Crown Heights Center For Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, New York.
- Location
- 810 20 St Marks Avenue, Brooklyn, New York 11213
- CMS Provider Number
- 335609
- Inspections on file
- 20
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Crown Heights Center For Nursing And Rehab during CMS and state inspections, most recent first.
A resident with a history of falls and moderately impaired cognition was observed by an OTA sliding from a wheelchair to the floor. Facility policy required immediate notification of the resident and/or representative and the physician for changes in condition, but there was no documentation that the resident’s representative or MD were notified. An RN supervisor confirmed that, although an assessment revealed no visible injury or trauma, neither the physician nor the resident’s representative was informed of the incident, and the DON stated that such notification was required.
A resident with a history of falls and moderately impaired cognition slid from a wheelchair to the floor on two occasions observed by an OTA, who reported the incident to an LPN and documented it on a facility form. The RN supervisor on duty stated they were notified and performed a full body assessment with no injuries or pain noted, but did not document the incident or update the resident’s fall-related care plan. There was no evidence that the interdisciplinary team reviewed or revised the care plan or held a team meeting to address the sliding event, despite facility policy requiring care plans to be revised when a resident’s condition changes.
A resident with a history of constipation and moderately impaired cognition requested a stool softener, and an LPN administered two tablets for constipation without a physician’s order and without proper medication documentation, contrary to facility policy requiring verification of orders before giving oral meds. The resident subsequently experienced abdominal pain and constipation symptoms, was transported to the ED after calling 911, and had large bowel movements there, with no bowel obstruction identified. Review of the medical record confirmed there was no active stool softener order at the time, and the attending physician reported receiving no request for such an order.
A resident with a history of falls, chronic pain, and moderately impaired cognition had an order to use a standard wheelchair with elevating leg rests and one-person assistance for transfers, but there were no documented nursing instructions on how staff should supervise the resident to prevent falls. An OTA observed the resident sliding from the wheelchair to the floor on more than one occasion and reported this to an LPN and wrote a statement, yet there was no documented body assessment, no notification to the MD or family, and no documented investigation. An RN supervisor later stated they assessed the resident but did not complete a fall assessment or notify the MD, and the DON reported being unaware of the incident.
A resident with chronic pain, a history of falls, and moderately impaired cognition slid from a wheelchair to the floor, as documented by an OTA. Despite facility policy requiring documentation of all incidents, accidents, and changes in condition, there was no nursing or MD documentation of any assessment following the event. An RN supervisor acknowledged being informed of the incident and not entering a progress note, and the DON confirmed that a nursing progress note should have been completed.
The facility failed to maintain proper records of monthly inspections for portable fire extinguishers. During a survey, it was found that the fire extinguisher in the 1st floor atrium had no recorded inspections, and further inspection revealed no records for extinguishers on all floors. The facility's inspection log was also incomplete, lacking a full inventory of extinguishers.
The facility failed to maintain a safe and homelike environment, with observations of damaged furniture, mismatched paint, and dirty medical equipment across various units. Staff interviews revealed inconsistent maintenance and cleaning protocols, with ongoing remodeling efforts but no specific timelines for completion. The facility's policies on cleaning and disinfecting were not adequately implemented, compromising residents' living conditions.
The facility failed to report several incidents of abuse and injuries of unknown origin to the New York State Department of Health. One resident with Alzheimer's was found with a hematoma, another incident involved a resident-resident altercation causing injuries, and a third involved a resident with a toe fracture. The facility did not report these incidents, believing they did not meet the criteria for reporting.
The facility failed to investigate allegations of abuse and injuries of unknown origin. A resident with Alzheimer's was found with a hematoma, and the cause was not determined. In another incident, two residents were injured in an altercation, but the investigation was incomplete, lacking a report for the aggressor. The facility did not adhere to its abuse prevention policy, compromising resident safety.
The facility failed to adhere to food safety standards, with staff observed not wearing proper hair and beard restraints in the kitchen. Additionally, improper storage of food thickening powder was noted, with an open box and torn plastic bag found in the dry storage room. The facility's policies lacked specific uniform requirements, contributing to these deficiencies.
The facility failed to post required signage reminding residents and staff of COVID-19 vaccination availability, as observed during a survey. The signage was removed during renovations, and staff were unaware of the ongoing requirement. Interviews with the Infection Preventionist, DON, and Administrator revealed a lack of awareness about the need to maintain the signage.
The facility was found non-compliant with NFPA 101: 19.1.6.1 due to its Type II (000) construction exceeding the allowed two stories, with four floors observed. A time-limited waiver is in place while the facility works on creating a rated ceiling system to address this issue.
The facility failed to maintain electrical system safety, with unlocked circuit panels accessible to the public and non-GFCI outlets near sinks, violating safety codes.
The facility did not ensure proper enclosure of hazardous areas as per 2012 NFPA 101 standards. Observations included a non-fire-resistant plywood wall in the generator room, an open door, missing ceiling tiles, and improper sealing in the automatic transfer switch room. Additionally, doors to the trash compactor and boiler rooms lacked self-closing mechanisms and hardware, and the maintenance shop door was held open with a magnet not tied to the fire alarm system.
The facility failed to maintain clear egress routes, with obstructions noted in corridors and a locked exit gate. Combustible items and boxes reduced corridor widths, and a locked gate impeded egress from stair B. These issues were acknowledged by the Director of Maintenance.
The facility failed to maintain the sprinkler system as per 2011 NFPA 25 standards. Missing escutcheons were noted in several areas, and there was no record of the 5-year internal pipe inspection. The Director of Maintenance acknowledged these issues during the survey.
A survey found that the facility's egress stairs lacked required contrasting marking stripes on handrails and landings, violating NFPA 101 standards. Additionally, a door at the first-floor landing was missing a fire rating label, breaching NFPA 80 standards. The Director of Maintenance acknowledged these deficiencies.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately reflected their activity preferences, while another's did not document the use of a physician-ordered wander guard. Errors were attributed to oversight by the Activities Director and MDS Assessor.
Three residents in the facility were not provided with activities that met their preferences, specifically the ability to watch television in their rooms. Despite being aware of the residents' preferences, the facility failed to reinstall television sets after maintenance, leaving the residents without their preferred activities. The facility's staff acknowledged the issue but did not resolve it promptly, resulting in a deficiency in meeting the residents' physical, mental, and psychosocial well-being.
A resident with cognitive impairment and behavioral issues sustained a foot injury after placing their foot on a radiator with sharp edges. The facility failed to report the incident to the Department of Health, and staff interviews revealed inconsistencies in the facility's response and maintenance checks.
A resident with End Stage Renal Disease did not have documented physician orders for dialysis, despite attending regular sessions. The facility's policy required order reconciliation during admissions, but this was not followed during the resident's readmission. Staff were aware of the dialysis schedule, but the necessary orders were not documented, leading to a deficiency in care.
The facility failed to store medications according to professional standards, with expired Heparin flush syringes and intravenous fluids found in two units' medication rooms. Staff interviews revealed inconsistent monitoring and removal of expired items, despite monthly inspections by the Consultant Pharmacist. The lack of regular checks and communication breakdowns contributed to the oversight, posing a risk to resident safety.
The facility failed to follow its menu policy, resulting in food items being omitted or substituted without informing residents. Several residents with cognitive impairments were served meals missing items like milk and salad, which were crossed out on tray tickets without appropriate substitutions. Staff interviews revealed inconsistencies in handling menu changes, and the Director of Food Service and Registered Dietitian were not always consulted, leading to the deficiency.
A facility failed to maintain infection control practices, as a CNA did not perform hand hygiene between assisting residents, and an LPN did not follow proper wound care protocols, including hand washing and gown use, for a resident with a stage 4 pressure ulcer. Despite training, these lapses were observed during a survey.
The facility failed to maintain an effective pest control program, as evidenced by observations of a live rodent in the dining room and flies in various units. Staff and residents reported sightings of mice and flies, indicating a deficiency in the pest control program despite the facility's policy for weekly pest control services.
A refrigerator in the employee cafeteria was improperly plugged into a relocatable power strip, violating the facility's policy against connecting high amperage loads to power strips. Additionally, there were no records of periodic testing for power strips in the building.
The facility was found deficient in maintaining continuous illumination for egress as required by NFPA 101 standards. During a survey, it was noted that the 1st floor egress passageway had switches that could manually turn off all lights, compromising safety. The Director of Maintenance acknowledged the issue.
The facility did not ensure full sprinkler system coverage, with no protection under stair D and unclear coverage in the atrium. Additionally, electrical BX cable was improperly suspended from sprinkler piping in the fire pump room.
The facility did not have a policy in place to ensure occupant safety during a fire alarm system impairment lasting more than four hours. This deficiency was identified during a life safety survey, revealing the absence of procedures to protect occupants when the fire alarm system was out of service.
A facility was cited for not having a policy for actions when the sprinkler system is out of service. A surveyor found a covered sprinkler head in a construction area, rendering it inoperable, with no fire watch conducted. The facility lacked a policy for protecting occupants if the system was down for over 10 hours.
