Crouse Community Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Morrisville, New York.
- Location
- 101 South Street, Morrisville, New York 13408
- CMS Provider Number
- 335068
- Inspections on file
- 14
- Latest survey
- January 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Crouse Community Center Inc during CMS and state inspections, most recent first.
The facility failed to provide adequate pharmaceutical services by inappropriately borrowing controlled substances among residents. A resident's oxycodone was used for others due to medication unavailability, contrary to policy. Staff interviews revealed borrowing was considered a policy, though undocumented, and used when residents lacked prescriptions or faced delivery delays. The emergency medication supply was insufficiently stocked, leading to reliance on borrowing, which was confirmed as inappropriate by the DON and Pharmacist.
A facility failed to obtain informed consent from a resident before using a chair alarm, despite the resident's discomfort and lack of falls. The resident, with a history of falls and muscle weakness, was not consulted about the alarm, which was initiated as a precaution. Staff interviews revealed that the alarm's necessity was not reevaluated, and the resident was not present at their care plan meeting where the alarm's use should have been discussed.
A resident with Parkinson's disease and other conditions experienced significant weight loss over three months, but the facility failed to notify the physician as required by policy. Despite dietary interventions, the resident's weight decreased from 160 to 139 pounds. Interviews revealed communication breakdowns among staff, leading to the physician being uninformed of the resident's condition.
The facility violated resident privacy by posting dietary status outside rooms, visible to the public. Two residents with feeding tubes had their NPO status displayed, which staff confirmed was a breach of confidentiality. Despite education on privacy, the facility exposed sensitive health information.
A resident with dementia and fragile skin experienced a skin tear on their left arm, which was not timely investigated to rule out abuse or neglect. The LPN who discovered the injury did not report it properly, and the facility failed to conduct a thorough investigation or notify the medical provider. The DON and staff did not follow the facility's policy for reporting and investigating alleged violations, leading to a deficiency in care.
Two residents in an LTC facility were found to have incomplete care plans during a survey. One resident had a chair alarm not documented in their care plan, while another was on anticoagulant medication without specific interventions noted. Staff interviews revealed gaps in documentation and communication, contrary to facility policies requiring regular updates and reviews of care plans.
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. One resident with osteoarthritis and vertebral artery stenosis did not receive proper pain evaluations when as-needed medication was administered, and pain flow sheets were left blank. Another resident experienced pain during transfers with a sit-to-stand lift, but there was no documented evidence of pain evaluations or adjustments to the transfer process. The facility's policy on pain assessment was not followed, resulting in inadequate care.
The facility did not complete a required semi-annual inspection of the kitchen fire suppression system for the first half of 2024 and failed to address deficiencies identified in a July inspection. The Maintenance Director acknowledged the oversight and the importance of maintaining functional fire suppression components.
The facility failed to maintain its 500-kilowatt diesel emergency generator per NFPA 99 standards. Deficiencies included undocumented transfer times, missed annual fuel tests, and incomplete load tests. The Maintenance Director was unaware of specific requirements, leading to these oversights.
The facility did not conduct the required annual and monthly tests for the battery-operated emergency light in the basement generator room. The Maintenance Director was unaware of the testing requirements, leading to a lack of documentation for the tests in 2023 and 2024.
A survey found that a facility failed to maintain proper electrical installations in four resident rooms, with items plugged into unapproved adapters and extension cords. The Maintenance Director was unaware of these violations, despite a policy requiring inspection of all electrical items for compliance. This oversight highlights a lapse in adherence to safety standards.
The facility did not maintain electrical equipment according to NFPA 99 standards, as observed during a survey. An electric tree in a resident room, a curling iron in the beauty salon, and a hair dryer in the C-Unit shower room lacked current inspection labels. The Maintenance Director confirmed that equipment inspections were not tracked, and there was no documentation for inspections in 2023 or 2024, violating the facility's safety policy.
The facility did not maintain the medical gas and vacuum system per NFPA 99 standards. An inspection report from early 2024 noted deficiencies such as inadequate electrical controls and missing hour meters in the vacuum source system. The Maintenance Director was unaware of these issues due to a lack of communication from the third-party vendor. Additionally, the basement system lacked failure labeling.
The facility failed to conduct a quarterly sprinkler inspection for Q3 2024 and did not repair a failed backflow prevention device identified in February 2024. Additionally, there were structural issues, including a missing ceiling tile in the A-Unit janitor's closet and holes in the main kitchen ceiling, which were not reported or addressed, indicating lapses in maintenance oversight.
