Cortland Park Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cortland, New York.
- Location
- 193 Clinton Avenue, Cortland, New York 13045
- CMS Provider Number
- 335218
- Inspections on file
- 24
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cortland Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors identified that multiple medication carts contained opened insulin pens, inhalers, and eye drops that were not labeled with open dates or resident identifiers, contrary to facility policy. LPNs reported uncertainty about when medications were opened and did not notice missing labels, resulting in the use of potentially expired or misidentified medications. The Assistant DON confirmed expectations for labeling but acknowledged confusion among staff regarding proper procedures.
A resident with muscle weakness, a spinal fracture, and dementia was repeatedly found without their call bell within reach, despite facility policy and a care plan requiring it to be accessible due to fall risk. Staff confirmed the expectation that call bells be kept within reach, but multiple observations showed the call bell on the floor and inaccessible, leading the resident to state they would yell for help if needed.
A resident with severe cognitive impairment and high fall risk experienced two unwitnessed falls in one day without timely RN assessment or medical notification, as required by facility policy. The resident's call bell was repeatedly observed out of reach, and staff failed to provide required assistance with toileting, leaving the resident unsupervised during transfers and bathroom use.
The facility failed to maintain the left walk-in cooler at a safe temperature, with food items measured between 45 to 54 degrees Fahrenheit, exceeding the required 41 degrees Fahrenheit. The facility lacked a preventative maintenance policy for the coolers, and staff did not verify thermometer accuracy by checking food temperatures. This posed a risk of bacterial growth and potential foodborne illness among residents.
The facility failed to ensure that eight emergency exit stairwell door frames had fire-rated labels, as required for safety. The Director of Maintenance was unaware of this issue, and the annual inspections conducted in 2023 and 2024 did not document the fire rating of the door frames.
The facility failed to maintain food safety standards in the main kitchen, with uncovered food in the walk-in freezer, unprotected kitchen lighting, and unclean surfaces. Observations revealed ice build-up, exposed wiring, and broken floor tiles. Interviews indicated inadequate cleaning practices and long-standing issues with lighting protection.
The facility failed to address grievances and long call bell wait times, affecting all residents reviewed. Nine residents were unaware of the grievance process, and long call bell wait times were a recurrent issue. Observations showed significant delays in call bell responses, with staff ignoring active calls. Interviews confirmed the issue was known, but solutions were ineffective.
A facility failed to maintain an effective infection control program, as evidenced by a resident's urinary drainage bag lying on the floor and a non-functional sink in a medication room. The resident, with severe cognitive impairment and an indwelling urinary catheter, had their drainage bag improperly stored, risking contamination. Additionally, the medication room sink was unusable, forcing staff to seek alternative handwashing locations. These issues were reported but not resolved, highlighting lapses in infection control practices.
The facility failed to properly label and store medications, resulting in deficiencies in medication management. Observations revealed that multiple medication carts and a storage room contained medications without proper opened or discard dates, and one cart was found unlocked and unattended. Nursing staff acknowledged the importance of labeling medications to ensure effectiveness, but the facility's procedures were not consistently followed, leading to these deficiencies.
The facility failed to provide residents with food that was palatable and served at appropriate temperatures. During meal observations, hot food items were below the required 135°F, and cold items were above 41°F. Residents and staff reported dissatisfaction with the food quality, leading some residents to order food from outside. The Corporate Regional Director confirmed the food temperatures were not acceptable.
The facility failed to maintain a safe, clean, and homelike environment in several resident units, with issues such as missing paint, unpainted patched holes, and missing door thresholds. Staff interviews revealed a lack of awareness and communication regarding these issues, and the facility's work order system was not effectively utilized to address maintenance needs.
The facility's automatic sprinkler system was not properly maintained, with missing ceiling tiles, incorrect and damaged sprinkler heads, and improper installations identified during a survey. The Director of Maintenance was unaware of these issues, and the facility's quarterly inspections failed to document the deficiencies, indicating a lapse in oversight and communication with the sprinkler vendor.