Failure to Notify Resident Representative of Change in Condition After Wheelchair Incident
Penalty
Summary
The facility failed to notify a resident’s representative of a change in condition after the resident was observed sliding from a wheelchair to the floor. Facility policy dated 12/2024 required that changes in a resident’s condition or treatment be immediately shared with the resident and/or resident representative and reported to the attending physician, and that staff be educated to identify and report such changes. Resident #1, who had diagnoses including constipation, chronic pain syndrome, history of falling, and moderately impaired cognition per the 11/22/2025 MDS, was seen on 12/06/2025 at 5:00 PM by Occupational Therapist Assistant #1 sliding from the wheelchair to the floor. Record review showed no documented evidence that Resident #1’s representative was notified of this event. During interview, Registered Nurse Supervisor #2 stated that upon body assessment there were no visible injury, trauma, or skin changes, and acknowledged that neither the medical doctor nor the resident’s representative was informed of the incident. In a separate interview, the Director of Nursing stated that Registered Nurse Supervisor #2 was required to notify the medical doctor and the resident’s family representative when the resident slid from the wheelchair to the floor. This failure to notify the representative of a change in condition was cited under 10 NYCRR 415.3(e)(2)(ii)(b).
Failure to Review and Revise Care Plan After Wheelchair Sliding Incident
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan by the interdisciplinary team after a change in condition, as required by facility policy and regulation. The resident had diagnoses including constipation, chronic pain syndrome, a history of falling, and a Minimum Data Set showing moderately impaired cognition. The existing care plan for an actual fall, initiated months earlier, included interventions such as keeping personal items within reach, neuro checks, physical therapy, and routine rounding. On a specific date and time, an occupational therapist assistant (OTA) observed the resident sliding from a wheelchair to the floor, reported the incident to an LPN, and documented the event on a facility statement form. The RN supervisor on duty acknowledged being notified that the resident had slid from the wheelchair to the floor and stated that a full body assessment was performed, with no injuries, trauma, or pain reported by the resident. However, the RN supervisor also stated they did not document the sliding incident and did not update the resident’s care plan. There was no documented evidence that the care plan was reviewed or revised with new interventions following this event, and no documentation of a team meeting to discuss the incident. The DON reported being unaware of the sliding incident and stated that the RN supervisor should have completed an incident report and updated the care plan. This lack of documented care plan review and revision after the resident slid from the wheelchair to the floor formed the basis of the cited deficiency under 10 NYCRR 415.11.
Unauthorized Administration of Stool Softener Without Physician Order
Penalty
Summary
The deficiency involves the failure to provide treatment and care in accordance with professional standards and physician orders when a nurse administered a stool softener without a valid order and failed to document it. Facility policy on administering oral medications, dated 12/2024, required verification of a physician’s medication order prior to administration. Resident #1, admitted with diagnoses including constipation, chronic pain syndrome, and a history of falling, had a care plan addressing bowel incontinence with interventions such as checking the resident every two hours, assisting with toileting, observing incontinence patterns, and initiating a toileting schedule if indicated. The Minimum Data Set dated 11/22/2025 documented moderately impaired cognition for Resident #1. Review of physician orders from 12/01/2025 to 12/29/2025 showed no active order for any stool softener. On 12/19/2025 at 11:11 AM, a nursing progress note by Licensed Practical Nurse (LPN) #1 documented that Resident #1 requested a stool softener and that the medication was given and tolerated well. Resident #1 later reported they informed LPN #2 of constipation and received medication for it, but continued to have pain and subsequently called 911. LPN #2 confirmed in interview that, at the resident’s request, they administered two tablets for constipation despite there being no physician’s order for the medication. The administration was not documented as a medication entry in the record. The Emergency Department note for that same date recorded that Resident #1 presented with constipation, intermittent cramping, and abdominal pain, reported no bowel movement for three days, had received medication at the facility and had a bowel movement just before arrival, and then had a large bowel movement in the ED with resolution of pain and no bowel obstruction found. The attending physician (Medical Doctor #1) stated that after an initial 30‑day bowel regimen at admission, there were no further constipation complaints and no call requesting a stool softener order on the date in question. The Administrator acknowledged that LPN #2 administered a stool softener without a physician’s order.
Failure to Supervise High Fall-Risk Resident and Document Wheelchair Fall Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as high risk for falls. The resident had diagnoses including constipation, chronic pain syndrome, a history of falling, and a Minimum Data Set showing moderately impaired cognition. A physician’s order dated 11/11/2025 allowed the resident to be out of bed to a standard wheelchair with bilateral elevating leg rests and required partial to moderate assistance during manual transfer by one person. Despite a facility fall risk assessment policy requiring identification and documentation of fall risk factors and evaluation of conditions that may predispose residents to falls, there was no documented evidence on the Documentation Survey Report or Resident Nursing Instructions form describing how staff should supervise this resident to prevent falls. On 12/06/2025 at approximately 5:10 PM, an Occupational Therapist Assistant observed the resident sliding off a wheelchair on the third floor. The assistant reported that the resident got up independently, sat back in the wheelchair, and then slid off again, after which the assistant informed an LPN and wrote a statement left at the nursing station. There was no documented body assessment, no documentation that the physician or family were notified, and no documented facility investigation of the incident. The RN Supervisor later stated they were informed that the resident slid out of the wheelchair, asked the resident what happened, and performed a body assessment but did not document a fall assessment because there was no trauma, injuries, or skin changes, and did not inform the physician. The Director of Nursing stated they were not aware of the incident and acknowledged that the RN Supervisor should have initiated an incident report, collected staff statements, and reported the fall to the physician and the resident’s family representative.
Failure to Document Nursing Assessment After Wheelchair Slide Incident
Penalty
Summary
Surveyors identified a failure to maintain medical records in accordance with accepted professional standards when an incident involving a resident sliding from a wheelchair to the floor was not documented by nursing staff or a physician. The facility’s Charting and Documentation policy, dated 01/2026, requires that all services provided, and any incidents, accidents, or changes in a resident’s condition, be recorded in the medical record. Occupational Therapist Assistant #1 documented on 12/06/2025 at 5:00 PM that Resident #1 was seen sliding from a wheelchair to the floor. However, review of the medical record from 12/01/2025 through 12/30/2025 revealed no nursing or physician documentation indicating that the resident was assessed following this event. Resident #1 had diagnoses including constipation, chronic pain syndrome, a history of falling, and was documented on the 11/22/2025 MDS as having moderately impaired cognition. During an interview, Registered Nurse Supervisor #2 stated that on 12/06/2025 they were informed that Resident #1 had slid from the wheelchair to the floor and that the resident reported they did not fall. RN Supervisor #2 acknowledged they did not write any progress note in the resident’s medical record regarding this incident. In a separate interview, the Director of Nursing confirmed that RN Supervisor #2 had been working at the time and stated that RN Supervisor #2 should have written a nursing progress note in the resident’s medical record. This lack of documentation was cited under 10 NYCRR 415.22(a)(1-4).
Failure to Maintain Fire Extinguisher Inspection Records
Penalty
Summary
The facility failed to maintain proper records of monthly inspections for portable fire extinguishers as required by NFPA 101 and NFPA 10 standards. During a life safety survey, it was observed that the fire extinguisher located in the 1st floor atrium had a hang tag with no monthly inspections recorded. A vendor was seen changing the tag on this extinguisher shortly before the finding, and the Director of Maintenance explained that it was their policy to remove old tags if the record was full. However, the new tag also lacked any recorded inspections. Further inspection revealed that no monthly inspections were recorded for any extinguishers on all four floors of the building. Additionally, the facility's fire extinguisher inspection log was incomplete, lacking a full inventory of all extinguishers in the building. This deficiency indicates a failure to comply with the required standards for fire safety equipment maintenance and documentation.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: All fire extinguishers in the building including the 1st floor atrium, were inspected immediately to ensure compliance with fire safety standards. The maintenance staff will ensure that each extinguisher has a correctly dated inspection tag. Old hangtags will only be removed after transferring all records to the new tag. A specific protocol was established for transitioning all records to the new tag. A specific protocol will be established for transitioning between old and new tags to prevent lapses in inspection documentation. A meeting will be held with the vendor to review their inspection responsibilities and documentation standards. Element 2: All residents have the potential to be affected by this practice; however, no residents were affected as a result of this practice. Element 3 Systemic Changes: Policy was reviewed and revised to reflect that old hand tags will only be removed after transferring all records to the new tag. A specific protocol will be established for transitioning between old tags to prevent lapses in inspection documentation. The maintenance will implement a Fire Extinguisher log to ensure compliance. The maintenance director will audit to ensure all fire extinguishers are inspected and documentation is up to date. Element 4: The maintenance director will audit to ensure all fire extinguishers are inspected monthly and documentation is up to date. The maintenance director will monitor compliance and report findings to the administrator monthly. The maintenance director will report findings to the QAPI Committee on a quarterly basis for 3 quarters. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance director.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of deficiencies across various units. Resident rooms were found with scratched and damaged furniture, mismatched paint, holes in drywall, and duct tape on floors. Additionally, enteral feeding pumps and poles were observed with cream-colored stains, and shared bathrooms and whirlpool tubs were noted to be dirty and in disrepair. The kitchen area also exhibited several issues, including leaking kettles, cracked tiles, and grease residue on metal shelves. Interviews with staff revealed that maintenance and cleaning protocols were not consistently followed or effectively communicated. Dietary aides reported broken kitchen tiles and leaking kettles, while housekeeping staff were unsure of reporting procedures for damaged furniture. Maintenance staff acknowledged the need for repairs and replacements but indicated that matching paint and replacement doors were still pending. The Director of Maintenance confirmed ongoing remodeling efforts but did not provide specific timelines for completion. The facility's policies on cleaning and disinfecting resident care items and equipment were not adequately implemented, as evidenced by dusty and stained medical equipment and furniture. Staff interviews highlighted a lack of clarity regarding cleaning responsibilities and the frequency of maintenance checks. Despite some efforts to address these issues, the facility's environment remained substandard, compromising the residents' right to a homelike and safe living space.