Champlain Valley Physicians Hosp Med Ctr S N F
Inspection history, citations, penalties and survey trends for this long-term care facility in Plattsburgh, New York.
- Location
- 75 Beekman Street, Plattsburgh, New York 12901
- CMS Provider Number
- 335442
- Inspections on file
- 10
- Latest survey
- January 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Champlain Valley Physicians Hosp Med Ctr S N F during CMS and state inspections, most recent first.
The facility's emergency preparedness plan was found deficient as it lacked documentation on resident populations at risk during emergencies and the services to address their vulnerabilities. The plan did not identify the resident population, strategies for their needs, or how to maintain continuity of care during emergencies. This deficiency could affect all residents. The Director of Emergency Management acknowledged the need for updates.
The facility did not ensure that 18 of 63 staff received annual training in emergency preparedness policies and procedures, as identified during a recertification survey. There was no documented evidence of training completion for these staff members, which could affect all residents. A registered nurse acknowledged the issue and planned to consult with the Organizational Development Coordinator.
The facility failed to provide emergency lighting in the activities room and dining room, as required by NFPA 101 Life Safety Code. The absence of automatic emergency lighting along the means of egress was confirmed by the Associate Vice President of Patient Care Operations, who stated that installation would occur in the skilled nursing unit.
The facility's emergency preparedness plan was found deficient as it did not include strategies for addressing the loss of call bell, loss of emergency generator, and cyber-attack. This was identified during a recertification survey through record review and an interview with the Director of Emergency Management and Life Safety.
A facility failed to protect residents from abuse and neglect, resulting in incidents involving three residents. A resident with quadriplegia reported wrist twisting by a nurse, leading to bruising. Another resident with dementia fell due to a lack of required assistance and bed bolster, and a third resident suffered a skin tear when a CNA failed to follow the care plan for resistive behavior. These incidents highlight the facility's failure to adhere to care plans and protect residents' rights.
The facility was cited for not marking empty oxygen cylinders in the Clean Supply room as required by NFPA 99 standards. During a survey, it was observed that four empty cylinders were unmarked, and an LPN confirmed the status of three tanks. This non-compliance was noted during a recertification survey.
The facility did not provide required training on the risks and proper handling of pressurized oxygen cylinders to 19 out of 63 employees, including those in the physical therapy and medical treatment sections, as per NFPA 99 standards. This deficiency was identified during a recertification survey through record review and staff interviews.
A resident with impaired vision and cognitive intactness did not receive optometry consultations or a care plan for vision needs. Despite using corrective lenses, there were no records of optometry visits since admission. The resident expressed the need for a new prescription, and a nurse confirmed the absence of an eye doctor visit, stating a request was made to add the resident to the optometry list.
The facility did not adhere to professional standards for food service safety, as cleaning chemicals were improperly stored, equipment was not maintained, and proper testing equipment for sanitizing solutions was unavailable. Additionally, certain areas were found to be unclean, and the administrator acknowledged these issues.
A facility failed to report an alleged physical abuse incident involving a resident with dementia within the required 2-hour timeframe. The incident, which resulted in a skin tear, was observed by staff but not reported to the New York State Department of Health until the following day. The facility's administrator acknowledged the delay in reporting, which violated the facility's policy on timely reporting of incidents involving bodily injury.
A facility failed to immediately remove a CNA from resident care following an abuse allegation involving a resident with dementia. The CNA, who did not follow the care plan requiring two staff during behavioral episodes, caused a skin tear on the resident's hand. Despite the incident being documented, the CNA continued working until the end of their shift, and the incident was not promptly reported to the Administrator or DON.
A resident with dementia and epilepsy, requiring two-person assistance, fell out of bed when a CNA provided care alone without using a bed bolster, contrary to the care plan. The incident was witnessed, and the CNA confirmed acting alone. No injuries were reported.
The facility did not have a facility Authorized Person sign the necessary forms for criminal history checks before requesting them for five new employees, including a CNA and three Nutrition Service Workers, as required by regulations.