A resident requiring substantial assistance with oral hygiene did not receive necessary oral care, as per facility policy. Despite being cognitively intact and having a care plan indicating the need for assistance, the resident reported not receiving oral care on multiple occasions, resulting in a dry mouth and thick white substance on their mouth and tongue. Staff interviews confirmed the oversight, with oral care not documented on several days.
The facility did not maintain electrical equipment according to NFPA 99 standards, as observed during a survey. An electric tree and a compact disc player in two resident rooms lacked required asset labels. The facility's policy mandates asset labeling and biennial testing of non-patient care electrical equipment. The Director of Maintenance was unaware of the missing labels and could not provide inspection documentation, indicating non-compliance with safety protocols.
The facility did not maintain the first-floor soiled utility room properly, as the door had three unsealed holes. The Director of Maintenance noted that a temporary lock was installed after the original lock broke, but the holes were not sealed, which is crucial to prevent smoke spread.
The facility failed to maintain electrical equipment in the main kitchen according to NFPA 70, 2011 Edition. The milk walk-in cooler light had liquid in its protective cover, and the walk-in freezer had an open junction box with exposed wires. The Food Service Director and Director of Maintenance were unaware of these issues, and no work orders had been submitted, despite staff training.
The facility did not maintain the required emergency food supply as per their Emergency Preparedness Plan. An observation revealed only one case of beef stew instead of the required 3.2 cases, and no meat ravioli was present. The Food Service Director noted the unavailability of ravioli and planned to substitute it, but there was no documentation of attempts to order the missing items.
The facility did not submit the required New York State Department of Health Request for Criminal History Record Check forms for two employees. The HR Director acknowledged the oversight and identified gaps in the policy that led to this deficiency.
The facility did not obtain the required Criminal History Record Check form 102 for two employees, as mandated by their policy. The HR Director confirmed the oversight and acknowledged policy gaps that led to this deficiency.
Failure to Properly Label and Store Medications on Multiple Medication Carts
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were stored and labeled according to professional standards and facility policy across three medication carts. Specifically, opened insulin pens and inhalers were found without open dates or resident identifiers, and eye drops were present without proper labeling or identification. LPNs interviewed were unsure when the medications were opened, did not notice missing labels, and acknowledged that medications such as insulin pens and inhalers should have been labeled with open and expiration dates. Some medications were used despite the lack of labeling, and staff could not confirm whether the medications were expired or which resident they belonged to if packaging was separated. Facility policies required medications, including insulin pens, inhalers, and eye drops, to be dated when opened and labeled with resident information. However, observations revealed that these requirements were not consistently followed. Staff interviews indicated confusion about labeling requirements and expiration timeframes, and some staff deferred to policy or were unsure about specific procedures. The Assistant Director of Nursing confirmed expectations for labeling and organization but also expressed uncertainty about some labeling practices. The findings were observed on multiple units and involved several residents' medications.
Call Bell Not Kept Within Reach for Resident at Risk for Falls
Penalty
Summary
A deficiency was identified when a resident with muscle weakness, a thoracic vertebra compression fracture, and dementia did not have their call bell within reach on multiple occasions. Facility policy and the resident's care plan both required that the call bell be accessible at the bedside, especially given the resident's fall risk. Despite these requirements, surveyors observed the call bell on the floor between the bed and the wall, out of the resident's reach, during several checks over two days. The resident reported being unable to locate the call bell and stated they would yell for help if needed. Interviews with staff confirmed that call bells should be kept within reach and that the resident was capable of using the call bell if it were accessible. Both a CNA and an LPN acknowledged the expectation that call bells be clipped to the bed and within reach of residents. However, the repeated observations showed that this was not consistently done for the resident in question, resulting in a failure to reasonably accommodate the resident's needs and preferences as required by facility policy and the care plan.