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F584 Element 1 Immediate Corrective Action:** The Maintenance Director and Food Service Director immediately took action to correct the deficiencies identified in the kitchen. A 1/2-inch quick valve was replaced to correct the leak on the kettle. The Quarry floor tile has been ordered, and all cracked kitchen tiles will be replaced throughout the kitchen. The gap in the wall edge by refrigerator #3 will be repaired. Metal shelving in the kitchen holding washed dishes was immediately cleaned. Cracked flooring and baseboard tiles in the dish room were replaced. The cracked floor tile identified in freezer #2 has been removed and will be replaced with quick-dry cement and epoxy. Next, work will begin on Refrigerator #1, and the floor will be replaced. The dish room handwashing sink opening has been closed in the tile surrounding the pipe. The metal stairs identified by the compactor were replaced on (MONTH) 14, 2025, and the wheelchair parts stored were removed. The Housekeeping and Maintenance Directors immediately acted to correct the deficiencies identified in the nursing units. **2 East:** The Director of Housekeeping audited to ensure that all feeding pumps were cleaned. Any pumps with stains, including E209, W203, and W238, were immediately cleaned or replaced. In E206, the floor tile was replaced, the duct tape was removed, and the garbage can was replaced with a new one. The drywall on the elevator bank on 2 East elevators #1, #2, and #3 was repaired and replaced with corner guards. The fan was cleaned and removed. **2 East:** The 3 areas identified with a gap around the piping in the shower rooms under the sink were filled, the shower drain cleaned, and the drain cover replaced. All debris noted in the century tub was removed and cleaned. Hoyer canvas was removed for routine cleaning. The Director of Maintenance did a whole house audit to ensure all a/c units were clean and dust-free. Areas identified were immediately cleaned to include the following rooms: W238, W203, W208, E318, E302, E311, E308, E315, E306, E302, E317, and the 4 units on 4 West Dayroom. **2 West Medication Room:** The company who built the cabinets was contacted to replace the peeling veneer on the upper middle cabinet door. The kitchenette and refrigerator/freezer in the staff lounge were cleaned immediately. **2 W room [ROOM NUMBER]:** The call light box was replaced on the wall. **room [ROOM NUMBER]:** The chip noted in the barn door was filled in, and the door was repainted. The medication cart on 2 West was removed and cleaned. **2 West Main shower room:** Debris identified in the century tub was removed, and the tub was cleaned. The bariatric shower chair was removed and cleaned, and any rusty wheels will be replaced. The cracked tile under the sink was replaced. The sharps container on the Wound Care Cart was adhered correctly to the cart to ensure it was closing. **2 West Lobby Area:** The baseboard heater cover had fallen off and was clipped back on. The ice machine vent was cleaned immediately. The hole in the wall behind the refrigerator was repaired, and the gap between the fridge and the false pantry will be repaired as we proceed. **3 East:** Brookstone Developers will begin renovating the following rooms starting (MONTH) 20, 2025: 3 East Rooms 300, 318, 306, 339, 303, 311, 308, 317, 309, 315, 305, 304, 302, 308. This will include replacing ceiling tiles and grids, flooring, painting walls, nightstands, overbed tables, wardrobe closets, a handwashing sink inside resident rooms, and new tile and showers inside each resident's bathroom. **3 West:** Brookstone Developers completed the renovation of the 3 West Main Shower Room and removed the Century Tub. This renovation includes new ceiling tiles, lighting and grids, fixtures, tile, and flooring. All old equipment, such as commodes, has been discarded. **Pantry:** All areas within the pantry were cleaned, and the metal ladle in the drawer under the microwave was discarded. **3 West Medication carts:** In (MONTH) 2023, Specialty Pharmacy provided Crown Heights Center with new medication carts; each unit has 2 medication carts and 1 treatment cart. The housekeeping department schedules the monthly cleaning of medication carts using a pressure washer. During this process, the Director of Housekeeping will in-service the staff to clean the bottom of the medication cart. All medication carts identified as being dusty or soiled were immediately cleaned. **4 West:** The 4th-floor hallway and the opposite side of the elevators were repainted. Room [ROOM NUMBER] was completely renovated and painted. W 417 Resident Room chair was replaced. The 5 Tier Linen cart with a cracked left edge was repaired. Bedside tables will be replaced in the following rooms: W400, 414, 406, 403, 408, 407, 409, 417, 421, 432, 428, 405. **Element 2 Residents at Risk:** All residents have the potential to be affected by this practice. The Food Service Director immediately audited all trays. Any cracked trays will be removed. The Director of Maintenance and the Director of Housekeeping conducted a visual inspection of the entire facility, and no other issues were identified. **Element 3 Systemic changes:** Policies and procedures were reviewed, and no revisions were necessary. On (MONTH) 6, 7, and 8th, maintenance and housekeeping staff were in-serviced to maintain a safe, clean, and comfortable environment. The housekeeping director is responsible for ensuring all equipment is clean and operable. The director of maintenance is responsible for ensuring preventative environmental rounds are routinely conducted and any identified issues are corrected immediately. An audit tool has been developed to monitor compliance. **Element 4 Monitoring of Corrective Action:** On a weekly basis for 6 months, Maintenance and Housekeeping directors will conduct environmental audits. The maintenance and housekeeping director will report findings to the administrator monthly. Any issues identified will be corrected as soon as possible. Maintenance and housekeeping directors will report findings to the QAPI Committee for two quarters. The QAPI Committee will determine if any further action is required. **Element 5 Responsibility:** Director of Maintenance, Housekeeping Director, and the Administrator.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report several incidents of abuse and injuries of unknown origin to the New York State Department of Health within the required timeframe. One incident involved a resident with Alzheimer's disease who was found with a hematoma on the forehead. Despite the family expressing concerns about the injury resembling a punch, the facility did not report the incident as an injury of unknown origin. The investigation did not provide evidence of how the injury occurred, and the facility's interdisciplinary team concluded that the incident was not reportable. Another incident involved a resident-resident altercation where one resident pushed two others, resulting in injuries that required hospital evaluation. The aggressor was identified, but the incident was not reported to the Department of Health. The Director of Nursing and Assistant Director of Nursing reviewed the incident but decided it did not meet the criteria for reporting, despite regulations requiring immediate reporting of abuse allegations. A third incident involved a resident with a severely impaired cognition who sustained a laceration and fracture to the toes. The injury was attributed to contact with a radiator, but there was no documented evidence of sharp edges on the radiator. The facility did not report this injury to the Department of Health, as the Director of Nursing believed the cause of the injury was known and did not require reporting.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin, as evidenced by two specific incidents involving residents. In the first incident, a resident with Alzheimer's disease and severe cognitive impairment was found with a hematoma on the forehead, which was not witnessed by any staff. Despite the resident's inability to communicate how the injury occurred, the facility did not conduct a comprehensive investigation to determine the cause of the injury. Interviews with staff revealed inconsistencies in their accounts, and there was no documented evidence of a thorough investigation or rationale for not reporting the incident as required by facility policy. In the second incident, a resident-to-resident altercation occurred involving three residents, resulting in two residents being pushed to the floor and sustaining injuries. The facility's investigation was incomplete, as it did not include an incident report for the resident identified as the aggressor. Interviews with staff indicated that the incident was not reported to the Department of Health, and the facility did not consider the incident as abuse due to the cognitive impairments of the residents involved. The Director of Nursing and Assistant Director of Nursing failed to ensure that all necessary documentation and reporting were completed. Overall, the facility did not adhere to its policy on abuse prevention and reporting, which requires immediate reporting and thorough investigation of all alleged violations. The lack of a comprehensive investigation and failure to report these incidents demonstrate a deficiency in the facility's handling of potential abuse and injury cases, compromising the safety and well-being of the residents involved.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F610 Corrective Actions for Residents Identified: No further occurrences related to abuse, including injury of unknown origin, resident-to-resident altercation, neglect, and mistreatment, were identified by the ADNS/Risk Manager. All accidents/incidents will be reviewed and reported immediately if they meet the reporting criteria but not later than 2 hours. Abuse care plans are in place for all 3 residents, #251, #214, #268, and #589 (no longer in the facility). Resident #251 is placed in the hallway or the dining room with activities for close observation. Resident #214 is placed in the hallway or in the dining room with activities for close observation. Resident #268 is placed at the nursing station with activities for close observation. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The ADNS and DNS completed an audit tool to review accidents/incidents investigated in the past three months to determine whether an occurrence is abuse, neglect, injury of unknown origin, or mistreatment. This alleged deficient practice has not identified similar findings or adverse effects. Element 3 Systemic Changes: The Administrator, Director of Nursing, Assistant Director of Nursing, and Medical Director will continue to review and revise, as indicated, the policies and procedures related to Abuse Prevention, including timely reporting of all allegations and or observations of abuse to the Administrator and other officials as outlined in the regulations and State Law. The ADNS will in-service staff in all departments on abuse prevention, focusing on initiating an investigation of abuse allegations. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: ADNS (Risk Manager) or designees will review the 24-hour report and all accidents or incidents to ensure there are no allegations that need to be investigated or any occurrences that require investigation for the next 4 weeks. The DNS will audit all AI weekly for four weeks to ensure that outstanding issues and incidents requiring investigation are compliant and have no outstanding issues. DNS will report to the Administrator. DNS will report to QAPI for one quarter. QAPI Committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Responsible Person: Director of Nursing, Assistant Director of Nursing, and Administrator.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. During the recertification survey, multiple instances were observed where staff did not wear appropriate hair and beard restraints in the kitchen. The Food Service Director, Dietary Aides, and a contracted pest control person were all observed without proper hair or beard nets, despite having noticeable facial hair. Interviews with the staff revealed that some were aware of the requirement but failed to comply due to discomfort or forgetfulness. Additionally, the facility's dry storage room was found to have an open box of instant food beverage thickening powder with a torn plastic bag and a paper cup inside. This box was observed on two separate occasions, indicating a lack of proper storage practices. The Dietary Aide responsible for checking the dry storage room admitted to not knowing who tore the bag and acknowledged that the food should be covered to prevent contamination. The Director of Food Services confirmed that the thickener should be stored in a container and not left open. The facility's dietary policies and procedures were found to be lacking in specific uniform requirements related to food handling. Although the policies outlined the need for safe and sanitary food preparation and handling, they did not explicitly mention the use of hair and beard nets. The facility's sanitation inspection and audit processes were also noted, but the observed deficiencies suggest that these measures were not effectively implemented or enforced.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 Element 1 F812 Corrective Action: The Staff that were observed not wearing a beard net were immediately educated on wearing appropriate face beard covers inside the kitchen. All vendors will also be educated on the hair and beard coverings procedure. The open thickener box was removed, and the product was disposed of properly. A complete inspection of all dry storage areas was conducted to identify and remove any other improperly stored items. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All Dietary Staff were monitored to ensure compliance with beard and hair net coverings were in place. All dry storage areas were inspected to identify and remove any other improperly stored items. There were no issues that were identified. Element 3 Systemic Changes: Personal hygiene and protective equipment policies were reviewed to reflect strict enforcement of beard and hair nets. All dietary staff received mandatory in-service training on proper food safety protocols, including wearing hair and beard nets. Policies on food and dry storage were reviewed to ensure they included all food and beverages in dry storage that are labeled, and in approved containers. No revisions were required. Staff received training on proper storage requirements and food safety protocols. Audit tools are being developed to monitor compliance. Element 4 Monitoring of Corrective Action: Food Service Director will conduct daily spot checks to ensure compliance with personal protective equipment requirements. Non compliance will be documented and addressed with immediate corrective action. The Food Service director or designee will conduct daily inspections of storage area to ensure compliance with food safety protocols. Non compliance will result in retraining and possible disciplinary action. Monthly audits of kitchen and storage areas will be conducted, and results will be reviewed monthly with the administrator for a period of 6 months. On a quarterly basis, the results will be presented by the Food Service director to the QAPI committee. The QAPI Committee will decide if further action is required. Element 5 Completion date: (MONTH) 19, 2025 Person responsible: Food Service Director and Food Service Supervisor.
