Casa Promesa
Inspection history, citations, penalties and survey trends for this long-term care facility in Bronx, New York.
- Location
- 308 East 175 Street, Bronx, New York 10457
- CMS Provider Number
- 335780
- Inspections on file
- 22
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Casa Promesa during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of elopement, equipped with a wander alert device, exited the facility undetected after a security guard, untrained on the wander alert system, mistakenly allowed the resident to leave and failed to respond to the alarm. Staff monitoring and communication lapses contributed to the delayed discovery of the resident's absence.
The facility failed to update comprehensive care plans for four residents following incidents of resident-to-resident altercations. Despite documentation of the incidents, care plans were not revised to reflect changes in residents' status. Interviews with the Director of Social Services and the DON revealed a lack of clarity regarding responsibility for updating care plans.
The facility did not adhere to professional standards for storing medications and biologicals. Expired Heparin syringes were found in the 4th Floor Medication Room, and food items were improperly stored with IV bags on the 3rd Floor. Staff acknowledged these storage breaches.
The facility was found to have expired food items, including beef stew and frozen omelets, during a recertification survey. The facility's policy requires stock rotation and date marking, but the Assistant Food Manager acknowledged an oversight in checking expiration dates.
A resident's right to refuse care was not respected when a CNA forcefully provided care despite the resident's refusal, citing concerns about skin integrity. The facility's policy emphasizes self-determination, but the CNA did not report the refusal to nursing staff. Interviews with other staff indicated that the proper protocol was not followed.
A resident with COPD and other conditions received oxygen at a flow rate inconsistent with the physician's order, and there was no documentation of when the oxygen tubing was last changed. Staff were unaware of the discrepancy, and the facility's policy on oxygen therapy was not followed.
The facility's Infection Preventionist did not complete the required specialized training in infection prevention and control, as identified during a survey. Despite being in the role since early 2023, the Infection Preventionist only had a certificate in Infection Control and Barrier Precautions, which did not meet the requirement. Interviews revealed that the Infection Preventionist, Director of Nursing, and Administrator were unaware of the training requirement.
During a life safety code survey, it was observed that a Christmas tree in the third floor lounge was plugged into an unapproved power strip, violating NFPA codes. This was noted on one of the four units surveyed.
The facility did not maintain fully functional lighting in the egress path of a stairwell leading to Anthony Avenue, with two lighting tubes partially illuminated. This was observed during a life safety code survey, affecting one out of four units. The Maintenance Director was informed of the issue.
The facility did not ensure that the soiled utility room door on the fourth floor latched properly, as observed during a life safety survey. The door to room 425 failed to latch when tested, and the maintenance director acknowledged the issue.
The facility inaccurately documented antiviral medications as antibiotics for three residents due to an electronic medical record system error. Additionally, a resident was incorrectly assessed with Non-Alzheimer's Dementia despite having no such diagnosis. These inaccuracies were identified during a recertification survey.
The facility failed to provide two residents with the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) upon the termination of their Medicare Part A benefits. The Minimum Data Set Coordinator, responsible for informing residents about their Medicare coverage, was unaware of this requirement, leading to a deficiency under regulation 10 NYCRR 415.3(h)(2)(i).