Failure to Provide Timely Assessment and Supervision for High-Risk Fall Resident
Penalty
Summary
A deficiency occurred when a resident with dementia, a brain tumor, and osteoporosis, who was assessed as high risk for falls, did not receive care and treatment in accordance with professional standards and their person-centered care plan. The resident experienced two unwitnessed falls in one day. After the first fall, which occurred early in the morning, the resident was found on the floor by an LPN. The LPN took the resident’s vital signs, cleaned them, and assisted them into a chair, but there was no documentation that a registered nurse assessed the resident, that a medical provider was notified, or that emergency medical services were contacted, as required by facility policy when no RN is present. The incident was not reported to the appropriate personnel until later in the day, after a second fall occurred and a registered nurse was notified by a certified nurse aide. Repeated observations over two days showed that the resident’s call bell was consistently clipped to the privacy curtain and not within reach while the resident was in bed or in their wheelchair. The care plan and facility policy required that the call bell be within reach at all times, especially for residents at high risk for falls. Staff interviews confirmed that the call bell was not accessible to the resident and that this was not in accordance with policy. Staff also acknowledged that the resident was capable of using the call bell but did not do so, further emphasizing the importance of ensuring accessibility. Additionally, the resident was observed transferring themselves between bed, wheelchair, and bathroom without staff assistance, despite care plan interventions requiring supervision and assistance with toileting. On one occasion, an LPN observed the resident alone in the bathroom but did not assist or notify anyone, leaving the resident unsupervised. These actions and inactions were inconsistent with the resident’s care plan and the facility’s fall prevention policy, contributing to the deficiency.
Improper Temperature Maintenance in Kitchen Walk-In Cooler
Penalty
Summary
The facility failed to maintain the left walk-in cooler in the kitchen at a safe operating temperature, which is a critical requirement for food safety. The cooler was observed to have an external thermometer reading of 45 degrees Fahrenheit, while a small white thermometer inside read 30 degrees Fahrenheit, indicating a discrepancy in temperature readings. During observations, various food items stored in the cooler were measured at temperatures ranging from 45 to 54 degrees Fahrenheit, exceeding the required maximum of 41 degrees Fahrenheit for safe food storage. The facility lacked a policy or procedure for preventative maintenance of the walk-in coolers, and the staff did not consistently check the internal temperature of the cooler contents to verify the accuracy of the thermometer readings. Interviews with the Food Service Director and Regional Food Service Director revealed that cooler temperatures were checked twice daily, but there was no verification of the thermometer's accuracy by measuring the temperature of the food contents. The staff responsible for checking the cooler temperatures were not fully aware of the required temperature standards and relied on a posted form for guidance. The facility's failure to maintain proper cooler temperatures and ensure accurate temperature monitoring posed a risk of bacterial growth in food, which could lead to foodborne illness among residents, particularly those with compromised immune systems.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Disposal of all food within the left walk-in cooler - Vendor came in the same day to inspect the unit, adjustment to the thermostat made The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - All refrigeration units in the kitchen were inspected to ensure they are in proper working order and maintaining temps within required range The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Implement a Policy and Procedure for preventative maintenance on walk-in coolers - Cooler temperature log revised to monitor temps 3x/day - Dietary staff educated on the new temperature log and the requirements for cold food storage The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing walk-in cooler x3 a day for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services
Deficiency in Fire-Rated Door Frames in Emergency Exit Stairwells
Penalty
Summary
The facility was found to have deficiencies in maintaining vertical openings during a Life Safety Code recertification survey. Specifically, eight emergency exit stairwell door frames across various floors lacked fire-rated labels. These included the first, second, and third-floor south emergency exit stairwells, the second and third-floor northwest emergency exit stairwells, the second and third-floor northeast emergency exit stairwells, and the second-floor center emergency exit stairwell. The absence of fire-rated labels on these door frames was identified during observations conducted on January 13, 2025. The Director of Maintenance was interviewed and revealed that they were unaware of the missing fire-rated labels on the door frames of the emergency exit stairwells. The Director stated that the door frames had been inspected annually by a third party in 2023 and 2024, but the inspection forms did not include a section to document the fire rating of the door frames. The Director acknowledged the requirement for the door frames to have a 1-hour fire-rated label and recognized the importance of this for the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Ensured vertical openings maintained and fire rating labels placed on the first-floor south emergency exit stairwell, second-floor south emergency exit stairwell, third-floor south emergency exit stairwell, second-floor northwest emergency exit stairwell, third-floor northwest emergency exit stairwell, second-floor northeast emergency exit stairwell, third-floor northeast emergency exit stairwell, and the second-floor center emergency exit stairwell. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit vertical openings and fire rated doors for fire rated labels. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education of fire rated doors to have label to door tracking to maintenance staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit all fire rated doors for vertical opening and fire rated labels x3 months 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance.