Failure to Post COVID-19 Vaccination Signage
Penalty
Summary
The facility was cited for failing to ensure conspicuous signage was posted throughout the facility to remind residents and staff that COVID-19 vaccinations were available. This deficiency was identified during a Recertification Survey conducted from December 12, 2024, to December 19, 2024. The Dear Administrator Letter #23-15, dated in 2023, required facilities to post such signage at entry and exit points and in each residential hallway. However, observations during the survey revealed that no signage was present in the lobby, hallways, or resident units. The facility's policy for COVID-19 vaccination for healthcare personnel, dated January 31, 2024, did not include procedures for posting signage. Interviews with facility staff revealed a lack of awareness regarding the ongoing requirement to post COVID-19 vaccination signage. The Infection Preventionist stated that the signage had been removed during facility renovations and was unaware of the continued requirement. The Director of Nursing also confirmed the removal of the signage following the lifting of the mask mandate and was not aware that the signage needed to remain posted. The Administrator acknowledged that while the facility provided COVID-19 vaccinations, they were not aware that the signage had to be maintained, as they had only circulated flu vaccine signage.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 Immediate corrective Action: On 12/19/24, signage announcing the availability of the COVID-19 vaccination was printed and posted in highly visible locations within the building, including all entryways, lobby, hallways, time clocks, and resident units. Element 2 All residents have the potential to be affected by this practice. All residents' representatives/family contacts will receive a message through the Care Connect messaging system informing them of the availability of the COVID-19 vaccine. The Activities Department will inform all residents currently residing in the building of the availability of the COVID-19 vaccine. Element 3 The facility updated the infection control policy to include a requirement for posting of COVID-19 vaccination signage. The policy outlines the specific locations for signage placement and a procedure for routine checks to ensure compliance. Element 4 The Infection Preventionist or designee will conduct weekly environmental rounds for 3 months to ensure signage is posted. The Results of the environmental rounds will be reported to the Administrator monthly. The Infection Preventionist will report the findings of the audit to the QAPI Committee for the 1st quarter of 2025. QAPI Committee will decide if further action is required. Element 5 Completion Date: (MONTH) 19, 2024 Person Responsible: Infection Preventionist or designee.
Non-compliance with Building Construction Type Limitations
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: 19.1.6.1 regulation, which limits existing health care occupancies to specific building construction types. The building in question was identified as Type II (000) construction, which is restricted to two stories in height and requires complete automatic sprinkler protection. However, the facility was observed to have four floors, indicating a violation of the construction type limitations. This deficiency was noted during a life safety survey conducted on December 17, 2024, between 8:30 am and 11:00 am. The facility is currently working to create a rated ceiling system throughout to address this non-compliance, and a time-limited waiver is in place until October 31, 2025, to allow for the completion of the necessary repairs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K 161 Corrective Action: The facility was approved for a limited-time waiver with an expiration date of (MONTH) 31, 2025. Brookstone Contractors began the current ceiling replacement with materials and assemblies that are UL-listed to provide a 2-hour rating, and this project started on (MONTH) 19, 2024. Project Status: - Lobby: All ceiling grids, tiles, and lighting have been replaced throughout the lobby, kitchen, IT Room, and all non-clinical areas. - 2 East: Dayrooms/Common area grids, ceiling tiles, and lighting have been completed. - 3 West: Dayroom/Common area grids, ceiling tiles, and lighting have been completed. - 3 East: Dayroom Common area grids, ceiling tiles, and lighting have been replaced. Work to begin on (MONTH) 11, 2025, in the following resident rooms: E 300, 302, 303, 304, 305, 306, 308, 309, 311, 315, 317, 318, 339. - 4 East: Completed. - 4 West: Dayroom Common area grids, ceiling areas, and lighting have been completed. Work on the following resident rooms has been completed: 400, 402, 404, 406, 408, 410. Element 2: All residents have the potential to be affected by this practice. Element 3: The maintenance director oversees the project to ensure Interim Life Safety plan compliance. Staff members responsible for facility maintenance are trained on the periodic inspection of fire-rated ceiling systems. The facility will communicate quarterly updates to the Department of Health. Element 4: Monitoring: The maintenance director will audit weekly measures such as fire watch during construction, increased fire drills, and staff training at the facility. The results of this audit will be reported to the administrator monthly. The maintenance director will submit quarterly reports to the QAPI Committee for 3 quarters. The QAPI Committee will determine if any further action is required. Element 5: Person Responsible: Director of Maintenance.