The facility did not maintain smoke barrier doors properly in the F-Unit and D-Unit, as observed during a survey. Unsealed cable and data wires were found passing through the walls of these units. The Maintenance Director was unaware of these issues and had not followed up on the last smoke barrier check, which inaccurately documented the barriers as being in good condition.
A survey found an unsealed hole in the E-Unit pantry door of a facility, which was left after a door lock set replacement in 2023. The Maintenance Director was unaware of the issue until it was identified during the survey, highlighting the importance of maintaining properly sealed corridor doors for safety.
The facility did not conduct a required fire drill for the evening shift in the first quarter of 2024. During a survey, it was found that documentation for this drill was missing. The Maintenance Director admitted the oversight and acknowledged the importance of conducting quarterly fire drills for each shift to ensure safety.
Inappropriate Borrowing of Controlled Substances Among Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by the inappropriate borrowing of controlled substances among residents. Specifically, the facility used one resident's oxycodone to administer to three other residents when their medication was unavailable. This practice was contrary to the facility's policy, which required controlled drugs to be fully labeled and stored securely, and did not have a documented policy on borrowing medications. The deficiency involved four residents, each with physician orders for oxycodone to manage pain. The facility's records showed that one resident's oxycodone was borrowed multiple times for other residents over a period of several weeks. Interviews with nursing staff revealed that borrowing medications was considered a facility policy, although it was not documented, and was used as a stopgap measure when residents were readmitted from the hospital without prescriptions or when there were delays in medication delivery. The Director of Nursing and the Pharmacist confirmed that borrowing controlled substances was not appropriate and could lead to issues such as diversion and billing problems. The facility had an emergency medication supply system, but it was not fully stocked with all necessary narcotic pain medications, leading to reliance on borrowing. The Medical Director stated that electronic prescriptions could be sent for immediate fills, but this was not utilized, resulting in the inappropriate borrowing of medications.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 F755- Pharmacy Services/Procedures/Pharmacist/Records: Crouse Community Center will ensure medications are available for residents when needed. Corrective action: Resident # 1, #208, #209 had new prescriptions obtained with their own sufficient, designated supply of medications received. Resident # 88 has a sufficient supply of medications. Other residents: All other residents with orders for controlled substances were reviewed to ensure sufficient supply of medication. Systemic Changes: Crouse Community Center will ensure that all residents with controlled substances will have a sufficient supply of medications. Licensed staff was educated on the modifications made to the facility Stat Safe. Pharmacy was consulted, and the facility Stat Safe medication emergency supply system was updated with additional emergency controlled substances added. Monitoring: Audits will be conducted weekly by the Director of Nursing to ensure sufficient supply of controlled substances. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing
Failure to Obtain Informed Consent for Chair Alarm Use
Penalty
Summary
The facility failed to promote and facilitate resident self-determination for a resident by not obtaining informed consent before initiating a chair alarm. The resident, who had diagnoses including repeated falls and generalized muscle weakness, was observed with a chair alarm without documented evidence of consent. The facility's policies required that residents be informed and have the right to refuse such interventions, but there was no documentation of discussions with the resident or their representative regarding the alarm's use. The resident expressed discomfort with the chair alarm, stating it was bothersome and that they had never fallen from the chair. They also mentioned that the alarm was loud and took a long time for staff to respond to. Interviews with facility staff revealed that the alarms were often initiated on admission as a precaution for high-risk residents, but the ongoing need for the alarm had not been reevaluated since the resident's admission. Staff acknowledged that unnecessary alarms could be undignified and that residents had the right to fall. The Director of Nursing stated that alarm use was determined on admission and reassessed during care plan meetings. However, the resident was not documented as present at their care plan meeting, and there was no evidence that the use of the alarm was discussed with them. The facility's failure to obtain informed consent and properly document the resident's preferences and needs led to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F561- Self-determination: Crouse Community Center will ensure that the facility is promoting and facilitating resident self-determination through support of resident choice, focusing on significant aspects of his/her life in the facility. Corrective action: Resident #4 was re-interviewed by Nurse Manager and declined the use of alarms. Alarms were discontinued and Care plan and CNA notification sheet updated on (MONTH) 10, 2025. Other residents: All residents in the facility were reviewed for fall risk. If alarm use is determined to be an appropriate fall alert intervention, consent forms will be completed by resident or designated representative and comprehensive care plan will be implemented. Systemic changes: The facility will promote self-determination with focus on alarm use and resident choice. Consent forms were created and all staff educated on obtaining consent prior to alarm use. Monitoring: Audits will be conducted by Director of Nursing to include Alarm use and Care planning. This will be done by checking physician orders [REDACTED]. This audit will be done monthly with 100% compliant threshold and reported monthly to QAPI. Responsible Party: Director of Nursing