A resident with a mood disorder and aphasia reported verbal abuse by a CNA to a Social Worker a week after the incident. The Social Worker placed the grievance in the DON's mailbox, leading to a delayed report to the Department of Health, contrary to the facility's policy requiring immediate reporting.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision and Staff Training
Penalty
Summary
A resident assessed as cognitively impaired and at risk for elopement, with a history of previous elopement attempts, exited the facility undetected. The resident was admitted from the hospital with diagnoses including deafness, dementia related to a communicable disease, and altered mental status. Hospital records indicated the resident lacked capacity and had a history of attempting to leave care settings. Upon admission, the resident was identified as an elopement risk, and a wander alert device was placed on their ankle. The care plan included interventions such as ensuring proper placement and function of the wander alert device, informing staff of the elopement risk, and providing the resident's picture to security. Despite these measures, the resident was able to leave the facility without detection. On the day of the incident, the resident was last seen at 10:00 AM during hourly monitoring. Surveillance footage showed the resident leaving their room, entering the elevator, and exiting through the main lobby. The security guard at the front desk released the door for the resident, mistaking them for an employee, and did not recognize the activation of the wander alert alarm. The security guard heard a beeping sound after the resident exited but did not investigate, search the lobby, or notify other staff. The security guard later stated they had not been educated on the wander alert system or the appropriate response to an alarm. The resident's absence was not discovered until a visual check at 11:00 AM, at which point a search and Code Yellow were initiated. Interviews with staff revealed gaps in monitoring and communication. The certified nursing assistant assigned to the resident did not observe the wander alert device during vital sign checks and was unaware of the resident's whereabouts until after the elopement. The security guard was new and had not received training on elopement prevention or the wander alert system. The resident's picture had not been obtained for security purposes, and there was no documented evidence of staff education on the wander alert system. The facility's policies required the use of wander management systems and staff accountability for resident safety, but these were not effectively implemented, resulting in the resident's undetected elopement.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to ensure that comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team following incidents of resident-to-resident altercations. The care plans were not updated to reflect changes in the residents' status after these incidents, which is a requirement as per the facility's policy. The incidents involved verbal and physical altercations between residents, which were documented in the facility's records but not followed by necessary updates to the care plans. Resident #42, diagnosed with Bipolar Disorder and Anxiety Disorder, was involved in a verbal altercation with Resident #51, who has Peripheral Vascular Disease and PTSD. The altercation was triggered by transphobic text messages sent by Resident #42 to Resident #51. Despite the incident being documented and verified, there was no evidence that the care plans for either resident were reviewed or revised to include new interventions addressing the altercation. Similarly, Resident #50, with severe cognitive impairment, was involved in a physical altercation with Resident #61, who has Alcohol Dependence and other diagnoses. Resident #61 threw water at Resident #50 without apparent cause. Although the incident was documented, the care plans for both residents were not updated to reflect the altercation. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of clarity and responsibility regarding the updating of care plans following such incidents.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Director of Social Services on 12/09/2024 and 12/10/2024 conducted care plan reviews and revision to assess Resident #42, Resident #50, Resident #51, and Resident #61 for physical, emotional, and behavioral changes post-altercation. DSS updated findings in the medical records and ensured appropriate interventions were implemented. The updated care plans include specific behavioral interventions, safety measures, and triggers identified during the assessment. - The Director of Social Services conducted an urgent IDT huddle on 12/10/2024 to review and revise care plans for all residents involved in the incident. The IDT team was informed of the care plan updates and instructed on implementing the new interventions. Identification of Others Potentially Affected: The facility respectfully submits all residents were reviewed and were not affected by this practice. System Changes to Prevent Recurrence: - The Compliance team on 12/12/2024 reviewed the facility’s care plan policies. No amendments were needed. The Compliance officer re-in-serviced the DSS and social workers to mandate immediate IDT care plan reviews and updates following significant resident incidents, such as altercations, falls, or changes in condition. - The Social Services team and senior nursing team received mandatory training on 12/12/2024 by the compliance officer on Identifying triggers for care plan updates, Proper documentation of incidents and interventions, Collaboration during care plan reviews, and implementing a communication system to ensure direct care staff promptly report significant resident incidents to the IDT for review. - The Compliance team on 12/13/2024 instilled protocol for monitoring and documenting behavior changes following incidents, and responsibilities for ensuring care plan alignment. IDT and all direct care staff as of 12/31/2024 were in-serviced. Quality Assurance Monitoring: - The DSS will perform weekly audits of resident incident reports to verify care plan updates were completed for all significant changes. The DSS will also review a random sample of 10% of care plans weekly for three months to ensure they reflect the resident’s current status and needs. - The audit results will be discussed at monthly Quality Assurance (QA) meetings to adjust training or policies based on findings from the ongoing audits. - The Performance Metrics is set at a compliance target of 100% for care plan updates following significant resident-to-resident incidences. - Audit Tool created. Responsible Party: Director of Social Services