Electrical System Safety Deficiencies
Penalty
Summary
The facility failed to maintain all components of the electrical system in a safe manner, as observed during a life safety survey. Specifically, electrical circuit panels were found to be unlocked in areas accessible to the public, which poses a safety risk. Additionally, these panels were lacking panel directories, which are essential for identifying circuits and ensuring proper maintenance and emergency response. Furthermore, non-GFCI outlets were identified within six feet of a sink in the employee cafeteria and connected to a fish tank in the atrium off the lobby. This is a violation of the National Electrical Code, which requires ground-fault circuit-interrupter protection for receptacles in such locations to prevent electrical shock hazards. These deficiencies indicate a failure to comply with established safety standards for electrical systems.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: All circuit panels identified as unlocked were immediately secured with compliant locking mechanisms. All electrical circuits panels were checked for complete directories. Any electrical circuit panels found lacking directories were corrected. Element 2: All residents have the potential to be affected by this practice; however, no residents were harmed by this specific practice. All areas were checked for similar deficiencies. None were found. Element 3 Systemic Changes: A policy has been implemented requiring all electrical panels in public areas to be locked at all times. The maintenance staff have been in-serviced on the revisions to this policy to ensure compliance on securing electrical panels as a part of safety compliance. Element 4 Monitoring: The maintenance director will audit all outlets monthly that are near water sources throughout the facility to identify any additional non-compliant areas. The maintenance director will audit all electrical panels monthly for directories throughout the facility to identify any additional non-compliant areas. The maintenance director and consultant from Ridgefield Associates will inspect records and maintenance logs quarterly to ensure sustained adherence to electrical safety standards. The results of all audits will be reported to the administrator for compliance. Any areas identified as non-compliant will be corrected immediately. The maintenance director will report the results of all audits to the QAPI Committee quarterly for a period of 3 quarters. The QAPI Committee will determine if any further action is required. Element 5 Person Responsible: Maintenance director
Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to ensure that all hazardous areas were properly enclosed in accordance with the 2012 NFPA 101 standards. During a life safety survey, several deficiencies were observed on the first floor. In the generator room, a plywood wall covering was not labeled as fire-resistant, and there was a large opening in the concrete wall that communicated with the adjacent automatic transfer switch room. Additionally, the door to this room was propped open. The automatic transfer switch room lacked sprinkler coverage, had missing ceiling tiles exposing unprotected steel beams, and wall penetrations were sealed with non-approved fire blocking foam. The trash compactor room door was not self-closing and lacked a latch due to missing hardware. Similarly, the boiler room door was missing hardware, allowing smoke to pass into the corridor. Lastly, the maintenance shop room door was held open with a magnet not connected to the fire alarm system.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K321 Corrective Action: The maintenance director immediately audited all areas within the building to ensure any hazardous area has a 1-hour fire resistance rating, and the areas shall be separated from other spaces by smoke partitions in accordance with 2012 edition of NFPA 101. The following corrections have been made: On 12/20/2024, the concrete wall surrounding the generator room had an opening of 3-4', communicating with the adjacent transfer switch room. This area has been sealed with concrete blocks to comply with a 1-hour fire rating. The tiles missing in the automatic transfer switch room were replaced. On (MONTH) 13, 2025, the door to the trash compactor room had the hardware replaced to include a panic bar door handle and latch to ensure the door was self-closing. On (MONTH) 13, 2025, the hardware on the boiler room door was replaced to ensure it was self-closing and did not allow the penetration of smoke. All penetrations in the walls that were sealed with fire blocking foam have been removed and replaced with an approved fire rated stopping material. Element 2 Residents at Risk: While no other residents were affected by this practice, the potential existed for all residents and staff to be affected by this practice. All hazardous areas were inspected for similar deficiencies. None were found. Element 3 The policy and procedure for hazardous doors was reviewed and revised. All maintenance staff will be in-serviced on 2012 NFPA 101 19.3.2.3 hazardous areas shall be safeguarded with a 1-hour fire rating. Documentation checklist for Life Safety Code Standards Observations will be implemented and include all components of hazardous areas shall be safeguarded by a fire barrier having a one-hour resistance rating. Any negative findings will be addressed immediately. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director or designee will inspect all Hazardous Areas to ensure all areas are safeguarded by a fire barrier having a 1-hour fire resistive rating. The findings of all these audits to inspect all Hazardous Areas to ensure a 1-Hour Fire Rating will be reviewed monthly and reported to the Administrator. The maintenance director or designee will report findings to the QAPI Committee quarterly for a period of 6 months. The QAPI Committee will determine any further actions. Element 5 Person Responsible: Maintenance Director
Obstructed Egress and Locked Exit Gate
Penalty
Summary
The facility failed to maintain clear and unobstructed means of egress as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the first-floor corridor near the morgue was obstructed by combustible items, including wheelchairs and a floor polishing machine, stored next to the door leading to an adjacent corridor. Additionally, in the first-floor corridor behind the kitchen, numerous boxes were stored on either side, reducing the corridor's width to less than the required 48 inches. These obstructions were noted during the survey and were stated by the facility to be temporary, yet they persisted over multiple observations. Furthermore, the discharge from stair B, which leads to a sprinklered parking structure and then out to a gate leading to the public way, was found to be locked. A means to open this gate was not made available to all staff, further impeding the egress route. These deficiencies were acknowledged by the Director of Maintenance at the time of the survey, indicating a lapse in maintaining the required safety standards for egress in the facility.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K 211. Immediate Corrective Action: The maintenance and housekeeping director immediately removed the wheelchairs, floor polishing machines, and other obstructive items stored near egress routes. All boxes observed in the corridor were removed. Metro Fire Alarm system and Technology tied the garage gate to the fire alarm system on (MONTH) 6, 2025; the gate now opens when the Fire alarm is activated. Element 2: All residents have the potential to be affected by this practice. The maintenance and housekeeping director immediately audited all hallways within the building to ensure means of egress were not blocked, and no other issues were identified. Element 3: The fire alarm system's policy and procedure were reviewed, and the installation of an automatic parking lot gate opening will be added to the policy. All staff will be in-serviced for this new procedure. Maintenance and security will be trained to ensure that the gate is opened due to fire alarm activation and that it immediately closes when the alarm has been cleared. Element 4: The maintenance and housekeeping director will audit all corridors weekly to ensure they are free of impediments to egress and maintained at 48 in width. Results will be reported to the administrator monthly. On a monthly basis for three quarters, the maintenance and housekeeping director will report findings to the QAPI Committee for review. QAPI Committee to determine if further action is required. Element 5: Persons responsible: Maintenance and housekeeping director.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to inspect, test, and maintain all components of the sprinkler system in accordance with the 2011 NFPA 25 standards. During a life safety survey conducted on December 16 and 17, 2024, it was observed that sprinkler heads were missing escutcheons in several areas, including the 1st floor IT room, the secondary ATS room next to the IT room, the 1st floor oxygen storage room, and the exit passageway leading from the 1st floor landing of stair C. Additionally, there was no record of the required 5-year internal pipe inspection in the maintenance, testing, and inspection records. These deficiencies were acknowledged by the Director of Maintenance at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: 1) The facility installed escutcheon plates on the identified sprinklers on the 1st floor next to the IT room, the secondary ATS room on the 1st floor next to the IT room, the 1st floor oxygen storage room, and the exit passageway leading from the 1st floor landing of stair C. 2) The facility engaged our licensed sprinkler inspection and testing vendor to complete the 5 year internal pipe inspection; testing was completed on (MONTH) 8, 2025. Element 2: While no residents were affected by this practice, the potential exists for residents to be affected by this practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy requirements to maintain the sprinkler system. Training will include: Inspection and testing requirements for the Automatic Sprinkler system in accordance with 2012 NFPA 25, and the maintenance of all components of the sprinkler system. An audit tool was developed to monitor compliance. Element 4: Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis for 3 quarters/6 months. The QAPI Committee will determine if further action is required. Element 5: Person Responsible: Maintenance director
Deficiencies in Egress Stairs and Fire Door Labeling
Penalty
Summary
The facility was found to have deficiencies in maintaining egress stairs in accordance with the 2012 NFPA 101 standards. During a life safety survey, it was observed that all four of the facility's stairwells, labeled as A, B, C, and D, were lacking the required contrasting colored marking stripes on the handrails and landings. This deficiency indicates a failure to comply with the specific requirements for exit stair treads, landings, and handrails as outlined in the NFPA 101, which mandates that these components must have consistent and uniform marking stripes to ensure safe egress. Additionally, the survey noted that the door at the first-floor landing was missing the required fire rating label, which is a violation of the NFPA 80 standards for fire doors and other opening protectives. This oversight suggests a lapse in the facility's adherence to fire safety protocols, as fire-rated door assemblies are crucial for preventing the spread of fire and smoke. The Director of Maintenance acknowledged these deficiencies during the survey, indicating awareness of the issues at hand.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1: Immediate Corrective Action: A full inspection of all stairways used as a means of egress was audited to identify areas lacking compliant marking stripes and was conducted by the maintenance director. The maintenance staff immediately began marking the handrails and landings in all areas noted for compliance. The facility engaged a licensed Fire Door vendor to inspect and affix a fire rating tag on the identified fire door on the 1st floor landing. Element 2: All residents have the potential to be affected by this practice. No residents were harmed due to this practice. Element 3: The policy and procedure for Egress and marking stripes were reviewed, and revisions have been made on means of egress and marking of handrails and landings. The maintenance director was educated on the means of egress requirements, explicitly marking the handrails and landings in all stairwells. Education and training will be given to all staff on the markings of handrails and landings. Element 4: Monitoring of Corrective Action: The maintenance director or designee will audit all stairwells and fire doors weekly to ensure that all handrails and landings are appropriately marked in accordance with 2021 NFPA 101. The results of this audit will be reported to the administrator monthly. The maintenance director will report the findings of this audit for one quarter to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Maintenance director