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's physical status, specifically regarding unplanned weight loss. Resident #30, who had diagnoses including Parkinson's disease, diabetes, and gastro-esophageal reflux disease, experienced a notable weight loss over a period of three months. Despite the facility's policy requiring notification of the physician in such cases, there was no documented evidence that the physician was informed of the resident's weight loss. The resident's weight decreased from 160 pounds in October 2024 to 139 pounds by January 2025, indicating a 13.1% weight loss over three months. The facility's care plan included monitoring the resident's nutritional status and implementing dietary interventions, such as providing Ensure Plus high protein supplements. However, the physician was not notified of the resident's significant weight loss, as confirmed by interviews with the dietetic technician and the registered nurse unit manager. Interviews with facility staff revealed a breakdown in communication and documentation processes. The dietetic technician and registered nurse unit manager both indicated that they relied on established procedures for communicating weight changes, which involved passing information through various staff members. However, the physician was not informed of the resident's weight loss, and there was no documentation in the resident's chart regarding the weight change. The physician stated they expected to be notified of significant weight changes, but this did not occur in this instance.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F580- Notify of Changes: Crouse Community Center will ensure that the physician is notified when there is a significant change in the resident’s physical, mental, or psychosocial status with, potentially, the need to alter treatment. Corrective action: The facility will ensure that the physician is notified with any significant change in condition with a focus on unplanned weight loss. For resident #30, the physician was notified of the weight loss by the nurse manager. A significant change in status assessment was initiated due to the resident’s change in status in order for the IDT and family to establish appropriate goals of care. Diet consistency and level of assist with eating was changed as the immediate intervention with high protein supplements added by dietary. Resident transitioned to comfort care and expired on [DATE]. Other residents: The physician has reviewed and documented on all residents who had significant weight changes (5%/month or 10%/6months) in order to ensure adequate treatment. Systemic changes: All licensed staff will be re-educated on our Change in Condition-Notification policy, and Weight policy. Focus will be on significant weight loss and timely notification. The facility will ensure that the physician is notified with any significant change in condition with focus on unplanned weight loss. Monitoring: Audits will be conducted by Director of Nursing monthly with a 100% compliance threshold and reported to QAPI monthly. Responsible Party: Director of Nursing
Violation of Resident Privacy Due to Public Posting of Dietary Status
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, specifically for two residents who had their dietary status posted outside their rooms, visible to the public. Resident #3, diagnosed with cerebral palsy and quadriplegia, was dependent on a feeding tube for nutrition and had an NPO (nothing by mouth) order. Observations during the survey revealed that signs indicating the NPO status were placed outside the resident's room on multiple occasions, which was visible to visitors and non-pertinent staff. Similarly, Resident #13, who also had cerebral palsy and was dependent on a feeding tube, had their NPO status posted outside their room. Interviews with various staff members, including the Social Services Director, Certified Nurse Aide, LPN, and RN Unit Manager, confirmed that the posting of such information was a violation of the residents' privacy. Despite staff education on maintaining confidentiality, the facility's actions led to the exposure of sensitive health information, contravening the residents' rights to privacy.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 F583- Personal Privacy/Confidentiality of Records: Crouse Community Center will ensure all residents their right to privacy and confidentiality. Corrective action: For resident # 3 and resident # 13, NPO signage was removed from the resident’s door and replaced with a water drop symbol with an “X” through it on (MONTH) 13, 2025. Other residents: Thickened Liquids-Swallowing eval policy was updated to include new symbol for NPO. All other residents on an altered fluid consistency were reviewed to ensure that the appropriate symbol was on their door as per policy. Discrete facility approved signage will be utilized to ensure privacy and confidentiality to all residents. Medical abbreviations will not be placed on residents' doors, only discrete symbols. Systemic Changes: Thickened liquids policy was updated with staff education on the new symbol utilized for NPO residents. Discrete facility approved signage will be used as a communication tool for staff; medical abbreviations will not be utilized. Residents' diet, diagnosis, and/or conditions will not be displayed as to protect their privacy and confidentiality. Monitoring: Audits will be conducted by the Director of Nursing to ensure confidentiality and privacy are not violated by using medical signage. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing
Failure to Investigate Alleged Violation and Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged violation involving a skin tear on a resident's left arm, which was not timely assessed to rule out abuse or neglect. The incident was first identified by an LPN who noticed an open area on the resident's arm, which appeared to be a bruise that had opened. The LPN cleansed and wrapped the wound but did not report it in the 24-hour report or notify a registered nurse for further assessment. The incident report was not signed by the physician until several days later, and there was no documented evidence of a timely investigation. The resident involved had a history of dementia with behavioral disturbances, diabetes, and a history of falls. The care plan indicated the resident required extensive assistance with activities of daily living and was at risk for impaired skin integrity due to fragile skin. Despite these known risks, the facility did not conduct a timely investigation or notify the medical provider about the injury. Staff interviews revealed that the resident was combative during care, which may have contributed to the skin tear, but no thorough investigation was conducted to rule out abuse or neglect. The Director of Nursing and other staff members failed to follow the facility's policy for reporting and investigating alleged violations. The Director of Nursing did not report the injury of unknown origin to the appropriate authorities and did not obtain staff statements or conduct interviews. The resident's statement that they were not harmed by staff was taken as sufficient evidence to rule out abuse, despite the lack of a comprehensive investigation. The Medical Director was also unaware of the injury, indicating a breakdown in communication and reporting within the facility.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 F610-Investigate/Prevent/Correct Alleged Violation: Crouse Community Center will ensure that allegations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated. This includes measures to prevent further abuse, neglect, exploitation, or mistreatment while investigation is in progress and the incident is reported to the Administrator/Director of Nursing within 2 hours to ensure appropriate corrective actions are taken if alleged violation is verified. Corrective Action: Incident report and investigation was completed for Resident # 25. Upon investigation of the incident, root cause analysis and witness statements have determined it to be non-reportable. The bruising/skin tear was considered accidental secondary to Dementia with behaviors and fragile skin. Plan of correction includes continued application of arm protectors, use of 2 CNAs with all cares. Medication management will be reviewed to increase dose of Anti-Anxiety and Pain medication due to her behaviors. Other Residents: All licensed staff will be re-educated with our policy and procedures for reporting injuries of unknown etiology. All residents with an injury of unknown origin will have a skin assessment completed by a registered nurse with provider notification directly following assessment to obtain a treatment order if indicated. The RN will then initiate an Incident report with investigation if needed. Systemic Changes: Incident reporting of injuries of unknown origin will be included in facility orientation and annual Inservice training with Residents Rights and Abuse Reporting. Incident reports of injuries of unknown etiology must be reported immediately to the RN Nurse manager or RN Supervisor on duty to initiate the investigation, notify provider, and implement a treatment if indicated. After thorough investigation is complete, if abuse or serious bodily injury is suspected, the Director of Nursing will be notified and report the incident to the appropriate agency within 2 hours. Monitoring: Audits will be conducted by the Director of Nursing monthly on investigations of injuries of unknown origin. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure the development and implementation of comprehensive person-centered care plans for two residents, leading to deficiencies identified during a recertification survey. Resident #57, who had diagnoses including diabetes and hypertension, was observed with a chair alarm attached to their shirt, despite their care plan not including the use of such an alarm. Interviews with staff revealed that the resident's care plan and certified nurse aide information sheet did not document the use of a chair alarm, and staff were unaware of its use, indicating a lack of communication and proper documentation. Resident #43, diagnosed with atrial fibrillation, heart failure, and dementia, was receiving an anticoagulant medication, Eliquis, as per physician orders. However, their care plan did not include specific interventions for the use of this blood-thinning medication, such as monitoring for bleeding or bruising. Interviews with nursing staff and management confirmed that the care plan should have included these interventions, but they were missing, highlighting a gap in the care planning process. The facility's policies required care plans to be updated with accurate information and reviewed regularly, but these requirements were not met for the residents in question. The lack of comprehensive care plans for both residents indicates a failure in the facility's processes to ensure that all necessary interventions and safety measures are documented and communicated to staff, potentially impacting the quality of care provided to the residents.