Two residents experienced delayed reporting of abuse allegations in an LTC facility. One resident with cognitive impairment was allegedly struck by a CNA, while another resident faced inappropriate behavior from a different CNA. In both cases, the witnessing CNA delayed reporting due to fear of retaliation and uncertainty about the process, leading to a failure to meet the facility's immediate reporting policy.
Emergency Preparedness Plan Lacks Critical Resident Information
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. The deficiency was identified through a record review, which revealed that the facility's emergency plan, dated 03/31/2024, lacked documentation regarding the resident populations at risk during an emergency and the specific services in place to address their unique vulnerabilities. The plan did not include identification of the resident population served, strategies to address their needs, a description of services the facility could provide during an emergency, or how continuity of care would be maintained to protect residents' health and safety if normal operations were disrupted. This deficiency could potentially affect all residents at the facility. During an interview, the Director of Emergency Management and Life Safety acknowledged the need to update the emergency preparedness plan to include this critical information.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 1. Champlain Valley Physicians Hospital will revise that the Emergency Operations Plan includes all Skilled Nursing Unit residents and addresses the unique needs of the population. A. Strategies the facility had put in place to address the needs of the population, B. Description of the types of services the facility could provide in the event of an emergency, and C. How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. Review will be conducted by (MONTH) 15, 2025. 2. All skilled nursing facility residents have the potential to be affected by alleged deficient practice. 3. The Skilled Nursing Facility staff will be educated on the revised Emergency Operations Plan annually and as needed. 4. The Director of Emergency Management will conduct one policy audit per quarter, and as needed, to confirm: - Identification of the resident population served and their unique needs, - Strategies the facility had put in place to address the needs of the population, - Description of the types of services the facility could provide in the event of an emergency, and - How the facility would maintain continuity of care to their client population to adequately protect their health and safety in the event of limitations or cessation of normal operations during an emergency. All revisions to the Emergency Operations Plan will be reviewed at Skilled Nursing Facility Quality Assurance Committee for recommendations and approval. 5. Director of Life Safety & Emergency Management.
Emergency Preparedness Training Deficiency
Penalty
Summary
The facility failed to ensure that 18 out of 63 staff members received annual training in emergency preparedness policies and procedures. This deficiency was identified during a recertification survey through record review and interviews. There was no documented evidence to confirm that these staff members had completed the required training in the emergency plan. During an interview, a registered nurse acknowledged the oversight and mentioned consulting with the Organizational Development Coordinator to address the training gap. This deficiency could potentially affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 1. There were eighteen (18) staff identified as not having completed annual Emergency Preparedness Education. B. Any staff member who was identified as incomplete will complete the annual Emergency Preparedness Training prior to 3/04/2025. Any staff who did not complete the Emergency Preparedness Training by 03/04/2025 will be removed from the schedule and unable to work on Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. B. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Organizational Development Coordinator will run completion reports. An Educational report for completion status of the Emergency Preparedness Training will be reviewed monthly to ensure all staff are compliant with Emergency Preparedness Training. 4. Completion report of the Emergency Preparedness Training will be reviewed at the monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee
Deficiency in Emergency Lighting in Resident Areas
Penalty
Summary
The facility was found to be deficient in providing emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8. During a recertification survey, it was observed that the activities room and dining room did not have emergency lighting that would operate automatically without manual intervention along the means of egress to the public way. This deficiency was confirmed during an interview with the Associate Vice President of Patient Care Operations, who acknowledged the absence of emergency lighting in these areas and stated that it would be installed in the skilled nursing unit.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 1. Lighting controls within the Dining and Activity rooms will be changed to maintain constant illumination within the Dining and Activity Room per NFPA 101: 7.8. Specific fixtures identified will be connected to emergency power circuits. 2. Facilities will verify the lights operate continuously and cannot be turned off with a wall switch. Facilities will survey all other areas of the Skilled Nursing Unit and the adjacent, 5 Main East wing to verify that the emergency lighting system conditions are in compliance with NFPA 101: 7.8. This survey will be completed by (MONTH) 10, 2025. 3. The Environment of Care Checklist will be modified to include evaluation of emergency lighting to ensure conformance with NFPA 101: 7.8. This will be completed by (MONTH) 10, 2025. 4. The Facility currently conducts checks of all emergency lighting on the Skilled Nursing Unit on a monthly frequency. Documentation is maintained by Facilities. 5. Associated Vice President of Facilities