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessments accurately reflected the status of two residents. For one resident with diagnoses including unspecified dementia, anxiety disorder, and depression, the MDS assessment inaccurately documented that it was not very important for the resident to keep up with the news and do their favorite activities. This was contrary to an Activities Evaluation which indicated these activities were very important to the resident. The Activities Director admitted to an error in coding due to being busy, which led to the inaccurate documentation in the MDS assessment. For another resident with diagnoses including unspecified dementia, muscle weakness, and difficulty in walking, the MDS assessment failed to document the use of a wander guard, which was ordered by a physician and used for safety due to the resident's wandering behavior. The MDS Assessor did not recall the presence of the wander guard during the assessment and acknowledged the error after reviewing the medical record. The MDS Coordinator stated that their role was to ensure timely completion and submission of MDS assessments, not to review their accuracy.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F641: The MDS assessments for resident #237 were modified, and television was immediately provided to the resident. Resident #237 was re-interviewed, and the activity preference was updated to reflect the current choices. The Care Plan was updated and implemented. Activity staff will continue to monitor for changes in preference. On 12/19/2024, the MDS for resident #436 had not been locked for submission; therefore, no MDS modification was required. The MDS was reviewed and locked on 12/19/2024 and cued for submission, which was still within the allowable time frame. MDS Nurse was re-in-serviced to properly assess and review records to accurately reflect resident needs in MDS. Element 2 Residents at Risk: This practice could affect all residents. A full audit was conducted on all active MDS assessments within the last 90 days to identify any additional inaccuracies. No other issues were identified. Element 3 Systemic changes: The Policy and Procedures for MDS Guideline for Completion were reviewed, and no revisions were required. All RN Assessors were re-in-serviced on the Policy and Procedure MDS Guidelines for Completion, emphasizing that MDS accurately reflects the residents' current status with emphasis on Section P. Activities director/designees will cross-check Section F for MDS accuracy. Training includes proper data collection, resident interviews, and validation of information before transmission. The Activity Director will audit for accuracy every week to ensure the accuracy and consistency of the resident's preferences. Staff will complete the activity form on all comprehensive assessments, initiate and implement the care plan, and complete MDS. Activity will complete activity preference form on all comprehensive assessments and as needed if residents' preferences change. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: To ensure ongoing accuracy, the MDS Coordinator/RN assessors and Activities Director will conduct random audits of 10% of completed MDS assessments weekly for 3 months. The audit results will be reported to the Administrator and Director of Nursing for compliance. Audit results will be reviewed in quarterly QAPI meetings for one quarter. If any trends of inaccuracy are noted, additional interventions will be implemented. QAPI Committee will determine if any further action is required. Element 5 Completion Date: February 12, 2025 Responsible Persons: MDS Coordinator, RN Assessors, Activities Director.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of three residents. These residents were not provided with activities that aligned with their preferences, specifically the ability to watch television in their rooms. The facility's policy required the Activity Leader to record the recreational interests and needs of each resident upon admission, and the Activity Director was responsible for planning a varied program of activities to meet these needs. However, this was not implemented effectively for the residents in question. Resident #219, diagnosed with Alzheimer's disease and other conditions, expressed a desire to watch television in their room, a preference that was not met due to the removal of the television set for maintenance. Despite being cognitively intact and having no vision or hearing problems, Resident #219 was left without their preferred activity for several weeks. The Comprehensive Care Plan and Activities Evaluation both documented the importance of keeping up with the news and engaging in favorite activities, yet no alternative activities were provided. Similarly, Resident #237, with diagnoses including dementia and anxiety disorder, and Resident #436, with dementia and muscle weakness, were also left without their preferred activity of watching television. Both residents had tablets in their rooms, but they did not know how to use them. The facility's staff, including the Activities Director and the Director of Maintenance, acknowledged the issue but failed to resolve it promptly. The delay in reinstalling the television sets was attributed to the need for new equipment, but no interim solutions were provided to ensure the residents' activity preferences were met.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1: F679 Corrective Actions for Residents Identified Interest and activity preferences of residents #219, #237, and #436 were reviewed. Televisions were immediately installed inside the rooms of the identified residents. Care Plans were updated, reflecting changes in interests or abilities. Element 2: Residents at Risk All residents have the potential to be affected by this practice. The activities department audited to ensure all resident assessments and activities of choice were accurately provided based on their documented interest and needs. There were no more issues identified. An audit tool was developed to monitor compliance. Element 3: Systemic Changes Policies and Procedures Regarding Resident Preferences and Activity Planning were reviewed; no revisions were required. Activity staff is being trained on the importance of individualized activities and how to incorporate them into daily care. Education will be provided on creative engagement techniques for residents with dementia or sensory impairments. In-service on effective communication between activity staff, CNA, LPNs, and RN's, Social Service, and Rehab to ensure seamless integration of activities into daily routines. Tools such as Questionnaires and resident Council Meetings will gather feedback and suggestions, which will be used to refine the activity program continuously. Any outstanding findings will be immediately corrected and reported to the administrator. Element 4: Monitoring of Corrective Actions The Activities Director will conduct weekly checks for 90 days and monitor residents' participation and satisfaction with activities. Five to seven residents will be randomly selected to ensure that provided programs support their choice of activities. On a monthly basis, the Activities Director will submit findings to the administrator. The Activity Director will report findings to the QAPI Committee quarterly for 3 quarters. The QAPI Committee will determine if further action is required. Element 5: Date of completion: (MONTH) 12, 2025 Person Responsible: Activity Director.
Inadequate Supervision and Hazardous Environment Lead to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for Resident #24, who is cognitively impaired and exhibits agitated behaviors. The resident sustained a laceration and fractures to the right foot after being found with their foot on a radiator, which was reported to have sharp edges. Despite the incident, the facility did not report the accident to the New York State Department of Health as required. Resident #24 has a history of severe cognitive impairment, anxiety disorder, bipolar disorder, and schizophrenia. The resident is frequently incontinent and requires supervision for daily activities. On the day of the incident, the resident was found with a laceration on the right foot, which was bleeding. The injury was severe enough to require hospital evaluation and treatment, including orthopedic surgery and laceration repair. Interviews with staff revealed inconsistencies in the facility's response to the incident. The Registered Nurse on duty observed sharp edges on the radiator, but the Maintenance Director and Worker later reported no sharp edges. The Director of Nursing did not report the incident, believing it was unnecessary since the cause of the injury was known. This lack of communication and failure to report the incident highlights deficiencies in the facility's accident prevention and reporting protocols.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F689 Corrective action for Resident Identified: Nursing conducted an immediate assessment of resident #24 to address their safety and supervision needs. Care plan for resident #24 was updated to ensure safety and proper monitoring. A review of the resident's environment was conducted to ensure any necessary devices are in proper working order and available for use. Individualized interventions such as increased supervision i.e. spending more time supervised in the activities/dayroom to mitigate risks were implemented. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The facility conducted an environmental assessment for all residents to identify potential hazards and supervision needs. Results of this assessment were reviewed by the Administrator, DNS and ADNS. No other residents were found to be affected by this practice. An audit tool was developed to monitor compliance. Element 3 Systemic Changes: The facility policy and procedure titled Accident and Incident Report was reviewed and no revisions were required. Staff Education and training: The Risk Manager/ADNS will provide training to appropriate staff (CNA, LPN, RN, maintenance, housekeeping, and social services and rehab) on accident prevention, hazard identification, and the proper use of assistive devices. The training will emphasize the importance of timely reporting and addressing potential hazards. Routine preventative room rounds conducted by all nursing staff are being implemented to ensure that residents whose preference is to remain in their room receive adequate supervision to prevent any further occurrences. Element 4 Monitoring of Corrective Action: On a weekly basis for one quarter, the DNS, ADNS, and Medical Director will audit incident reports weekly to identify trends and ensure follow-up action is completed. Monthly audits of care plans, supervision, and environmental safety measures will also be monitored. The Maintenance Director will conduct weekly routine environmental audits for 3 months to identify and eliminate physical hazards. On a monthly basis for 3 months, the results of the audits will be reported to the administrator; any negative findings will be addressed immediately. The results of the audit will be presented to the QAPI Committee for 3 quarters for monitoring and compliance. The QAPI committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Responsible Persons: Director of Nursing, ADNS and Maintenance Director
Lack of Physician Orders for Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, specifically for a resident undergoing dialysis. The resident, who was diagnosed with End Stage Renal Disease and Coronary Artery Disease, did not have documented physician orders for dialysis, including the frequency and monitoring of the permcath. Despite the resident's care plan indicating the need for hemodialysis, there was no evidence of physician orders to support this treatment. Observations and interviews revealed that the resident was alert and oriented, and regularly attended dialysis sessions. However, the facility's documentation did not reflect this, as there were no physician orders in the system for the resident's dialysis schedule. The facility's policy required medication order reconciliation during admissions and routine reviews, but this was not adhered to in the case of the resident's readmission. Interviews with facility staff, including a CNA, RN Manager, and the Director of Nursing, indicated that the omission of the dialysis order was an error during the resident's readmission process. The staff were aware of the resident's dialysis schedule, but the necessary orders were not documented in the system. The Medical Doctor confirmed that the resident was stable and that the omission was likely an oversight during the readmission process.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F711 Corrective Actions for Residents Identified: Resident # 71 was seen by an attending physician on 12/19/2024. During the visit, the resident's total program of care, including medications and treatments, was reviewed and documented. Resident # 71 received [MEDICAL TREATMENT] without interruption of services; Resident # 71 had an order placed immediately. The Care Plan was initiated on 8/19/2024 and has been reviewed and updated for [MEDICAL TREATMENT]. Element 2 Residents at Risk: All Residents receiving [MEDICAL TREATMENT] have the potential to be affected by this practice. A list of current residents receiving [MEDICAL TREATMENT] in the past three months was obtained, and the Medical Record was audited to ensure that all physician orders [REDACTED]. No Other issues were identified. Audit tool was developed to monitor compliance. Element 3 Systemic Changes: Policy and Procedure for physician's orders [REDACTED]. All Registered Nurses are being educated on the importance of timely physician visits, documentation review, and order accuracy. The nursing supervisor will review care notes weekly to ensure all visits and orders are correctly documented. An audit tool was created to confirm that all physician orders [REDACTED]. Element 4 Quality assurance Monitoring: Conduct weekly audits for 90 days to ensure compliance with physician visits, regulations, care note reviews, and orders. Findings will be reported to the administrator monthly, and any negative findings will be corrected immediately. On a quarterly basis, x 3 quarters ADNS or designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Element 5: Persons Responsible: Completion Date: (MONTH) 12, 2025 Director of Nursing Services: Oversee the P(NAME) implementation and staff education. Medical Director: Collaborate with physicians to ensure timely visits and documentation.