Deficiencies in Kitchen Food Safety and Maintenance
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, it was observed that food in the walk-in freezer was not protected, with an uncovered open box of hamburgers and food and packaging debris under shelving. Additionally, there was ice build-up on the ceiling and an open junction box with exposed wiring. The kitchen lighting was not properly shielded, with the majority of lights lacking protection, and the facility could not confirm if the bulbs were shatter resistant. The condenser outside of the cooler had dirt and grease build-up, and there were several broken floor tiles under the three-door freezer in the dry storage room, which were not smooth or easily cleanable. Interviews with the Regional Food Service Director and Kitchen Supervisor revealed that the facility's cleaning and maintenance practices were inadequate. The Kitchen Cleaning log audit for December 2024 and January 2025 was blank, indicating a lack of documentation for cleaning activities. The Regional Food Service Director emphasized the importance of proper food storage and cleanliness to prevent contamination and pest control issues. The Kitchen Supervisor admitted that the light covers had been missing for several years and was unsure if the bulbs were shatter resistant, highlighting a long-standing issue with kitchen lighting protection. These deficiencies indicate a failure to adhere to the facility's policy on food storage and safety standards.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Dispose of uncovered hamburgers in box in cooler - Fixed and cover the exposed wiring within the junction box - Remove ice buildup on the ceiling, and identify and correct source of ice - Remove and dispose of food and packaging debris under shelving in walk-in-freezer - Lights uncovered in kitchen – Replace with Shatterproof bulbs - Clean outside cooler of debris and dirt - Repair cove base below 2-sink bay - Repair/Replace tiles under 3-door freezer The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit kitchen for food procurement, storage, preparedness and serving - Work orders placed for any areas requiring repair The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on food procurement and storage in the kitchen to dietary staff The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing food procurement and storage in the kitchen through the cleaning log for the kitchen for x1/day for 4 weeks, then x1/week for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services
Failure to Address Grievances and Long Call Bell Wait Times
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for all residents reviewed, including one specific resident who filed a formal grievance. Nine residents expressed during a group meeting that they were unaware of the grievance official or the process to file a grievance. The facility's policy required that residents be provided with the means to file grievances, but there was no posted information about the grievance officer or accessible grievance forms observed during the survey. Long call bell wait times were a recurrent issue reported in monthly resident council meetings, and these concerns were documented in meeting notes from July to November 2024. Resident #446 had filed a formal grievance regarding the long call bell wait times, which was not promptly addressed. Observations during the survey revealed significant delays in call bell responses, with instances of call bells going unanswered for extended periods, ranging from 28 to 45 minutes. Staff members, including a Registered Nurse Unit Manager and other unidentified staff, were observed ignoring active call bells. Interviews with the Director of Activities, Director of Social Services, and Director of Nursing confirmed that long call bell wait times were a frequent grievance. The Director of Social Services, who served as the grievance officer, acknowledged the issue and stated that investigations and staff education were conducted, but the problem persisted. The Director of Nursing noted that despite in-services and changes in staff assignments, a solution to the long call bell wait times had not been found, indicating a systemic issue within the facility's operations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Public post throughout the facility the Official Grievance Officer, their contact information, and where to file an official grievance. - Educate nursing staff on call bell timeliness. - Review with resident council who the grievance officer is and how to contact them. - Notify Resident #446 of grievance outcome and resolution and complainant satisfaction and reassessment if needed. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit Call (NAME) wait times, educate, monitor and enforce timeliness. - Audit units for posting on Grievance Officer name, contact information and process/availability – ensure posting of information is available throughout the facility. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on the Grievance Procedure/Officer to resident council. - Education on Call-Bell Timeliness to LPN/CNA staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Post information on Grievance Officer, contact information and process/availability to file a grievance. - Audit Call (NAME) Timeliness x5 a week per unit for 3 continuous months for 100% compliance. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager.