Emergency Preparedness Plan Lacks Key Strategies
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. Specifically, the facility's emergency preparedness plan lacked documented strategies for addressing certain emergency events identified in the facility's risk assessment. These missing strategies included plans for the loss of call bell, loss of emergency generator, and cyber-attack. This deficiency was identified through record review and an interview with the Director of Emergency Management and Life Safety, who acknowledged the absence of these plans in the emergency preparedness documentation.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 1. The Emergency Preparedness Plan will be reviewed and revised. B. The Emergency Preparedness plan will be revised to include response actions that address loss of generator, loss of nurse call, cyber-attack, and missing residents specific to the Skilled Nursing Facility. Review of the Emergency Preparedness Plan will be complete by (MONTH) 15, 2025. 2. The skilled nursing facility will review and revise the Emergency Operations Plan to ensure compliance with all emergency preparedness requirements. 3. The Skilled Nursing Facility staff will be educated on the policies for loss of generator, loss of nurse call, cyber-attack, and missing residents on an annual basis and with any changes to the Emergency Preparedness plan. 4. The Director of Life Safety and Emergency Preparedness Plan will review the Emergency plan annually at a minimum and as needed to ensure all emergency events in the facility risk assessment are addressed. B. The Emergency Preparedness plan will be presented quarterly at the skilled nursing facility Quality Assurance and Performance Improvement committee and as needed for approval. 5. The Director of Life Safety & Emergency Management.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect Resident #1 from abuse when a staff member, Registered Nurse #2, allegedly twisted the resident's wrist and removed their call light. Resident #1, who has quadriplegia and is cognitively intact, reported the incident, which resulted in a reddened area and bruising on their wrist. The care plan for Resident #1 included ensuring the call bell was within reach and temporarily interrupting care if the resident became verbally abusive, which was not followed by the staff member involved. Resident #14, who has severe cognitive impairment due to dementia, experienced neglect when a Certified Nurse Aide provided care without the required assistance of a second staff member, as outlined in the resident's care plan. This neglect led to a fall from the bed because the bed bolster was not in place, although no injuries were reported. The care plan specified the use of posey rolls and a two-person assist for bed mobility, which were not adhered to during the incident. Resident #23, also severely cognitively impaired, suffered a skin tear on their hand due to the actions of Certified Nurse Aide #3, who failed to follow the care plan requiring two staff members to assist when the resident was resistive to care. The aide was observed grabbing the resident's hands, leading to the injury. The care plan emphasized allowing time for the resident to de-escalate and re-approaching if agitated, which was not followed, resulting in the resident's injury.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #1 had a skin check completed by registered nurse. Skin check revealed reddened area to wrist on 6/23/2024. Director of Nursing was notified on 6/23/2024. Administrator was notified per policy on 6/23/2024. Registered Nurse #2 was immediately placed on administrative leave and removed from facility pending investigation on 6/23/2024. Department of Health notified on 6/23/2024. Provider ordered diagnostic studies on 6/24/2024 which revealed no fractures. Registered Nurse #2 was terminated from employment on 6/26/2024 and Office of Professions notified of incident. B. Resident #14 had a recorded witnessed fall on 12/22/2024 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024. Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024. Resident #14 sent to emergency room on [DATE] and returned on 12/22/2024 with no findings. Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. C. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024. Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024. Registered Nurse #4 was educated/reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. Certified Nurse Assistant was placed on administrative leave on 12/25/2024. Certified Nurse Assistant was terminated on 12/27/2024. 2. Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency. A review of all residents with behavior care plans was completed on 02/21/2025. One additional resident was identified as requiring 2 assists with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention, Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18, 2025. Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. The Abuse Reporting and Investigation policy was reviewed on 2/10/2025 with no changes. C. There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee.