Expired Medications Found in Facility Medication Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in accordance with professional standards of practice, as evidenced by the presence of expired Heparin lock flush syringes and intravenous fluids in the medication rooms of two units. During the recertification survey, it was observed that eighteen expired Heparin lock flush syringes were stored in the medication rooms on the 2 [NAME] and 2 East Units. Additionally, a bag of expired intravenous dextrose was found. The facility's policy requires that expired medications be removed and disposed of immediately, but this was not adhered to. Interviews with staff revealed a lack of consistent monitoring and removal of expired medications. Licensed Practical Nurse #4 and Registered Nurse #2 acknowledged the presence of expired items and admitted that the medication room is stocked weekly, but expired items were not always identified and removed. Housekeeping staff found expired items but left them for nursing staff to sort, indicating a breakdown in communication and responsibility. The Consultant Pharmacist confirmed that monthly inspections are conducted, and reports are emailed to the facility, yet expired items remained in the medication rooms. The Assistant Director of Nursing/Infection Preventionist stated that daily rounds are conducted, but they had not specifically checked the Heparin flushes. The Unit Manager and other nursing staff admitted to not regularly checking for expired medications, with some not having checked since April 2024. This lack of regular and thorough inspection contributed to the oversight, resulting in expired medications being available in the facility, which is against the facility's protocol and poses a risk to resident safety.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F 761 Immediate corrective Action: The expired [MEDICATION NAME] was removed from the medication room on 2 West and 2 East and discarded immediately on [DATE]. The RNs and the medication nurses on duty were in-serviced on medication storage on [DATE]. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All medication carts and storage rooms were inspected for medications and biologicals beyond their expiration date, and none were found. Element 3 Systemic changes: The facility policy titled Medication Storage was reviewed, and no revisions were needed. All nurses are being in-serviced on Medication Storage policy and procedure. A new process is being implemented for medication storage monitoring to ensure compliance (LPN to check med carts daily; Unit RN to check med rooms daily). An audit tool was developed to monitor for compliance. Element 4 Monitoring of Corrective Changes: On a weekly basis for one quarter, DNS or designee will inspect 2 medication rooms and 2 medication carts, to ensure compliance with medication storage. Any outstanding issues will be addressed immediately. On a monthly basis, DNS or designee will report findings to Administrator. On a monthly basis, DNS or designee will report findings to QAPI Committee. QAPI Committee to determine if further action is required. Element 5 Monitoring of Corrective Action: Completion Date: (MONTH) 19, 2025 Director of Nursing ADNS/ Designee.
Menu Substitution Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that menus were followed as written, resulting in food items being omitted or substituted without informing the residents. This deficiency was observed during the Dining Observation task for five residents. The facility's policy requires that any menu substitutions be documented, including the reason for the substitution, and that these changes be visible to residents. However, the survey found that items such as milk, salad, and tartar sauce were crossed out on tray tickets without appropriate substitutions or notifications to the residents. Several residents with varying degrees of cognitive impairment were affected by these omissions. For instance, one resident with severe cognitive impairment was served a dinner tray missing milk, which was crossed out on the tray ticket. Another resident, also with severe cognitive impairment, was served a tray missing assorted juice, which was similarly crossed out. These omissions were not documented in the menu substitution log, and the residents were not informed of the changes. Interviews with staff revealed inconsistencies in the handling of menu substitutions. Certified Nursing Assistants and Dietary Aides indicated that items were crossed out when unavailable, but there was no consistent process for substituting or notifying residents. The Director of Food Service and the Registered Dietitian were not always consulted on these changes, which is contrary to the facility's policy. This lack of communication and documentation led to the deficiency noted in the survey.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F803 Corrective Actions for Residents Identified: The Registered Dietitian reviewed menus for residents #97, #156, #212, #252, and #271 to ensure they met their nutritional needs as per national guidelines (e.g., Dietary Guidelines for Americans, RDA). The Registered Dietitian interviewed residents or resident representatives #252, #271, and #212 to review and discuss their meal preferences. Meal tickets were adjusted to reflect their preferences. Residents #97 and #156 were discharged, and no changes were required. Dietary staff immediately received training on following planned menus and compliance with meal tickets. Element 2 All residents have the potential to be affected by this practice. All residents were immediately audited to ensure all dietary preferences were being met. All meal tickets were reviewed to ensure that what was printed on the resident's meal ticket was being served; no issues were identified. Element 3 Systemic Changes: Policy and Procedure for Resident food Preferences were reviewed, and no revisions were required. All menus will be reviewed and approved quarterly by a licensed RD to ensure nutritional adequacy and compliance with guidelines. Monthly Food Committee meetings will be scheduled to ensure menus reflect resident preferences while maintaining nutritional needs. Food purchasing, inventory management, and meal preparation will be implemented to ensure timely adherence to planned menus. Dietary staff will be in-serviced regarding menu preference, menu item substitution, and adherence to meal tickets on the tray line. The new process was implemented to notify residents of any menu substitution by posting changes in each nursing unit. This new process will be discussed at the next resident council meeting on (MONTH) 21, 2025. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Actions: 10 resident trays will be audited daily for 30 days to confirm that meals served match planned menus, resident preferences, and nutritional standards are being met. Documentation will be maintained of all menu changes, resident-specific adjustments, and training sessions. The RD will conduct quarterly audits x 2 quarters to monitor menu compliance and resident preferences, including nutritional analysis. The audit results will be shared with the administrator monthly. QAPI Integration will include menu compliance as a standing agenda in QAPI Meetings for 2 quarters. The Audit results, including resident feedback and RD recommendations, will be reviewed during QAPI meetings to identify and implement further improvements for 2 quarterly meetings. QAPI Committee will make sure to figure out if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Persons Responsible: Registered Dietitian, Food Service Director, and Food Service Supervisor.
Infection Control Deficiencies in Hand Hygiene and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed during a recertification survey. A Certified Nursing Assistant (CNA) was seen assisting multiple residents with hand hygiene in the dining room without performing hand hygiene between residents. The CNA used bare hands to distribute hand wipes and assist residents, failing to wash hands between interactions, which is against the facility's hand hygiene policy. This oversight was acknowledged by the CNA during an interview, where they admitted to not noticing the lapse in hand hygiene during the dining service. Additionally, a Licensed Practical Nurse (LPN) did not adhere to infection control protocols during a wound care procedure for a resident with a stage 4 pressure ulcer. The LPN placed supplies on the resident's mattress, failed to wash hands between glove changes, and did not wear a gown as required by the facility's Enhanced Barrier Precautions policy. The LPN acknowledged forgetting to wash hands between glove changes and not using a gown during the procedure, despite being trained on these protocols. The resident involved in the wound care incident had a history of stroke, neurogenic bladder, and hemiplegia, and was admitted with a stage 4 pressure ulcer. The facility's policies require specific infection control measures, including the use of gowns and gloves during high-contact care activities, especially for residents with wounds. Interviews with the Wound Care Coordinator and the Director of Nursing confirmed that staff had been educated on these precautions, but the observed practices did not align with the training provided.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F880: The CNA's who were observed failing to follow hand hygiene, particularly in between resident interactions, were in-serviced. Provided on the spot training and counseling to the CNAs regarding proper hand washing. Ensured all hand washing wipes were available in the dining room and other resident care areas. The identified LPN was immediately educated and retrained on proper infection prevention and control protocols, including hand hygiene and the use of personal protective equipment. All residents involved were assessed for any potential risks of infection. No adverse outcomes were identified. Element 2: All residents have the potential to be affected by this practice. The Infection Control Practitioner/or designee will monitor all CNA's, LPNs, and RNs for adherence to proper infection control practices. Proper handwashing and the proper use of personal equipment will be included in this routine monitoring. Immediate corrective action, such as re-education or disciplinary action, will be implemented for identified infection control breaches. Training sessions will be documented, and staff will be required to demonstrate competency. An audit tool was developed to monitor for compliance. Element 3: Systemic changes: On (MONTH) 10, 2025, the Administrator, Medical Director, Director of Nursing, and Infection Preventionist reviewed the facility's Infection Control Policy and Procedures for Handwashing between residents and the proper use of personal protective equipment; no revisions were required. Education will be provided to all CNAs, LPNs, and RNs related to general infection prevention and control practices. Education will emphasize the staff member's responsibility for proper handwashing. Education will continue to be provided to all staff during orientation and annually, and on an as-needed basis related to general infection prevention and control practices and protocol. In addition to hand hygiene competency upon hire and annually, the facility will conduct periodic hand hygiene competencies on handwashing and infection control practices. Element 4: Monitoring of corrective action: The facility will develop an audit tool to monitor compliance with Infection Prevention and Control protocol related to proper hand washing. On a weekly basis for one quarter, the DNS/designee will observe 2-5 direct care staff for proper handwashing technique and proper use of PPE. Any outstanding issues will be addressed immediately. All audit findings will be reported to the Administrator monthly for 3 months. All audit findings will be reported to the QAPI Committee for 1 quarter for evaluation, discussion, and follow-up. At this time, the QAPI Committee will make a determination for the need for ongoing auditing. The Infection Preventionist will continue to report a summary of all infection control activities and audit findings to the QAPI Committee for one quarter. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Director of Nursing and Infection Preventionist.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of pests and rodents during the recertification survey. A live rodent was found in a box trap in the dining room while residents were present, and flies were observed in various units, including near the nurse's station and in resident rooms. Additionally, roach droppings were noted on stored equipment in the atrium, and bait traps had not been updated since October 2024. Interviews with staff and residents revealed sightings of mice and flies, with some residents expressing concern about the presence of mice in their rooms. The facility's pest control policy, revised in May 2024, outlines a comprehensive program involving weekly services from an outside pest control company. However, the observations and interviews indicate that the program is not effectively implemented. Staff members, including the Director of Maintenance and the Infection Preventionist, acknowledged the presence of pests and the potential infection control issues they pose. Despite the facility's policy and procedures, the presence of pests and rodents suggests a deficiency in the execution of the pest control program.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F925 Corrective Action: The Housekeeping and Maintenance Director responded to, 2 West Dayroom, Nurses' station, room [ROOM NUMBER], 238, 239, 4 West Nursing Station, 4 West Hallway, Kitchen, and Atrium, to check all areas for flies and rodents. Any exposed food was either discarded or placed inside a plastic container. The Exterminator treated all areas on 12/26/24, 1/2/25, and 1/6/25. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The Housekeeping and Maintenance Directors immediately inspected all areas in the building; no other pest control issues were identified. Element 3 Systemic Change: The Pest Control Policy was reviewed; no changes were required. All Dietary, Housekeeping, Maintenance, Nursing (CNA's, LPN, RN's), Activities, and Rehab staff are being in-serviced on the procedure to follow when any areas within the facility require treatment. The Pest Control Company, in addition to 3 weekly visits, will be available for additional visits on an as-needed basis. An audit tool was developed to monitor compliance. Element 4 Monitoring: 3 times per week for one quarter, the Food Service Director/Designee will conduct rounds and audits for sanitation and signs of pest activity. Any adverse findings will be logged into the pest control book and reported to the administrator. For one quarter, the director of maintenance or designee will audit the environment weekly to assist in monitoring pest control service. Any issues identified will be responded to immediately, and reports will be made to the administrator weekly. The results of all audits will be reported to the QAPI Committee quarterly for 2 Quarters/six months. The QAPI Committee will determine if further action is required. Element 5 Date of Correction: (MONTH) 12, 2025 Persons responsible: Food Service, Housekeeping, and Maintenance Directors.