Infection Control Deficiencies in Urinary Catheter Care and Medication Room Sink
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two significant deficiencies observed during the recertification survey. The first deficiency involved Resident #17, who had severe cognitive impairment and an indwelling urinary catheter. Observations revealed that the resident's urinary drainage collection bag was lying directly on the floor without a barrier, contrary to the facility's policy that required catheter tubing and drainage bags to be kept off the floor. Interviews with staff, including a Certified Nurse Aide, a Licensed Practical Nurse, and a Registered Nurse Unit Manager, confirmed that the drainage bag should not touch the floor due to the risk of contamination and potential for urinary tract infections. The second deficiency was identified in the 2 South B side medication room, where the sink was found to be non-functional. The sink had a white substance on the handles, rust, and towels with a basin placed over them, preventing the water from being turned on. Staff interviews revealed that the issue had been reported to maintenance months prior, but the problem persisted, forcing staff to use alternative locations for handwashing. The Maintenance Director acknowledged the importance of having a functional sink for hand hygiene and was unaware of the ongoing issue in the medication room. These deficiencies highlight lapses in the facility's infection control practices, specifically regarding the proper storage of urinary drainage bags and the availability of functional handwashing facilities. The lack of adherence to established protocols and delayed maintenance responses contributed to the potential risk of infection for residents and staff.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Replace Resident #17 urinary catheter bag and place dignity bag over it, ensuring there is no contact with the ground when hung from the bed or wheelchair. - Clean and repair the sink in the medication room on 2 South. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit all urinary catheter bags in the facility and educate Nursing Staff on infection prevention. - Audit all sinks in medication rooms to be sanitary and in working order. Educate maintenance department on timely work order responses. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on infection prevention (specifically catheters) to Nursing Staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing urinary catheter bags throughout the facility x5/week times 3 months at 100%. - Auditing work order system repair timeliness and effectiveness x 5/week at 3 month 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Infection Preventionist.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, leading to deficiencies in medication management. During the recertification survey, it was observed that two of the five medication carts and one of the three medication storage rooms contained medications without proper labeling of opened or discard dates. Specifically, the 3 North A side cart had multiple medications, including eye drops, insulin vials, and inhalers, without opened or expiration dates. Similarly, the 2 North A side cart had diabetic pens without opened or discard dates, and the 3 North medication refrigerator contained expired vials and others without opened dates. Additionally, the 3 South B side medication cart was found unlocked and unattended in a common resident hallway, posing a risk of unauthorized access. Interviews with nursing staff revealed that the responsibility for labeling medications with opened dates was not consistently followed, and there was a lack of adherence to the facility's policy on medication storage. Nurses acknowledged that without opened dates, the effectiveness of medications could not be guaranteed, and expired medications might be administered inadvertently. The Director of Nursing confirmed that medications should be dated when opened to ensure their effectiveness and that medication carts should be locked when unattended. The facility's policy required that outdated medications be removed from inventory and that medication carts be audited weekly to ensure compliance. However, these procedures were not effectively implemented, leading to the observed deficiencies in medication management.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Dispose of opened and unlabeled medications from Med carts 3 North A and 2 South A, and influenza vaccine vials and tuberculin vial from 3 North Medication Storage Room. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit all medication carts, rooms, and refrigerators. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Educate all nurses on medication labeling and storage. - Educate all nurses on locking medication carts when left unattended. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit all medication carts, rooms, and refrigerators x1 per unit/week for 3 months until 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and served at appetizing temperatures during the recertification survey conducted from January 13 to January 17, 2025. Specifically, during lunch meals on January 14 and January 15, food was not served at the appropriate temperatures as per the facility's policy. Observations revealed that hot food items were below the required 135 degrees Fahrenheit, and cold items were above 41 degrees Fahrenheit. Residents expressed dissatisfaction with the food, describing it as lukewarm, tough, and lacking variety. These issues were corroborated by temperature measurements taken during meal observations, which showed that several food items did not meet the required temperature standards. Interviews with residents and staff further highlighted the ongoing concerns about food quality. Residents reported that the food was not appetizing, leading some to order food from outside the facility. Staff members, including a Certified Nurse Aide and the Director of Activities, acknowledged the complaints and emphasized the importance of serving food at appropriate temperatures to ensure resident satisfaction and prevent potential health issues. The Corporate Regional Director also confirmed that the food temperatures were not acceptable and stressed the importance of maintaining food safety standards to prevent bacterial growth.