Unmarked Empty Oxygen Cylinders in Clean Supply Room
Penalty
Summary
The facility failed to protect pressurized oxygen cylinders in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition. During an observation, four empty oxygen cylinders in the Clean Supply room were not marked as required. A Licensed Practical Nurse confirmed that three of the oxygen tanks in the unmarked rack were empty. This deficiency was identified during a recertification survey, and the facility was found to be non-compliant with the relevant regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were four (4) oxygen cylinders identified in the alleged deficient practice. B. The oxygen tank racks were inspected, and empty cylinders were moved to the empty cylinder rack at the time of the survey. C. Signage on the racks was updated to reflect the clean and empty racks and signs were secured to racks. 2. All residents with Oxygen Orders have the potential to be affected by this alleged deficient practice. B. All Current Skilled Nursing Facility staff will be educated on Compressed Gas. The Compressed Gas Training includes proper storage and placement of Oxygen Cylinders. C. All other staff working in the Skilled Nursing Facility will be reviewed for required completion and those who have not, will receive the training. 3. The Day shift Charge Nurse will complete daily inspection of compressed gas racks on the Skilled Nursing Unit to ensure signage is in place and cylinders are suitably stored. The inspection will be documented on the Environment of Care log. 4. Scheduled [MEDICATION NAME] and Environment of Care rounds are in place to document compliance with compressed gas storage. B. Results of daily Compressed Gas Storage and monthly Environmental Rounds will be reviewed at the monthly Quality Assurance Performance Improvement Committee for further recommendations. 5. Associate Vice President of Facilities.
Deficiency in Oxygen Cylinder Handling Training
Penalty
Summary
The facility failed to manage pressurized oxygen cylinders in accordance with the National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities 2012 Edition section 11.5.2.1. Specifically, 19 out of 63 employees who handle oxygen cylinders did not receive the required education on the risks associated with their handling and use. This deficiency was identified through record review and interviews during a recertification survey. It was noted that there was no documented evidence of periodic training for these employees, including those working in the physical therapy department and the medical treatment section. A registered nurse confirmed that staff in these areas had not received the necessary training on the risks and proper handling of oxygen cylinders.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. There were nineteen (19) staff identified as not having completed annual Compressed Gas Education. B. Any staff member who was identified as incomplete including staff in [MEDICAL TREATMENT] and Physical Therapy will complete the annual Compressed Gas Training prior to 3/04/2025. C. Any staff who did not complete the Compressed Gas Training by 03/04/2025 will be removed from the schedule and unable to work on the Skilled Nursing Unit until verification of completion. 2. All residents of the Skilled Nursing Facility have the potential to be affected by this alleged deficient practice. 3. The Organizational Development Coordinator will provide an Education report for completion status of the Compressed Gas Training. This will be reviewed monthly to ensure all staff of the Skilled Nursing Facility are compliant with Compressed Gas Training. Education will be documented in the facility electronic education software or on the education sign-in sheet. Staff who are not compliant will be removed from the schedule until verification of completion. All other staff working in the Skilled Nursing Facility will be reviewed for the required training, and those that have not will receive the training. 4. Completion Report of the Compressed Gas will be audited monthly, with audit results reviewed at the Monthly Quality Assurance Performance Improvement Committee for recommendations. Responsible Party - Director of Nursing / Designee
Failure to Provide Vision Services for a Resident