Improper Use of Power Strips in Employee Cafeteria
Penalty
Summary
The facility was found to be in violation of its policy regarding the use of relocatable power strips. During an inspection on December 16, 2024, at approximately 9:50 AM, a refrigerator in the employee cafeteria on the first floor was observed to be plugged into a relocatable power strip. This action was contrary to the facility's policy, which explicitly states that power strips must not be connected to high amperage loads. This indicates a failure to adhere to established safety protocols concerning electrical equipment usage within the facility. Additionally, the facility lacked records for the periodic testing of power strips throughout the building. This omission suggests a broader issue with compliance to safety standards and maintenance protocols, as regular testing is essential to ensure the safe operation of electrical equipment. The Director of Maintenance acknowledged the deficiency at the time of the finding, indicating awareness of the issue but not addressing any corrective measures taken at that moment.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 The refrigerator in the first floor employee cafeteria was immediately unplugged from the relocatable power strip and plugged directly into a wall outlet to comply with the facility policy and ensure safety. A comprehensive inspection of all power strips throughout the facility was conducted to identify any other instances of improper use such as high amperage being connected to power strips. No other issues were identified. The facility's policy regarding the proper use of power strips was reviewed; no revisions were required. Element 2 All residents have the potential to be affected by this practice; however, no other residents were affected by this practice. Element 3 The maintenance staff will receive training on the policy with emphasis on the risks associated with improper power strip usage and how to identify appropriate outlets for high-amperage appliances. The maintenance director will develop a log to monitor power strips and ongoing compliance and safety. Element 4 The maintenance director will conduct random monthly audits of power strip usage in the building to ensure ongoing compliance. Audit results will be reviewed and submitted to the administrator monthly. The maintenance director will submit results of the audit on a quarterly basis for 3 quarters to identify any patterns or recurring issues for 6 months. The QAPI Committee will determine if further action is required. Element 5 Person Responsible: The Maintenance Director
Egress Illumination Deficiency Due to Manual Switches
Penalty
Summary
The facility failed to ensure that the illumination of means of egress was protected from manual operation, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the egress passageway on the 1st floor, leading from stair C, was equipped with switches that could turn off all lights in the area. This deficiency was identified through observation and staff interviews, specifically with the Director of Maintenance, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1: Corrective Action: The light switches from stair C that shut off all lights in the 1st floor egress passageway were disconnected. The light source was reconnected to ensure that egress lighting is permanently powered and cannot be manually deactivated during building occupancy. Element 2: All residents have the potential to be affected by this practice. No residents were found to be harmed by this practice. All means of egress were inspected for similar deficiencies. None were found. Element 3: The policy for means of egress will be revised to reflect this new revision. Maintenance staff will be educated on this new revision. Element 4: Monitoring: The maintenance director will monitor all the stairwells monthly to ensure the handrails and landings are marked per NFPA 101 Illumination means of egress. The audit results will be reported to the administrator, and any areas of non-compliance will be immediately corrected. The maintenance director will report for one quarter the results of the audit to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance Director.
Inadequate Sprinkler System Coverage and Improper Use of Sprinkler Piping
Penalty
Summary
The facility failed to ensure that all areas of the nursing home were adequately protected by an automatic sprinkler system, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that there was no sprinkler protection underneath stair D at the first-floor lowermost landing. Additionally, the atrium off the lobby had sprinklers installed above the windows on one side, but it was unclear if these provided sufficient coverage for the entire space, which measured approximately 30' by 40'. Furthermore, in the fire pump room, electrical BX cable was improperly suspended from the sprinkler piping, violating the standard that prohibits using sprinkler piping or hangers to support non-system components. These deficiencies were noted during the survey and discussed with the Administrator during the exit conference.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: The facility immediately consulted a licensed fire protection vendor to add a head to provide sprinkler coverage under stairway D. The fire protection vendor conducted a thorough assessment to verify sprinkler head placements above the Atrium/Lobby windows. Additional sprinkler heads will be added every 7 feet to ensure necessary coverage for the entire space in the atrium. The BX cable suspended from sprinkler piping was immediately secured using appropriate non-piping support brackets to comply with NFPA 2012 101 19.3.5.1 requirements. All sprinkler piping in the facility was inspected to ensure no other electrical cables or utilities are improperly supported. The maintenance director visually inspected the entire facility; no other issues were identified. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: Maintenance and engineering staff were retrained on sprinkler system requirements including proper sprinkler head placement and coverage. Prohibition of using sprinkler pipes for utility support was emphasized. The facility's preventive maintenance program was updated to include a semi-annual review of sprinkler systems by our Life Safety Consultant from Ridgefield Associates. Maintenance logs will be reviewed by the maintenance director monthly to ensure compliance. Element 4 Monitoring: The maintenance director will conduct monthly inspections of sprinkler systems coverage and utility compliance. Quarterly audits of sprinkler systems will be conducted by an external fire protection contractor and Ridgefield Associates for the next 12 months. Audit results will be reported to the administrator for compliance; any negative findings will be corrected immediately. The maintenance director will report for the next 3 quarters the results of the inspections to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5 Person responsible: Maintenance Director
Lack of Fire Alarm System Impairment Policy
Penalty
Summary
The facility failed to ensure occupant safety during a period when the fire alarm system was impaired for more than four hours. During a life safety survey, it was discovered that the facility lacked a policy and procedure outlining the necessary actions to be taken if any part of the fire alarm system was out of service. This deficiency was identified during a document review of the facility's maintenance, inspection, and testing records. The absence of such a policy meant that there were no predefined measures to protect occupants in the event of a fire alarm system failure, leaving them potentially unprotected during the impairment period.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: On (MONTH) 12, 2025, the facility developed a comprehensive policy and procedure to outline the actions to be taken in the event of any impairment to the fire alarm system. The policy includes: - Immediate notification procedures for staff, residents, and local fire authorities. - Temporary fire watch procedures, as per NFPA 101, Life Safety Code guidelines. - Vendor contacted to correct impairment. - Documentation of the impairment and actions taken. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for all residents to be affected by this deficient practice. Element 3 Systemic Changes: A policy and procedure on Fire Watch was created. All maintenance and administrative staff will be trained on the newly developed fire alarm impairment policy. An updated maintenance checklist will be implemented to include a review of the fire alarm system and a requirement to verify that the impairment procedures are readily available. The facility contracts with a vendor to perform routine inspections and testing to proactively prevent system impairments. An audit was created to monitor compliance with the requirements of a Fire Watch. Element 4 Monitoring: The maintenance director will conduct monthly audits of fire safety documentation to ensure adherence to the fire alarm impairment policy. Results of the audit will be reported to the administrator monthly. Any deficiencies identified during the audits will be addressed immediately, and retraining will be provided if necessary. The results of the audit will also be reported quarterly to the QAPI Committee for two quarterly meetings. The QAPI Committee will determine if further action is required. Element 5 Person responsible: The Maintenance Director.
Deficiency in Fire Protection System Policy
Penalty
Summary
The facility failed to prepare and maintain a policy for actions to be taken if the sprinkler system is out of service, leading to a deficiency. On December 16, 2024, a surveyor found a sprinkler head in a closet on the first floor, which was under construction, fitted with a protective cover. This cover rendered the sprinkler head inoperable in the event of an emergency. It was unclear how long the sprinkler head had been covered, and there was no record of a fire watch being conducted in this area while the sprinkler head was impaired. Further review on December 17, 2024, revealed that the facility's sprinkler documents and emergency preparedness policy lacked a policy for the protection of occupants if the automatic sprinkler system was out of service for more than 10 hours. During the exit conference, the facility's Administrator acknowledged the absence of such a policy and stated that they would develop one. This lack of policy and oversight in ensuring the operability of the fire protection system led to the cited deficiency.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: The protective cover was removed immediately upon identification to restore full operability of the sprinkler head. A facility-wide inspection was conducted to ensure no other sprinkler heads were obstructed or otherwise impaired. All sprinkler heads were confirmed to be in proper working condition. A policy was developed and implemented to address the following: Procedures for protecting occupants when the sprinkler system or a portion of it is out of service for more than 10 hours, including interim life safety measures. Routine inspection of sprinkler systems during construction or maintenance projects. Prohibition of any action that impairs the functionality of sprinkler systems without proper documentation, risk assessment, and notification. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy and requirements to maintain the sprinkler system. Training will include: Recognizing and reporting conditions that impair sprinkler system operations. Steps to implement life safety measures when sprinklers are out of service. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis. The QAPI Committee will determine if further action is required. Element 5 Person Responsible: Maintenance Director
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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