Improper Storage of Medications and Biologicals
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored according to professional standards of practice, as observed during the Recertification Survey. On the 4th Floor Medication Room, nineteen Heparin lock flush syringes with expired dates were found in a drawer, indicating a lapse in removing expired medications from storage. Registered Nurse #2 acknowledged that medications should be used by their expiration date to maintain effectiveness. Additionally, in the 3rd Floor Medication Room, food items such as plastic containers of coffee and coffee creamer were improperly stored next to intravenous fluid bags inside a cabinet. Both Registered Nurse #3 and the Director of Nursing confirmed that food should not be stored in the Medication Room, highlighting a breach in the facility's policy on Medication Storage and Handling.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - All expired medication (19 [MEDICATION NAME] lock flush syringes) were removed and discarded from Unit 3 (4th floor) medication room. - All food items were removed from Unit 2 (3rd floor) medication room. - RN #3 and RN #4 were re-educated on the Medication Labeling / Storage policy and procedure. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - All Unit RN Managers will do daily rounds to ensure all medications rooms, drawers and cabinets are free from expired Medication and food. - Review of the Medication Storage and Handling Policy was done on 12/13/24. The policies align with the current standards and professional practice and regulatory guidelines. No modifications made. - All Nurses will be re-educated on the policy. - The Pharmacy Consultant will audit unit medication carts when onsite monthly for expired medications. Quality Assurance Monitoring: - The Director of Nursing developed a tool to audit all medication rooms and medication carts. - Audits will be performed by the Director of Nursing/designee. - Audits will be performed on all Medication Carts and Medication Rooms, bi-weekly for 3 months, then monthly thereafter, until 95% accuracy is achieved. - The Director of Nursing will maintain a list of negative findings and any corrective actions taken including but not limited to immediate reporting to the Administrator/designee, re-education of involved staff and progressive disciplinary actions. - Audit findings will be reviewed and presented to the QAPI Committee at least quarterly for needed revisions in the action plan, and improvement of our delivery and resident outcomes. - The lesson plan for this plan of correction will be included in the facility’s orientation and annual training of all Nurses. Responsible Party: Director of Nursing
Expired Food Storage Deficiency
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. During an initial tour of the kitchen, surveyors found multiple cans of expired beef stew in the emergency food storage and expired frozen omelets in the kitchen freezer. The facility's undated food storage policy requires that all stock be rotated with each new order received, using the First in - First out method, and that food be dated as it is placed on shelves. However, the Assistant Food Manager admitted during an interview that the expired food was an oversight and that they did not check the dates during rounds.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - All expired food was immediately removed and discarded. - Assistant Food Manager and Food Manager doubled check all emergency food storage for expired food. - Assistant Food Manager and Food Manager was re-educated on the food storage safety policy. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - The Compliance Officer reviewed the food storage safety policy on [DATE] and no modifications were made. The policy and procedure align with the standardized state and regulatory requirements. - The Compliance Officer in-serviced all kitchen staff on [DATE] on the food storage safety policy. - In order to improve our current intake monitoring system, we are implementing a check and balances rotation checkup form, which will consist of cataloging our inventory with the dates in which everything was received, contrasted with the expiration date on said products. Quality Assurance Monitoring: - Food Manager and Assistant Food Manager will audit the emergency food storage biweekly for 3 months, thereafter monthly. - All findings and/or deficiencies will be highlighted during the QAPI monthly meetings. - Audit tool was created and implemented for ongoing monitoring. Responsible Party: Food Manager/ Assistant Food Manager
Failure to Respect Resident's Right to Refuse Care
Penalty
Summary
The facility failed to respect and facilitate a resident's right to self-determination, specifically regarding the refusal of care by Resident #43. The resident, who had intact cognition and was dependent on staff for personal hygiene and other activities of daily living, reported an incident where their choice to refuse care was not respected. On one occasion, Certified Nursing Assistant #2 forcefully provided care despite the resident's refusal, which included removing the resident's covers and incontinence briefs against their will. This incident was reported by the resident to the administration, highlighting a breach in respecting the resident's autonomy and choice. The facility's policy on resident rights emphasizes the importance of self-determination and respect for resident choices. However, during the survey, it was found that the staff did not adhere to this policy. Certified Nursing Assistant #2 admitted to forcing care due to concerns about the resident's skin integrity but failed to report the resident's refusal to the nursing staff. Interviews with other staff members, including a Licensed Practical Nurse and a Registered Nurse, indicated that the proper protocol would have been to report the refusal and attempt to offer care later. The Director of Nursing and the Administrator acknowledged the grievance filed by the resident and reiterated the importance of respecting residents' rights to refuse care.