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F656- Develop/Implement Comprehensive Care Plan: Crouse Community Center will ensure the development and implementation of a person-centered Comprehensive Care Plan. Corrective action: Resident #43 anti-coagulant use was identified and implemented into the Comprehensive Care Plan for risk of bleeding or bruising on (MONTH) 14, 2025. Resident #57 has been determined not at risk for falls; therefore, chair alarm was removed and staff was educated on his plan of care on (MONTH) 6, 2025. Other residents: All other residents were reviewed for anti-coagulant use, and the Comprehensive Care Plan was updated for all of those residents to include at risk for bleeding or bruising complications to be monitored. All other residents in the facility will have a fall risk assessment completed and have appropriate interventions implemented and added to their Comprehensive person-centered Care Plan. Systemic Changes: All new residents admitted on anti-coagulant therapy or any other resident with a new order for anti-coagulant therapy will have a Comprehensive Care Plan implemented or updated to include at risk for bleeding or bruising complications to be monitored. This will also be communicated to the CNA staff utilizing the CNA information sheets. Moving forward, fall risk assessments will determine appropriate interventions and will be updated on the CNA information sheets and the Comprehensive person-centered Care Plan. All staff educated on following the CNA information sheets and the Comprehensive person-centered Care Plan. Monitoring: Audits will be conducted by the Director of Nursing monthly on Care planning for anti-coagulants with a 100% compliant threshold. This audit will be presented to QAPI monthly. Audits will be conducted by the Director of Nursing to include alarm use and Care planning. This will be done by checking physician orders [REDACTED]. This audit will be done monthly with a 100% compliant threshold and reported monthly to QAPI. Responsible Party: Director of Nursing
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, leading to deficiencies in care. Resident #30, who had diagnoses including osteoarthritis and vertebral artery stenosis, frequently experienced pain but did not receive proper pre and post pain evaluations when as-needed pain medication was administered. Observations noted the resident displaying signs of pain such as facial grimacing and moaning, yet the pain flow sheets were left blank, lacking documentation of the resident's pain levels and the effectiveness of the administered medication. Interviews with staff revealed a reliance on the resident to verbalize pain, despite their severely impaired cognition, and a lack of documentation of pain assessments. Resident #53, diagnosed with osteoarthritis and muscle weakness, experienced pain during transfers, particularly when using the sit-to-stand lift. Despite the resident's verbal complaints of pain during these transfers, there was no documented evidence of pre or post pain evaluations when as-needed Tylenol was administered. Observations showed the resident expressing pain during the transfer process, yet staff did not adequately address these complaints. Interviews with staff indicated an awareness of the resident's pain during transfers, but there was no follow-up with therapy or adjustments to the transfer process to alleviate the resident's discomfort. The facility's policy on pain assessment and management was not adhered to, as evidenced by the lack of documentation and follow-up on residents' pain levels and the effectiveness of pain interventions. The Director of Nursing acknowledged the expectation for nursing staff to document pre and post pain evaluations, highlighting a gap in practice that contributed to the deficiency. The failure to properly assess and document pain management interventions resulted in inadequate care for the residents involved.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F697- Pain Management: Crouse Community Center will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive centered care plan, and the resident’s goals and preferences. Corrective action: For resident #30, a new pain assessment and a therapy referral were completed. Medications were adjusted and is due for a review with provider. Care plan interventions updated. Resident #53 was transitioned to comfort care upon review of her MOLST with the family members and medication changes were made; she expired on [DATE]. Other residents: All licensed staff will be re-educated with the pain management policy which includes emphasis on pre and post pain evaluation and pain management documentation to ensure that pain management is appropriate and effective for all residents. All non-licensed staff will be re-educated on change in condition communication, pain identification, and reporting. Systemic changes: Pain Assessment and Management policy was updated and training will include accurate pain flow assessment record documentation and staff communication to ensure referrals to appropriate sources (i.e. therapy, psychosocial, medical, outside agencies referrals) were made. Monitoring: Audits will be conducted by the Director of Nursing monthly on pain flow sheet completion, and resident specific comprehensive care plan interventions. The audit will be reported to QAPI monthly with 100% compliant threshold expected. Responsible Party: Director of Nursing
Failure to Maintain Kitchen Fire Suppression System
Penalty
Summary