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - The affected residents were provided with replacement meal trays. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit meals using test trays. - When arriving to the dining table, check if meal is at temperatures that are appropriate: Hot food 135 degrees F or higher and cold items 41 degrees or lower, and taste if meal is flavorful. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on food temperatures to dietary staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit meals arriving to the residents' table are at temperatures that are appropriate: Hot food 135 degrees F or higher and cold items 41 degrees or lower. Items to be palatable and adequately appetizing. - Audit x3 meals for 1 month then 1 meal per month x3 months until 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services
Environmental Deficiencies in Resident Units
Penalty
Summary
The facility was found to have deficiencies in maintaining a safe, clean, comfortable, and homelike environment for residents in several units. Observations revealed multiple issues such as missing paint, unpainted patched holes, missing door thresholds, and accumulated dirt and debris in resident rooms across Units 2 North, 2 South, and 3 South. Additionally, the 2 South dining room lacked homelike decorations. These conditions were contrary to the facility's policies on resident rights and quality of life, which emphasize providing a dignified and homelike environment. Interviews with staff, including registered nurses, certified nurse aides, housekeepers, and maintenance personnel, indicated a lack of awareness and communication regarding the environmental issues. Staff members were expected to enter work orders for maintenance issues, but many were unaware of the existing problems or did not know how to use the work order system effectively. The Director of Housekeeping and Laundry noted that some housekeepers left handwritten notes instead of using the computerized system, and the Director of Maintenance stated that most work orders were completed within 24 hours, although there were no outstanding orders for missing thresholds. The facility's failure to address these environmental deficiencies was evident in the numerous open work orders and the lack of timely maintenance. The presence of dirty linens on the floor, missing thresholds, and unpainted areas contributed to an environment that was not homelike and posed potential tripping hazards. Staff interviews highlighted a disconnect between identifying issues and ensuring they were reported and resolved, leading to ongoing deficiencies in the facility's environment.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - 272B: Paint scrap behind the head of bed - 265B: Paint unpainted plaster - 225: Put in floor tile, paint near bathroom sink, put in door threshold - 220: Put in floor tile outside door, paint wall, put in door threshold - 206: Put in door threshold, pick-up and clean dirty linen and trash in room - 203: Put in door threshold, clean trash - 202: Clean sticky yellow spot at base of bed on the floor - 201: Put in door threshold 2 South Dining Room: repair hole in wall near floor, paint under television, paint unpatched patch on right side, add personalization to dining room with wall decals and colored paint, and picture frames 3 South Supply Closet: Add molding to doorknob side 3 South Nurses Station: Paint door scratch behind nurses station 305: Paint door jam frame paint chips The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken - Audit all units for homelike environment: All resident areas The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur - Education on homelike environment to maintenance and housekeeping departments The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit Resident areas on units for homelike environment x1 Month for 3 consistent months at 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance
Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in compliance with safety standards, as observed during a Life Safety Code recertification survey. Several deficiencies were identified, including missing ceiling tiles in the third-floor north housekeeping closet, the third-floor north air handler room, and the second-floor south soiled utility room. Additionally, the second-floor south utility room had a ceiling sprinkler head missing an escutcheon, and the main kitchen had sprinkler heads with unapproved escutcheons. Damaged sprinkler heads were found in the main kitchen dish machine area, and a side-wall sprinkler head in the oxygen storage room still had its safety cover on. Furthermore, improper sprinkler heads were installed in the main kitchen emergency exit exterior pathway. The facility's quarterly sprinkler inspections did not document these deficiencies, indicating a lapse in maintenance oversight. Interviews with the Director of Maintenance revealed a lack of awareness regarding the missing ceiling tiles and sprinkler deficiencies. The Director acknowledged the importance of maintaining ceiling tiles and sprinkler systems to prevent the spread of smoke and fire. The Director also noted that the sprinkler vendor was assumed to be responsible for checking every sprinkler head during inspections, but this was not effectively done. The improper installation of high heat sprinkler heads in a non-high heat area was attributed to the vendor's responsibility, highlighting a communication gap between the facility and the vendor regarding compliance with safety standards.