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Administrator held an audio conference with the Director of Nursing, Assistant Director of Nursing, and Compliance Officer on 12/06/2024 to review the current facility's policy titled Resident's Bill of Rights dated 10/2022; and strategize on maintaining fidelity during residents’ refusal of care to assure that all residents are guaranteed the right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration, and privacy in treatment and care while at the facility. The policy remains intact. - The Facility Administrator and Director of Nursing issued a memorandum on 12/06/2024 to resident #43, and all other residents and care unit representatives to reassure their bill of rights while at the facility in accordance with CFR(s): 483.10(f)(1)-(3)(8). Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - Resident #43 was interviewed on 12/09/2024 by the Director of Social Services to identify/address any additional grievances. Resident #43 did not have any additional grievances and requested to remain at the facility. - RN #2, LPN #2, CNA #2, and all other direct resident care nursing staff including the Interdisciplinary team were re-in-serviced on Resident Bill of Rights and Refusal of Care & Non-Adherence to Care Plan from 12/09/2024 to 12/12/2024 by the ADON. - From 12/09/2024 to 12/21/2024, the DON and RN Managers reviewed the nursing notes in Sigma care for all residents during the period of 08.2024 – 12.2024 to identify any refusal of care and reconciliation outline. No additional defective practice was identified. RN Managers and DON will observe ADLs (change of linens, grooming, etc.) for residents 2x per week over the next eight weeks. Quality Assurance Monitoring: - An audit tool has been created and implemented for ongoing monitoring. - The Director of Nursing Services will perform weekly audits for randomized resident(s) for the next 4 months, then quarterly thereafter to sustain 100% compliance. Defective Practices will be reported to the compliance team and findings presented to the quarterly QAPI team meetings. Responsible Party: Director of Nursing
Inconsistent Oxygen Therapy and Lack of Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for a resident diagnosed with Chronic Obstructive Pulmonary Disease, Hypertension, and Chronic Kidney Disease. The resident was observed receiving oxygen at a flow rate of 5 liters per minute, which was not consistent with the physician's order of 3 to 4 liters per minute. This discrepancy was noted over several days, and there was no documented evidence in the electronic medical record of a physician's order to increase the oxygen flow rate. Additionally, the facility did not document when the oxygen tubing was last changed for the resident, as required by their policy. Licensed Practical Nurses and the Registered Nurse were unaware of the change in oxygen flow rate and could not provide information on when the tubing was last changed. The Director of Nursing Service confirmed that oxygen should be administered as per the physician's order and that tubing should be changed weekly and dated, but this was not being documented in the medical record.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: - The DON and ADON on 12/04/2024 and 12/05/2024 immediately assessed and informed resident #36 and all other applicable residents to ensure they were receiving oxygen at the correct flow rate or replace any oxygen tubing as outlined in the physician’s order. The IDT team simultaneously reviewed resident #36 care plans and checked for any adverse effects due to the incorrect flow rate. - The Physician Assistant performed a general evaluation on 12.05.2024 to identify any symptomatic or chief complaints as a result of the error. No adverse effects were identified as of 01/02/2024. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - The Facility’s Policy and Procedure titled Oxygen therapy was reviewed by the IDT team on 12/12/2024. No amendments were made. - The compliance team and DON created and enforced the respiratory care policies dated 12/12/2024 to include verification of oxygen flow rates against physician orders [REDACTED], scheduled changes of oxygen tubing with proper documentation and labeling. - As of 01/02/2024, 100% direct nursing care staff (RNs and LPNs) were in-serviced on the respiratory care policy, ensuring oxygen flow rates align with physician orders [REDACTED]. - Audit tool created. Quality Assurance Monitoring: - The ADON will perform weekly audits for the first month, then monthly thereafter. Audit results will be reviewed in monthly QAPI meetings to assess compliance and determine if further action is necessary. Responsible Party: Assistant Director of Nursing Services
Infection Preventionist Lacks Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed the required specialized training in infection prevention and control. This deficiency was identified during a recertification survey conducted from December 2, 2024, to December 9, 2024. The review of the Infection Control Task revealed that the Infection Preventionist, who had been in the role since early 2023, did not have documented evidence of completing the necessary specialized training. The facility's job description for the Infection Preventionist clearly stated that the candidate must have completed such training, yet the only documentation provided was a certificate in Infection Control and Barrier Precautions with four contact hours dated February 28, 2023, which did not meet the specialized training requirement. Interviews conducted during the survey further highlighted the lack of awareness regarding the training requirement among the facility's leadership. The Infection Preventionist, Director of Nursing, and Administrator all stated they were unaware of the specialized training requirement for the role. The Infection Preventionist assumed the position without the necessary training, and the Director of Nursing and Administrator were not informed of this requirement, leading to the deficiency in the facility's infection prevention and control program.