The facility failed to ensure that the main kitchen fire suppression system was maintained in accordance with the National Fire Protection Association 96 Standard. Specifically, the facility did not complete a semi-annual inspection of the fire suppression system for the first half of 2024. During an interview, the Maintenance Director acknowledged the requirement for semi-annual inspections and admitted that they mistakenly believed two inspections had been completed in 2024. However, it was discovered that the vendor had not scheduled an inspection for the first half of the year. Additionally, deficiencies identified during the semi-annual inspection on July 5, 2024, were not corrected in a timely manner. The inspection report noted the need to replace seven tin type scissor links with steel scissor links and to replace two nozzles. The Maintenance Director admitted that they had not reviewed the comment section of the inspection report prior to the federal survey and acknowledged that these deficiencies had not been addressed. The importance of ensuring all fire suppression system components are functional was emphasized by the Maintenance Director.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 On 1/20/2025 the Fire Suppression System was inspected, and all repairs were made at the same time. Going forward, the Director of Environmental Services will have calendar reminders on when semi-annual inspections are due and ensure they are completed timely. The vendor committed to comply with strict semi-annual inspections. All Maintenance staff has been educated on the importance of hood inspections, including the aspect of why repairs need to be done immediately following the inspection. The Director of Facilities also reviewed hood inspection schedules. The Director of Environmental Services will monitor compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Deficiencies in Emergency Generator Maintenance
Penalty
Summary
The facility failed to properly maintain its 500-kilowatt diesel emergency generator in accordance with National Fire Protection Association (NFPA) 99 standards. The deficiencies included the lack of documentation for the transfer time from main power to the generator, which was not recorded in the monthly generator test log from April 2023 to July 2024. The Maintenance Director admitted to being unaware of the requirement for documenting transfer time until reviewing the regulations in 2024. Additionally, the facility did not complete the annual fuel test for 2023, and the 2024 fuel test failed to meet the necessary requirements. The Maintenance Director acknowledged not knowing the importance of testing the diesel fuel annually to prevent generator failure due to contaminants. Furthermore, the facility did not conduct the required three-year four-hour load test or the annual load bank tests for 2023 and 2024. Although a generator test log indicated a four-hour run on March 4, 2024, the actual load could not be calculated, and the recorded amperage was below the required 30 percent load. The Maintenance Director was unaware of the specific amperage value needed to achieve the 30 percent load and assumed incorrectly that the monthly load tests were sufficient. This lack of awareness led to the omission of the necessary annual 1.5-hour load bank test when monthly load values were under 30 percent.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. **Generator Transfer Time** Transfer times are now being recorded on the generator log since 1/13/2025. All Maintenance staff were educated on the importance of properly recording generator transfer times. 2. **Annual Fuel Test** In discussing with the fuel testing company, our fuel did not “fail” because of hi [MEDICATION NAME]. It showed “failed” because the test measures for [MEDICATION NAME] due to an EPA regulation for “on-the-road” fuel. Our generator takes residential fuel that is “low [MEDICATION NAME]” and will never meet the “on the road” standard with an “ultra-low” formula. This part of the report is NOT-APPLICABLE since the generator and the “low [MEDICATION NAME]” fuel it uses is not for an “on the road” use. 3. **Three-Year Four-Hour Load Test** Crouse Community Center has scheduled a load bank test with the generator vendor on 3/19/2025 to ensure proper load requirement and will conduct the four-hour load test on 3/19/2025 once proper load is confirmed. 4. **Annual Load Bank Test** Crouse Community Center has scheduled a load bank test on 3/19/2025 to ensure compliance with proper load requirement. All Maintenance Staff were educated on the importance of accurate readings to reflect that the generator is running at 30%. They were also educated on the importance of the four-hour load test as well as the annual load bank testing. The Director of Environmental Services will monitor compliance with a generator testing that includes transfer time and load amount during testing, both with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Failure to Test and Maintain Emergency Lighting in Generator Room
Penalty
Summary
The facility failed to ensure that the emergency lighting in the basement generator room was tested and maintained as required. Specifically, the annual 90-minute run test for the battery-operated emergency light was not completed in 2023 and 2024, and the monthly 30-second run tests were not documented from an unspecified month in 2023 to an unspecified month in 2024. During an observation, it was noted that the basement generator room contained a battery-operated emergency light. The Maintenance Director confirmed in an interview that the required tests had not been conducted and stated they were unaware of the testing requirements for the emergency light.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 The Maintenance staff was trained on the importance of emergency lighting in the generator room and the importance of monthly and annual testing of the emergency lighting and correctly documenting it on a newly revised form. Ninety Minute test run on (MONTH) 9, 2025, 30 second tests were run on (MONTH) 12, 2025 & 3/3/2025. The Director of Environmental Services will monitor compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Improper Electrical Installations in Resident Rooms