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Put in ceiling tiles in the third-floor north housekeeping closet, the third-floor north air handler room, and the second-floor south soiled utility room. - Put in escutcheon for sprinkler head on second-floor south utility room. - Fix and replace main kitchen sprinkler heads (7) with unapproved escutcheons; and replace damaged sprinkler heads (3) in the main kitchen dish machine area. - Oxygen storage room sprinkler head cover removed. - Improper sprinkler heads removed and replaced in the main kitchen emergency exit exterior pathway. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit ceiling tiles and sprinklers in facility. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on ceiling tiles to maintenance department. - Education on sprinklers to maintenance department. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit ceiling tiles x3 months 100%. - Audit sprinklers x2/month for 3 months 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance.
Failure to Provide Necessary Oral Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, the resident, who was cognitively intact and required substantial assistance with oral hygiene, did not receive oral care as planned. The facility's policy required that residents who could not independently perform activities of daily living receive necessary services to maintain oral hygiene. However, observations and interviews revealed that the resident had not received oral care on multiple occasions, resulting in a dry mouth and thick white substance on their mouth and tongue. Interviews with staff, including a Certified Nurse Aide and Licensed Practical Nurse Unit Manager, confirmed that oral care was not provided as required. The Certified Nurse Aide admitted to missing oral care in error, while the Licensed Practical Nurse Unit Manager was unaware of the deficiency. The resident's care plan indicated the need for substantial assistance with oral hygiene, and the facility's policy emphasized the importance of maintaining oral hygiene to prevent infection and ensure comfort. Despite these guidelines, oral care was not documented as being performed on several days, highlighting a lapse in the facility's adherence to its own policies.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Educate #8 C.N.A and all C.N.A’s on oral care under ADL’s - Resident #119 was provided oral care The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit ADL/Oral care for residents who are care planned for assistance The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on ADL/Oral Care to all CNA’s - Check Resident #119 morning and afternoon for 2 weeks, then weekly x3 months for ensuring oral care is being provided. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit Oral/ADL care for residents who need assistance x5 per unit/week for 3 months until 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Nurse Manager
Failure to Maintain Electrical Equipment in Compliance with NFPA 99
Penalty
Summary
The facility failed to ensure that electrical equipment was maintained in accordance with National Fire Protection Association 99 standards. During a Life Safety Code recertification survey, it was observed that two pieces of non-patient care electrical equipment, an electric tree and a compact disc player, in two separate resident rooms, lacked asset labels. The facility's policy, revised in March 2024, requires that all non-patient care electrical equipment be tagged with a numbered asset label and another label with the date and signature of the inspector, and that such equipment be tested every two years. However, during an interview, the Director of Maintenance admitted to being unaware of the missing asset labels and could not provide documentation of initial or biennial inspections for the equipment. This oversight indicates a failure to adhere to the facility's policy, potentially compromising the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - 372 electric tree inspected and tagged with a number asset label and another label with date and signature of inspector - 260 compact disc player inspected and tagged with a number asset label and another label with date and signature of inspector The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit electrical equipment within the facility for proper inspection labels, ensure done every two years The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on Electrical Equipment (NFPA 99) inspection and labeling to maintenance department The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit electrical equipment for inspection and labeling 10x/month for 3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance
Unsealed Holes in Soiled Utility Room Door
Penalty
Summary
The facility failed to ensure that hazardous areas were properly maintained, specifically in the first-floor soiled utility room. During an observation, it was noted that the door to this room had three unsealed small holes. The Director of Maintenance explained that the locking mechanism on the door had broken approximately two weeks prior, and a temporary lock was installed. However, they did not realize that the existing holes in the door were not sealed when the temporary lock was put in place. This oversight is significant as it is important for hazardous area doors to be properly sealed to prevent the spread of smoke to other areas.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Seal x3 small holes in the 1st floor soiled utility room access door. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit hazardous area room doors. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on hazardous area enclosure provided to maintenance staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit all hazardous doors x3 months 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance.