Plan Of Correction
Plan of Correction: Approved January 7, 2025 Immediate Corrective Action: - Assistant DON (Infection Preventionist) successfully completed the specialized training in infection prevention on 12/03/24. - In addition, we will continue the support of The Infection Control Preventionist from our Nurse Practitioner who provides additional onsite support. - DON and Assistant DON was re-educated on the Infection Preventionist policy and procedure. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - Compliance Officer reviewed and revised the Infection Preventionist job description and policy and procedure on 12/05/24. - DON, ADON and NP were in-serviced on the revised job description and policy and procedure on 12/10/24. - ADON and Nurse Practitioner will actively participate in IPRO QIN QIO that offers free access to AHCA/NCAL’s Infection Preventionist Specialized Training (IPCO). - Audit tool has been created and put into place for ongoing compliance monitoring. Quality Assurance Monitoring: - Infection Preventionist is a member of the facility’s QAA Committee. The Infection Preventionist routinely report to the QAA Committee on the facility’s IPCP. - Audit tool has been created and put into place for ongoing compliance monitoring. - The Director of Nursing will conduct auditing and monitoring to ensure surveillance and monitoring of active infections in the facility is being implemented, and the ADON (Infection Preventionist) is receiving specialized education and training. After 4 weeks of weekly monitoring and demonstrating that expectations are being met, monitoring will reduce to twice monthly for one month. Monthly monitoring will continue at a minimum for 2 months. Responsible Party: - Assistant DON and Nurse Practitioner
Non-compliance with Power Strip Regulations
Penalty
Summary
The facility failed to ensure the use of approved UL listed power strips, as observed during a life safety code survey. On the third floor lounge area, a Christmas tree was found plugged into an unapproved power strip. This observation was made on one out of four units, indicating non-compliance with specific NFPA codes.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and Facility Supervisor on 12.03.2024 removed the unapproved power strip on the third floor of the facility. A Christmas tree was plugged into the extension cord and as such, required a direct outlet. The Maintenance team rectified this deficiency as of 12.04.2024. The Senior Administrator and Quality Improvement team issued a memorandum on 12.03.2024 to the Maintenance Director and facility team regarding power strips in accordance to CMS K-Tag 920. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance team are now mandated to have biannual Life Safety Code checklist in-services. The maintenance and facilities supervisor will conduct daily (M-F) maintenance walk-through ensuring existing UL power strips are installed as outlined in K-Tag-920. Quality Assurance Monitoring: The Facility supervisor will audit the daily test logs, monthly test reports and complete the quarterly internal tracker -K category to ensure compliance with the required Life Safety Code lists. Any deficiency identified for K-Tag 920 will be rectified immediately and subjected to quarterly internal audit by the quality assurance unit until substantial measures are enacted. Responsible Party: Facility Supervisor
Deficient Lighting in Egress Path
Penalty
Summary
The facility failed to ensure that the lighting in the path of egress was fully functional. During a life safety code survey, it was observed that the egress path in a stairwell leading to Anthony Avenue had two lighting tubes that were only partially illuminated. This issue was noted on one out of four units. The observation was made on two consecutive days, and the Maintenance Director was informed immediately after the finding.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and Facilities Supervisor on 12.04.2024 effectively replaced the two identified lightbulbs/lighting tubes that were partially illuminated in stairwell egress to (NAME) Avenue - in accordance with NFPA 101 section 7.9. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Maintenance Director and facility team were re-in-serviced on 12.09.2024 for state requirements regarding Means of Egress and TAG K-291: Emergency Lighting specificities by the compliance officer. The Maintenance Director will continue to perform Monthly emergency Lights test - 30 seconds per month hold button; and annual checks of 90 minutes unplugged. In addition, the maintenance team are now required to observe, record and ensure the path of egress is functionally illuminated during daily environmental rounds. Quality Assurance Monitoring: The Maintenance Director will complete the updated daily compliance facilities testing tracker and immediately provide replacement or work order(s) for TAG K291 on the tracker in the event illumination is affected. The Internal Record of Inspection and Testing reports are then reviewed by the facilities Manager and the compliance team. Any deficient practice/findings will be reported for reconciliation during the QA monthly meetings. Responsible Party: Maintenance Director