Penalty
Summary
During a Life Safety Code recertification survey, it was found that the facility failed to ensure proper maintenance and installation of electrical installations in four resident rooms. The 2012 edition of NFPA 99, Health Care Facilities Code, mandates that all adaptors, extension cords, and attachment plugs must be listed for their intended purpose. However, the survey revealed that resident rooms A6 and B11 had electrical items plugged into unapproved 3-prong adapters, while rooms A9 and B2 had items plugged into unapproved extension cords. This was in violation of the facility's policy, which required that all incoming cords and power strips be inspected by the maintenance department to ensure compliance with UL ratings. The Maintenance Director, during an interview, admitted to being unaware of the presence of unapproved adapters and extension cords in the resident rooms. They acknowledged that any electrical items brought in by family members were supposed to be checked for electrical safety by the maintenance department, and that 3-prong adapters were not permitted. The director emphasized the importance of using proper electrical adapters to ensure the safety of residents and staff. This oversight indicates a lapse in the facility's adherence to its own policies and the requirements set forth by the Centers for Medicare and Medicaid Services.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 All unapproved extension cords and adapters were removed. Updated form in place for new admissions so resident and families understand regulation and memo to all staff to help police building from unauthorized cords and adapters. All Staff have been educated on the importance of regular room checks to ensure that there are no uninspected extension cords in any room. Families are informed upon admission, in the admission agreement, of our policy. The Director of Environmental Services will monitor compliance with extension cord an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Failure to Maintain Electrical Equipment Safety
Penalty
Summary
The facility failed to ensure that electrical equipment was maintained in accordance with National Fire Protection Association 99 standards. During the Life Safety Code recertification survey, it was observed that one non-patient care related electrical equipment and two patient care related electrical equipment lacked proper electrical inspection labels. Specifically, an electric tree in resident room B6, a curling iron in the beauty salon, and a hair dryer in the C-Unit shower room were found without current inspection labels. The facility's policy required all electrical equipment to be inspected and maintained to ensure resident safety, with annual preventative maintenance based on initial assessment and manufacturer's guidelines. The Maintenance Director confirmed that all electrical equipment should have been inspected by the maintenance department before being used in resident areas. However, the equipment was not currently tracked, and there was no documentation of inspections for the beauty salon curling iron and the C-Unit shower room hair dryer for 2023 or 2024. The Maintenance Director acknowledged the importance of maintaining electrical equipment for the safety of residents and staff, but the lack of inspection labels indicated a failure to adhere to the facility's Electrical Equipment Safety Checks policy.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Small electric tree was removed, and both the curling iron and hair dryer were inspected. A revised quarterly inspection tracking sheet was implemented and a memo for staff to help the maintenance staff identify any new electrical equipment brought into the facility. All Maintenance Staff were educated on the importance of inspecting all electrical equipment within the building. The Director of Environmental Services will monitor compliance with an Electrical Device Audit quarterly, with a 100% threshold, compliance with an audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Medical Gas and Vacuum System Deficiency
Penalty
Summary
The facility failed to ensure that the medical gas and vacuum system was inspected and maintained according to the National Fire Protection Association (NFPA) 99: Health Care Facilities code. The annual inspection report dated 2/1/2024 identified deficiencies in the vacuum source system, including inadequate electrical controls, missing hour meters, and the absence of a lag alarm. During an interview on 1/10/2025, the Maintenance Director admitted to being unaware of these deficiencies, as they were not informed by the third-party vendor responsible for the inspection. Additionally, an observation on the same day revealed that the basement medical gas system lacked labeling to indicate it had failed the annual testing.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 The vacuum system will be decommissioned on 2/20/2025. Additional portable suction devices were ordered and received. All staff have been educated on the decommissioning of the previous vacuum system and the implementation of the portable suction machines to be used in its place. The Director of Environmental Services will monitor all vendor reports to ensure no repairs are recommended in the notes of any section and complete an audit, with a 100% threshold, to report to the Quality Assurance Committee quarterly.