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain the vision ability for a resident with impaired vision. The resident, who was admitted with chronic obstructive pulmonary disease, hypertension, and dementia, was documented as being cognitively intact and using corrective lenses. However, there were no records of optometry consultations or a comprehensive care plan addressing the resident's vision needs. During interviews, the resident expressed the need for a new prescription and confirmed not having seen an eye doctor since admission. A registered nurse acknowledged the lack of an optometry consultation and stated that a request had been made to place the resident on the optometry list.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. Resident #28 A. An eye examination is scheduled for (MONTH) 14, 2025. 2. Other residents with visual deficits have the potential to be affected by this alleged deficient practice. A full house audit of all residents was completed on 2/18/2025 by the Intake Manager to identify residents with visual impairment. Each current resident identified as having visual impairment was offered an eye examination on 2/21/2025. The resident representative was contacted for all residents identified with visual impairment, who cannot make their own decisions on 2/21/2025. There were 15 additional residents identified with visual impairment whose last eye exam was over 1 year. 5 of the 15 residents and the other 10 declined. 3. The policy Vision and Hearing was created by the Director of Nursing on 2/18/2025. The Vision and Hearing Policy will include required consult documentation and comprehensive care plan development for Vision and hearing. B. All Nursing staff and the administrator will be educated on the Vision and Hearing Policy. Staff will complete a written post test to ensure comprehension of the policy. Education will be completed prior to 3/4/2025. 4. All current resident's Minimum Data Set Assessments will be reviewed to identify vision and or hearing needs. Residents identified as having vision or hearing needs will have consultations scheduled and upon admission for new residents then as needed. 5. A monthly audit will be completed for all residents to ensure vision appointments have been offered per policy. All Audit results will be reported to the monthly Quality Committee until three consecutive months of compliance is achieved then at the direction of the committee. 6. Director of Nursing / Designee
Deficiencies in Food Service Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations, it was noted that cleaning chemicals, specifically glass cleaner, were improperly stored above a food processor. Additionally, the warewashing area had a spray hose nozzle hanging below the sink flood rim, which was in contact with water, posing a risk of back-siphonage. The facility lacked the correct test papers to accurately measure the concentration of the sanitizing solution, as the available test papers did not show the required range of 150 to 400 parts per million of quaternary ammonium compound, as specified by the sanitizer concentrate label. Furthermore, the deli station's reach-down refrigerator door gasket was split and uncleanable, and various areas, including the underside of the floor mixer and floors under the baker's worktable and sink, were soiled with food particles or dirt. During an interview, the facility's administrator acknowledged the issues identified, including the improper storage of glass cleaner, the absence of appropriate sanitizer test papers, the spray hose's potential for back-siphonage, and the need for cleaning in specific areas.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 F812 (483.60) Spray hose and potential back siphonage issue with hose being too long and resting in standing pot water in pot room. 1. Work order placed by supervisor on duty 1/13/25 asking for shorter spray hose to be installed. Work order (# 5) completed on 1/19, issue permanently fixed. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the spray hose length is appropriate to prevent potential back siphonage. 3. Nutrition Services and Facilities team made aware that hose must be short and not rest in water. 4. Scheduled kitchen mock surveys in place to document compliance with spray hose length. If non-compliance is discovered a separate work order will be generated and issued to Facilities. 5. Target date for corrective action was 1/19/25. Director Nutrition Services is the responsible party. F812 (483.60) Deli Cooler Gasket was split and uncleanable. 1. Work order submitted on 1/13/25 requesting gasket replacement. Work order (# 1) completed on 1/18/25. 2. All residents have potential to be affected by this alleged deficient practice. 3. Cooler gasket checks have been added to routine cooler preventive maintenance schedule. Deli cleaning and closing checklist revised to add gasket cleaning. Deli staff will be educated on this revised cleaning list, understanding and awareness will be confirmed via employee sign off on this education. 4. Scheduled kitchen mock surveys in place to document compliance with gaskets in main kitchen, deli and SNF kitchen. If non-compliant gaskets are discovered a separate work order will be generated and issued to Facilities. 