Improper Latching of Soiled Utility Room Door
Penalty
Summary
The facility failed to ensure that a hazardous area door, specifically the soiled utility room door on the fourth floor, latched completely in its frame. This deficiency was observed during a life safety survey conducted on December 3rd and 4th, 2024, between 09:30 am and 02:30 pm. On December 3rd, at approximately 10:43 am, the door to room 425 was tested and found not to latch properly. During an interview, the maintenance director acknowledged the issue and indicated it would be corrected immediately.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Corrective Action: The Maintenance Director and facility team on 12.03.2024 adjusted the hinges on the door for the Soiled Utility Room (RM-425) that failed to latch in its frame. The facility team on 12.04.2024 successfully completed and tested the requested work order from the Senior Administrator to ensure the Hazardous Area – (RM-425) designated as the Soiled Utility Room was equipped with a door that properly latched. Identification of Others Potentially Affected: The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: The Compliance Officer has updated the daily compliance facilities testing tracker to identify hazardous areas that are artificially propped open or inoperable to latch in its frame. The facility supervisor will observe and test the latches within Hazardous areas during the daily (M-F) maintenance rounds. Any discrepancies will be logged and immediate work order(s) submitted for approval by the executive team. Quality Assurance Monitoring: The Maintenance Director will conduct weekly review/reconciliation on the test logs, monthly test reports and vendor reports to ensure complete compliance with the required Life Safety Code testing lists. Any maintenance/testing that is required will be documented and subjected to quarterly internal audit by the quality assurance unit. Responsible Party: Maintenance Director
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate assessments for four residents during a recertification survey. For three residents, antiviral medications were incorrectly documented as antibiotics in the Minimum Data Set (MDS) assessments. This error was attributed to the electronic medical record system, which automatically classified antivirals as antibiotics. Interviews with the Nurse Unit Manager, MDS Coordinator, and Director of Nursing revealed a misunderstanding of the classification of antiviral medications, which was not aligned with the Resident Assessment Instrument manual or Centers for Medicare and Medicaid Services guidelines. Additionally, the assessment for another resident inaccurately documented a diagnosis of Non-Alzheimer's Dementia, despite the resident having no such diagnosis in their medical records. The resident was noted to have mild cognitive impairment but was alert and oriented. The error was made by the Nurse Unit Manager, who checked off the dementia diagnosis in the MDS assessment. Interviews with the Physician Assistant and Director of Nursing confirmed the absence of a dementia diagnosis in the resident's medical records.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action: -The MDS coordinator on 12/06/2024 corrected immediately the deficiencies identified to accurately reflect the residents’ clinical diagnoses. The antibiotic checkbox was unticked for Resident #1, Resident #36, and Resident #42, and the corrected MDS was re-submitted to CMS. The MDS for the affected resident #54 was also immediately reviewed, corrected to remove the non-Alzheimer’s dementia diagnosis, and re-submitted to CMS. The error did not affect the residents’ quality of care at the facility. -The DON on 12/06/2024 held an IDT team huddle with the facility’s physician, physician assistant #1, unit RN managers, and individually informed the affected residents of the coding error and the corrective actions taken. -The IDT team from 12/06/2024 to 12/11/2024 performed due diligence in assuring that no care plan changes or interventions were affected by the incorrect coding, and no adverse impact occurred. No additional residents were inaccurately documented during the prior MDS submissions from 08/2024 to 11/2024. -The Compliance team on 12/12/2024 reviewed the facility’s Minimum Data Set Functional Coding Policy. No amendments were needed. Identification of Others Potentially Affected: -The facility respectfully submits all residents were potentially affected by this practice, after reviewing MDS records. System Changes to Prevent Recurrence: -The MDS coordinator was re-in-serviced on proper Section N (Medications) coding procedures, emphasizing accuracy and review processes. Training included the importance of cross-referencing the MAR indicated [REDACTED] facilitated by the compliance officer. In addition, training was also provided for proper coding for Section I (Active Diagnoses), including verifying [DIAGNOSES REDACTED] resident’s medical record before coding. -Subsequent