Electrical Equipment Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to ensure that electrical equipment in the main kitchen was maintained in accordance with NFPA 70, 2011 Edition, resulting in two deficiencies. During an observation and interview, it was found that the light fixture in the main kitchen milk walk-in cooler had liquid inside its protective glass cover. The Food Service Director acknowledged that the light had been in this condition for several years, but was unsure how the liquid entered the fixture. Additionally, the main kitchen walk-in freezer had an open junction box with exposed electrical wires, which were located in the direct path of a side-wall sprinkler head. The Director of Maintenance was unaware of the water in the light fixture and the missing protective cover on the junction box, which had been installed about a year ago. There were no work orders submitted regarding these issues, despite kitchen staff being trained to report such problems.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Main Kitchen walk-in cooler changed to NFPA 70 2011 Edition approved wiring - Junction box in Main Kitchen walk-in freezer exposed wire replaced by covered NFPA 70 2011 Edition approved wiring The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit electric and gas equipment The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on Electrical Equipment (NFPA) to maintenance department The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit electrical and gas equipment 10x/month for 3 months 100% The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Maintenance
Emergency Food Supply Deficiency
Penalty
Summary
The facility failed to maintain subsistence needs for residents and staff as required by their Emergency Preparedness Plan. During an observation and interview, it was found that the emergency food supply was insufficient, with only one case of beef stew available instead of the required 3.2 cases, and no meat ravioli present, contrary to the facility's emergency menu requirements. The Food Service Director acknowledged the absence of meat ravioli, stating it was unavailable during the last order attempt and planned to substitute it with meat sauce and rice. However, there was no documentation to support that the missing items were unavailable from the vendor or that attempts were made to order them. This deficiency was identified during the Emergency Preparedness Plan review in conjunction with a Life Safety Code Survey.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Update emergency menu to available in house items for emergency preparedness. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit Emergency food stock. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Emergency food stock education to dietary department. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Audit emergency food audit x1/day for 4 weeks, then 4/month for 3 months, 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Food Services.
Failure to Submit Criminal History Record Check Forms
Penalty
Summary
The facility failed to ensure the submission of a New York State Department of Health Request for Criminal History Record Check (Form 103) for two out of five employees reviewed during a recertification survey. Specifically, there was no documented evidence that Form 103 was submitted for Employees #28 and #29. The facility's policy, revised in November 2018, requires the Director of Human Resources or designee to obtain a signed authorization for the search and exchange of records (Form 102) from prospective employees. However, during an interview, the Human Resources Director acknowledged that Form 103 was missing for these employees and recognized gaps in the policy that needed addressing to prevent future occurrences.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Form 103 Criminal History and Record Check completed for employees #28 & #29. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit employee files for form 103 for CHRC. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education to Human Resources on CHRC regulation/license. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing of new hires and current employees for form 103 to occur x10/month for 3 months at 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Human Resources.
Failure to Obtain Criminal History Record Check Forms
Penalty
Summary
The facility failed to obtain a signed Acknowledgment and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form, known as Criminal History Record Check form 102, for two out of five employees reviewed during the recertification survey. The facility's policy, revised in November 2018, requires the Director of Human Resources or a designee to obtain this signed authorization from prospective employees. However, there was no documented evidence that Employees #28 and #29 had completed and signed the required form. During an interview, the Human Resources Director confirmed that the forms for these employees were not completed and acknowledged gaps in the policy that needed addressing to prevent future occurrences.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Form 102 Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information consent form completed for employees #28 & #29. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit employee files for form 102 for CHRC. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education to Human Resources on CHRC regulation/license. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing of new hires and current employees for form 102 to occur x10/month for 3 months at 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Director of Human Resources.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