Deficiencies in Sprinkler System Maintenance and Structural Integrity
Penalty
Summary
The facility failed to maintain its automatic sprinkler system properly, as evidenced by the absence of a quarterly inspection for the third quarter of 2024. The Maintenance Director acknowledged that the inspection was overlooked and only realized the omission after the fourth quarter had begun. The vendor confirmed that the third quarter inspection was skipped, highlighting a lapse in the facility's maintenance schedule, which is crucial for ensuring the safety of residents and staff. Additionally, the facility did not address a failed backflow prevention device in the basement, which was identified during an annual test on February 8, 2024. The Maintenance Director was unaware of the failure and confirmed that no repairs had been made. Furthermore, the facility had structural deficiencies, including a missing ceiling tile in the A-Unit janitor's closet and holes in the main kitchen ceiling. These issues were not reported through work orders, and the Maintenance Director was unaware of them, indicating a lack of communication and oversight in maintaining the facility's infrastructure.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Sprinkler system inspections are up to date in 2025. The backflow devices were inspected and repaired on 2/5/2025. A third backflow is now decommissioned. Missing ceiling tile was replaced. Going forward, the Director of Environmental Services will have calendar reminders on when quarterly inspections are due and ensure they are completed timely. A new vendor has been selected to inspect and repair backflows immediately if necessary. Ceiling tile visual inspections will be added to the daily tour logs to ensure no tiles are damaged or missing. All Maintenance staff have been educated on the importance of complying with quarterly sprinkler inspections. The Director of Facilities also educated staff on why it is important to review inspection reports prior to signing report repairs. The Director of Environmental Services will monitor compliance with audits that track scheduled quarterly sprinkler inspections, backflow inspections, and ceiling tile visual inspections with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Unsealed Smoke Barrier Penetrations in F-Unit and D-Unit
Penalty
Summary
The facility failed to ensure proper maintenance of smoke barrier doors in two of its six smoke barriers, specifically in the F-Unit and D-Unit. During the Life Safety Code recertification survey, it was observed that the F-Unit smoke barrier had an unsealed cable wire passing through the wall, and the D-Unit smoke barrier had an unsealed data wire passing through the wall. The Maintenance Director, during an interview, admitted to being unaware of these unsealed penetrations and acknowledged the importance of properly sealed smoke barriers to prevent the spread of smoke and fire. The facility's documentation indicated that the smoke barriers were checked quarterly, with the last check completed on 12/20/2024, but the Maintenance Director had not followed up on this check. The facility's Smoke Wall Checks inaccurately documented the D Wing and F Wing as being in good condition.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 Wall penetrations were repaired on 1/14/2025. Maintenance Staff was inserviced on the importance of sealing any wall penetrations when completing work. The Director of Environmental Services will monitor compliance with a smoke wall penetration audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Unsealed Hole in E-Unit Pantry Door
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the E-Unit pantry access door in the facility had an unsealed hole near the door handle. This deficiency was identified on January 8, 2025, at 11:25 AM. The Maintenance Director, during an interview on January 10, 2025, acknowledged that the door lock set for the E-Unit pantry had been replaced in 2023, but they were unaware that a hole was left from the previous door lock set until it was pointed out during the survey. The Maintenance Director emphasized the importance of ensuring that all corridor doors are properly sealed for the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 Door was repaired on 1/14/2025. Maintenance staff no longer employed. Education of Maintenance staff on importance of filling holes in doors when completing any work. The Director of Environmental Services will monitor compliance with a door audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
Missed Fire Drill for Evening Shift
Penalty
Summary
The facility failed to conduct a required fire drill for the evening shift during the first quarter of 2024. This deficiency was identified during a Life Safety Code recertification survey conducted from January 8 to January 10, 2025. The facility was unable to provide documentation proving that the evening shift fire drill had been completed for the specified period. During an interview on January 10, 2025, the Maintenance Director acknowledged that the evening shift fire drill was missed and confirmed awareness of the requirement to conduct quarterly fire drills for each shift to ensure the safety of residents and staff.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Fire drills are up to date. Maintenance Director will preplan quarterly fire drills to ensure no shift is ever missed going forward. All Maintenance Staff have been educated on the importance of fire drills, including maintaining the quarterly schedule per shift. The Director of Environmental Services will monitor compliance with a fire drill audit, with a 100% threshold, and report the results to the Quality Assurance Committee quarterly.
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.