5. Target date for corrective action was 1/18/25. Director Nutrition Services is the responsible party. F812 (483.60) Incorrect sanitizer test strips used in ware washing sanitizer sink. 1. Ecolab rep called immediately and delivered a supply of QT-40 test strips in less than one hour. All Qt-10 Test strips on site were immediately discarded. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor this area to verify that the QT-40 test strips are the only strips available and in use for testing PPM of sanitizing solution. 3. Electronic order guide updated to remove QT-10 and replace with appropriate Qt-40 test strip to help prevent the inappropriate test strip from being ordered. Education developed to include manufacturer recommendations for type of test strip to be used to test sanitizer ppm as well as target ppm range. This education will be provided bi-annually. 4. Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5. Target date for corrective action was 1/13/25 when all QT-10 were discarded and steps implemented as per above. Director Nutrition Services is the responsible party. F812 (483.60) Chemicals not stored properly. Spray bottle of glass cleaner left on windowsill in food prep area near equipment. 1. Spray bottle in question immediately removed from food prep area and stored properly. Inspection of other areas of kitchen revealed no other non-compliant chem storage issues. Staff working in impacted area made aware of non-compliance and reminded of proper storage. 2. All residents have potential to be affected by this alleged deficient practice. Nutrition Service Leadership will monitor the department for compliance with proper chemical storage. 3. Nutrition Service leadership will provide initial and then bi-annual training on proper storage of chemicals. 4. Routine weekly audits x 90 days to ensure compliance. Scheduled kitchen mock surveys in place to document compliance with use of QT-40 test strips. If non-compliance is discovered, we will retrain and reimplement weekly audits to document compliance. 5. Target date for corrective actions is 90 days from survey. Director Nutrition Services is responsible party. Audits and surveys will be shared with SNF QAPI monthly. F812 (483.60) Underside of the floor mixer, floor under the baker’s worktable and bakers sink were soiled. 1. Area under baker’s worktable and pots sink was swept/cleaned immediately by staff members. Work order # 3 submitted requesting removal of the mixer assembly on the underside of the floor mixer for proper cleaning. 2. All residents have the potential to be impacted by this alleged deficient practice. 3. Daily cleaning and closing checklist to be signed off on daily by staff/leader to ensure floors are appropriately cleaned along with other equipment in this area. Mixing assembly removed at underside of floor mixer and sent for cleaning, sanding, repainting. 4. Any non-compliance found daily during cleaning sign off will be addressed in real time. Trends in non-compliance with specific staff will be reviewed weekly when cleaning lists are reviewed prior to scanning into e-file. Non-compliance will be addressed with retraining and job performance disciplines as warranted. Scheduled kitchen mock surveys in place to document compliance with workstation and mixer cleanliness. 5. Target date for corrective action is 90 days from survey. Director Nutrition Services is the responsible party. Daily cleaning sign off and surveys will be shared with SNF Quality Assurance Performance Improvement monthly meeting.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of physical abuse involving a resident within the required timeframe. On December 25, 2024, at 2:00 AM, a staff member observed a Certified Nurse Aide (CNA) improperly handling a resident, resulting in a skin tear on the resident's right hand. The resident, who was admitted with dementia, atrial fibrillation, and anxiety disorder, was severely cognitively impaired and rarely understood by others. Despite the incident being documented in an accident report, it was not reported to the New York State Department of Health until December 26, 2024, at 3:19 PM, exceeding the mandated 2-hour reporting window for incidents involving bodily injury. The facility's policy on abuse prevention, investigation, and reporting, revised in August 2024, requires that incidents resulting in bodily injury be reported within 2 hours. However, the incident was not brought to the attention of the facility's administrator until 2:30 PM on December 25, 2024, and the CNA involved was subsequently suspended. The delay in reporting was acknowledged by the administrator during an interview, who stated that they should have been informed sooner. This failure to report in a timely manner constitutes a deficiency in the facility's adherence to regulatory requirements.