to a root cause analysis, the Administrator contacted the MDS software vendor on 12/10/2024 to address the automated logic or interface issues causing incorrect antibiotic selection. Thus, implementing software updates or adjustments to prevent related errors. -The DON on 12/10/2024 instituted a secondary review process for all MDS submissions: A designated staff member (Senior RN Manager or ADON) will verify accuracy before all submission. Quality Assurance Monitoring: -The DON will conduct weekly audits of 10% of MDS submissions for the next 90 days to ensure accuracy in functional coding, with special focus on Section I and Section N. Findings will be reviewed during monthly QA meetings, and adjustments to processes will be made as necessary. -The Performance Metrics is set at a goal of 100% compliance with accurate MDS coding. Any errors identified during audits will be addressed immediately. -Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator
Failure to Provide Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries, as required by Medicare guidelines. This deficiency was identified during a recertification survey, where it was found that two residents, who were receiving Medicare Part A Skilled Services, were not given the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN- form CMS-10055) upon the termination of their Medicare benefits. The facility's policy mandates the issuance of this notice to inform residents of potential liability for services not covered by Medicare, but there was no documented evidence that the notice was provided to the affected residents. Interviews conducted during the survey revealed that the Minimum Data Set Coordinator, who is responsible for informing residents about their Medicare coverage, was unaware of the requirement to issue the SNF ABN. The Director of Nursing Services stated that they were not involved in the beneficiary notification process, which is handled by the Minimum Data Set Coordinator. This lack of awareness and communication within the facility led to the failure to provide the necessary notices to the residents, resulting in a deficiency under the regulation 10 NYCRR 415.3(h)(2)(i).
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Facility Administrator on 12/09/2024 issued the Minimum Data Set Coordinator a memorandum regarding Medicaid/Medicare Coverage/Liability Notice and updated protocols for ensuring residents are aware of their rights. - An Adhoc meeting was held by the DON on 12/09/2024 with the MDS coordinator and Compliance Officer to review and discuss the notification process and policy. No amendments were made to the policy. Resident #24 and Resident #36 were individually notified at the conclusion of the meeting regarding the ineffective notification and the facility’s commitment to minimizing these deficiencies. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. A list of other residents that remained in the facility and were discharged from a MCR Part A stay were reviewed and will be given the SNFABN as appropriate. Systemic Changes to Prevent Recurrence: - The Compliance officer and DON formulated and reinstated the protocol and procedure for Medicaid/Medicare Coverage/Liability Notification on 12.10.2024. - The MDS coordinator and RN Managers were re-in-serviced on 12.12.2024 by DON for the protocols and procedures regarding NOTIFYING RESIDENTS OF MEDICAID/MEDICARE COVERAGE OR LIABILITY. Quality Assurance Monitoring: - The Minimum Data Set Coordinator will perform weekly audits for residents for the next 2 months, then monthly thereafter to maintain compliance. Any discrepancies identified during the audit will be reported and documented to the DON. The qualitative summary and analytics will be presented quarterly at the QAPI team meetings. - Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator
Delayed Reporting of Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the New York State Department of Health within the required timeframe. The incident involved a resident with a diagnosis of persistent mood disorder and aphasia, who reported verbal abuse by a Certified Nursing Assistant. The resident, who has intact cognitive status and uses a wheelchair, reported the incident to the Social Worker a week after it allegedly occurred. The Social Worker then placed the grievance in the Director of Nursing's mailbox, which was not checked until two days later, resulting in a delayed report to the Department of Health. The facility's policy mandates immediate reporting of any alleged abuse to the administrator and relevant authorities. However, the Social Worker did not follow this protocol, leading to a late notification to the Department of Health. Interviews with the Director of Social Services, Director of Nursing, and the Administrator confirmed the delay and acknowledged that the Social Worker should have reported the incident immediately via phone or in person. Attempts to contact the Social Worker for further clarification were unsuccessful.
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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