and behavioral health. However, interviews revealed that no behavioral health training had been conducted since May 2024, and the Registered Nurse Staff Educator was in the process of creating a training program. A behavioral health education plan was created, but training had not yet commenced by the time of the survey.
Deficiencies in Facility Administration and Reporting
Penalty
Summary
The facility was found to be deficient in its administration, failing to use its resources effectively and efficiently to ensure the highest practicable well-being of its residents. The facility's Assessment had not been reviewed or updated from July 31, 2021, to July 18, 2024, and the Administrator was unfamiliar with the document, indicating a lack of oversight and responsibility. Additionally, during an electronic system outage on July 19, 2024, the Administrator was unaware of the emergency plan to ensure continued access to medical records, which is crucial for the timely provision of medications and treatments. Furthermore, the facility failed to report the results of investigations to the New York State Department of Health as required by state law. Specifically, an allegation of abuse on April 19, 2024, and an injury of unknown origin on June 22, 2024, were not reported within the mandated timeframe. The Administrator admitted to submitting the reports late and was unable to confirm their submission, demonstrating a lack of compliance with regulatory requirements.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. During an abbreviated and partial extended survey, it was found that the facility did not have a Facility Assessment readily available for review upon request on 7/17/2024. The assessment had not been reviewed or updated since 7/31/2021, which is a requirement for ensuring that the facility can make informed decisions about direct care staff needs and service capabilities. On 7/17/2024, the surveyors requested the Facility Assessment, but the Administrator initially provided a Facility Survey Report instead. The Administrator admitted to not being familiar with the Facility Assessment document and acknowledged their responsibility for updating it. After consulting with a colleague and searching on the computer, the Administrator located the document and planned to complete the necessary information. The Facility Assessment Tool was eventually provided on 7/19/2024 with a review date of 7/17/2024, indicating a lack of timely documentation and review.
Inaccurate Minimum Data Set Documentation
Penalty
Summary
The facility did not ensure the Minimum Data Set (MDS) accurately reflected the resident's status for one resident. Specifically, the Quarterly MDS for a resident did not document the resident's rejection of care, presence of a pressure ulcer, and complaints of occasional mild pain. The resident had multiple diagnoses, including a non-pressure ulcer, cellulitis, chronic pain, lymphedema, depression, opioid dependence in remission, muscle weakness, and osteomyelitis. Despite these conditions, the MDS sections related to pain, pressure ulcers, and rejection of care were not accurately completed. Interviews with the Minimum Data Set Coordinator and the Social Service Director revealed that the facility's process for updating the MDS was flawed. The MDS Coordinator stated that there was no safeguard in place to ensure the accuracy of all sections of the MDS. The Social Service Director admitted that the resident had informed them about refusing care, but this information was not accurately reflected in the MDS. Further review of the resident's records showed documentation of care refusals and a non-pressure wound that were not coded in the MDS, indicating a failure in the facility's documentation and assessment processes.
Failure to Update Comprehensive Care Plans Timely
Penalty
Summary
The facility did not ensure comprehensive care plans were reviewed and updated quarterly and as needed in a timely manner. This deficiency was evident for one resident out of three reviewed for care planning. Specifically, the care plans for pain, osteomyelitis, lymphedema, pressure ulcer, and behavior for Resident #1 were not updated quarterly and after a comprehensive assessment. The facility's care plan policy requires updates quarterly, annually, upon readmission, and with significant changes in condition. However, the care plans for Resident #1 showed significant delays in updates, with some care plans not revised for several months. Interviews with the Director of Nursing and unit managers revealed that the responsibility for updating care plans fell on the registered nurses on the unit, but due to staffing issues, registered nurse supervisors were also involved. The system used by the facility provides alerts for due or overdue care plans, but these alerts were not acted upon in a timely manner. The Director of Nursing confirmed that the dates shown for the care plans were the only dates they were reviewed, indicating a failure to adhere to the facility's policy for timely updates.
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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