Plan Of Correction
Plan of Correction: Approved February 6, 2025 1. Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand. Registered Nurse #4 applied steri strips to skin tear on right hand. Registered Nurse #4 was reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. 2. Other residents do have the potential to be affected by alleged deficiency. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff will be educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education will include a posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. C. The Abuse Prevention, Reporting and Investigation Policy was reviewed. There were no system changes as this alleged deficient practice was related to one noncompliant staff member, Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee
Failure to Immediately Remove CNA After Abuse Allegation
Penalty
Summary
The facility failed to ensure the immediate removal of a Certified Nurse Aide (CNA) from resident care following an allegation of physical abuse involving a resident with dementia, psychotic disturbance, and anxiety disorder. The incident occurred when the CNA did not adhere to the resident's Comprehensive Care Plan, which required two staff members to be present during behavioral episodes. This resulted in a skin tear on the resident's hand. Despite the incident being documented in an accident report, the CNA was allowed to continue working until the end of their shift, contrary to the facility's policy on abuse prevention and investigation. The deficiency was further compounded by a lack of timely communication and action from the Nursing Supervisor, who failed to report the incident to the Administrator or Director of Nursing immediately. The incident was only discovered during a daily review of reports, leading to a delay in the suspension of the CNA. The facility's investigation substantiated the abuse allegation, and the CNA was eventually terminated. However, the initial failure to remove the CNA from resident care and report the incident promptly constituted a breach of the resident's right to be free from potential abuse.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Resident #23. Registered Nurse #4 witnessed event and saw bleeding from right hand on 12/25/2024. Registered Nurse #4 applied steri strips to skin tear on right hand on 12/25/2024. Registered Nurse #4 was educated reeducated on The Abuse Prevention, Investigation and Reporting Policy on 12/27/2024. Certified Nurse Assistant was placed on administrative leave on 12/25/2024. Certified Nurse Assistant was terminated on 12/27/2024. 2. Other residents with cognitive impairment and who behavior care planned to require 2 assists with behaviors have the potential to be affected by alleged deficiency. A review of all residents with behavior care plans was completed on 02/21/2025. One additional resident was identified as requiring 2 assist with behaviors. Skin checks of resident were completed on skin rounds on 2/13/2025 and 2/27/2025 with no shearing or bruising noted. 3. The Administrator, nurses, certified nursing assistants, therapy staff and ancillary staff were educated on The Abuse Prevention Investigation and Reporting Policy which includes an overview of the abuse regulation, who is required to report abuse, what abuse is, how to report abuse, who to report abuse to and the required time requirements to report abuse to Department of Health, steps of the investigation process, investigation documents and investigation summary. Education was completed on (MONTH) 18 2025. Education will include a written posttest to verify employee comprehension. All new employees will be educated on The Abuse Prevention, Investigation and Reporting Policy at new employee orientation. All facility staff will be educated on The Abuse Prevention, Investigation and Reporting policy annually. The abuse Reporting and investigation policy was reviewed on 2/10/2025 with no changes. Certified Nurse Assistant #3. Employee was terminated on 12/27/2024. 4. All incident and accident reports will be reviewed daily at the daily Interdisciplinary Team Meeting to ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were immediately reported to the State Agency within the required timeframes per regulation. Director of Nursing will audit daily all incident and accident reports that required reporting to the Department of Health to ensure compliance with reporting within the required time frames and the investigation steps were followed per regulation. The results of audits will be reported to the monthly Quality Assurance Performance Improvement committee until 100% compliance is met for three consecutive months and then the Quality Assurance Performance Improvement committee will determine the need to continue monthly reporting, move to quarterly reporting or discontinue reporting. 5. Director of Nursing/Designee
Inadequate Supervision and Assistive Devices Lead to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent accidents for a resident who required two caregivers for care. Specifically, the resident, who was diagnosed with dementia, epilepsy, and major depressive disorder, was assisted by only one caregiver, and a bed bolster was not in place, resulting in the resident rolling out of bed. The resident was severely cognitively impaired and required total dependence with a two-person physical assist for bed mobility, as documented in their comprehensive care plan. An accident/incident report documented that the resident had a witnessed fall out of bed while personal care was being completed by a Certified Nurse Aide (CNA) alone, contrary to the care plan's requirement for a two-person assist. The CNA provided a written statement confirming they had provided care without additional assistance. The Director of Nursing confirmed that the CNA had received education on following the care plan to prevent accidents and injuries. The incident did not result in any injuries to the resident.
Plan Of Correction
Plan of Correction: Approved February 25, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #14 had a recorded witnessed fall on 12/22/24 from bed landing on floor mat beside bed. Certified Nurse Assistant #3 witnessed fall on 12/22/2024. Certified Nurse Assistant reported fall to Registered Nurse on 12/22/2024. Registered Nurse performed skin check and vital signs within normal limits on 12/22/2024. Provider, Manager on call and Administrator notified per state and federal guidelines on 12/22/2024. Resident #14 sent to emergency room on [DATE] and returned on 12/22/2024 with no findings. Certified Nurse Assistant was immediately removed from facility on 12/22/2024 pending investigation. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. 2. All residents who have Activity of Daily Living care plans for bed mobility requiring 2-person assistance have the potential to be affected by this alleged deficient practice. A. A review of all current residents' Activity of Daily Living care plans was completed to identify all residents requiring two-person assistance with bed mobility on 2/21/2025. B. Twelve additional residents were identified as being care planned for 2-person assist for bed mobility. C. A review of all incident and accident reports since 12/22/2024 was completed on 2/21/2025 with no other incidents/accidents attributed to bed mobility care plan violations. 3. The incident and accident policy was reviewed by the Director of Nursing with no revisions made. A. Certified Nurse Assistant was provided care plan education on 12/23/2024. The education was provided by Nurse Educator on 12/23/2024. B. All current Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, and therapy staff will be educated on Activity of Daily Living care plans to include bed mobility requiring 2 assists. C. All new Registered Nurses, Licensed Practical Nurses, Certified Nurse Assistants, and Physical Therapy staff will be educated at new employee orientation. 4. A random weekly visual audit of 10% (4) residents of the in-house census will be completed to ensure that staff are following compliance with the level of assistance identified in the care plan. A. Audit will be completed weekly by the Director of Nursing or designee and will include day, evening, and night shifts. B. Audit results will be reported to the monthly Quality Committee until 100% compliance is maintained for 3 consecutive months and then at the recommendation of the committee. 5. Responsible Party: Director of Nursing/Designee
Failure to Sign Required Forms for Criminal History Checks
Penalty
Summary
The facility failed to comply with the requirements for obtaining criminal history information for new employees, as mandated by 10 New York Codes, Rules, and Regulations section 402.5(c). Specifically, the facility did not have a facility Authorized Person sign the Acknowledgement and Consent Form for Fingerprinting and Disclosure of Criminal History Record Information before requesting criminal history record checks. This deficiency was identified for five new employees, including a Certified Nurse Aide and three Nutrition Service Workers. The lack of documented evidence of the required signatures was confirmed during a recertification survey, and the Director of Employee Relations acknowledged the oversight during an interview.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 1. No resident was affected by alleged deficient practice. 2. Other residents have the potential to be affected by alleged deficient practice. 3. All prior Criminal History Record Check forms have been audited for signature. Those without signature are being reviewed with signatory for correction. B. Workflow and Human Resource system configuration has been updated to require written signature. C. Policy updated to highlight signature requirement. Authorized Human Resource employee who completed task has been reeducated by Human Resource Director. Two additional Human Resource employees have been set up with access through Criminal History Record Check and trained by Human Resource Director to support this work. D. A check system has been put in place, completed by a second person, to ensure all forms are verified for accuracy. 4. Human Resource Director will audit 100% of completed forms for past three months and for new hires. B. The results of all audits will be presented at the monthly Skilled Nursing Facility Quality Assurance Performance Improvement for further recommendations. 5. Human Resource Director is responsible for the accuracy of the process. HR Position Coordinators are responsible for completing the task.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe. Resident #1, who had severe cognitive impairment, was allegedly struck on the hand by a Certified Nurse Aide (CNA) after the resident grabbed the aide's wrist. The incident occurred in the evening, but the CNA who witnessed it did not report it until the following morning, citing fear of retaliation and uncertainty about the reporting process. The Director of Nursing and Administrator were not informed until later, resulting in a delay in reporting the incident to the Department of Health. In another incident, Resident #3, who was cognitively intact, was allegedly subjected to inappropriate behavior by another CNA. The CNA reportedly squished their breasts together and made inappropriate comments to the resident. The witnessing CNA delayed reporting the incident due to fear of retaliation, although they eventually informed a Registered Nurse Unit Manager. The Director of Nursing confirmed that the witnessing CNA had expressed fear of retaliation as a reason for the delay in reporting. The facility's policy requires immediate reporting of abuse allegations, with a two-hour window for notifying the Department of Health in cases of serious bodily injury. However, in both cases, the staff failed to adhere to these guidelines, resulting in delayed reporting of the incidents. The facility's administration acknowledged the lapses in timely reporting and the need for staff to feel comfortable reporting such incidents without fear of retaliation.
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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