Delmar Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Delmar, New York.
- Location
- 125 Rockefeller Road, Delmar, New York 12054
- CMS Provider Number
- 335735
- Inspections on file
- 24
- Latest survey
- January 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Delmar Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to meet the required staffing levels, leading to delays in resident care. From January 12 to January 17, 2025, the facility did not have enough RNs, LPNs, or CNAs to provide the mandated hours of care per resident. Residents and family members reported long wait times for assistance, particularly at night and on weekends. Staff interviews revealed struggles with inadequate staffing, and the facility faced challenges in recruiting due to pay structure issues.
A deficiency in nurse staffing was identified, with a resident experiencing delays in assistance due to insufficient nighttime staff. Discrepancies in reported staffing hours and reliance on agency staff were noted. The facility faces challenges in maintaining adequate staffing levels despite recruitment efforts.
The facility failed to maintain a safe environment to prevent infections, with staff not adhering to PPE and hand hygiene protocols. Observations included residents' medical equipment lying on the floor and shared personal care items not labeled. Interviews revealed inadequate staff education and monitoring of infection control practices.
The facility failed to uphold resident dignity and care standards, as evidenced by incidents involving four residents. A resident was unable to attend activities due to wheelchair access issues, while another felt like a burden due to staff unprofessionalism. A third resident experienced poor hygiene and delayed assistance, and a fourth had an uncovered urinary catheter drainage bag, violating privacy policies.
The facility failed to assess two residents for their ability to safely self-administer medications, as required by policy. Both residents were observed with inhalers on their overbed tables without documented assessments or physician orders. Interviews revealed that the inhalers were used under nurse supervision, but proper procedures for assessment and documentation were not followed.
The facility failed to maintain a safe and clean environment across all resident units, with issues such as scuffed handrails, insufficient hot water, and unclean bathrooms. Interviews revealed dissatisfaction with housekeeping and maintenance processes, and staff acknowledged the need for more consistent inspections. Despite ongoing projects to upgrade lighting and heating, immediate maintenance issues were not addressed, contributing to the deficiencies observed.
The facility failed to provide a means for residents to submit grievances anonymously, as required by regulations. Observations and interviews revealed no secured location for anonymous submissions, and staff were unaware of the process. Residents expressed fear of retaliation and difficulty in maintaining confidentiality. The facility's grievance policy was not effectively implemented, leading to a deficiency in honoring residents' rights.
A resident with a history of seizure disorder, morbid obesity, and bipolar disorder fell and sustained a serious injury while being assisted by a single CNA, contrary to their care plan requiring two staff members. The incident was not reported to the Department of Health as required by state regulations. Interviews revealed a lack of clarity and adherence to the reporting process, with the Administrator only reporting substantiated allegations, contrary to the regulation requiring all allegations to be reported within two hours.
A resident with a femur fracture and polysubstance abuse was discharged without proper planning or education. The facility failed to provide a discharge planning meeting, adequate education, or written notice of appeal rights. The discharge was due to insurance payment discontinuation, but the resident was not informed of their rights or the appeal process, leading to a deficiency in discharge procedures.
The facility failed to complete the required PASARR screenings for several residents with mental health diagnoses prior to admission. Incomplete or incorrect PASARR forms were found for residents with conditions such as major depressive disorder, PTSD, bipolar disorder, and schizophrenia. Staff interviews revealed a misunderstanding of the PASARR process, with some believing Level II evaluations were unnecessary based on admission reasons or corporate guidance.
The facility failed to develop comprehensive care plans for several residents, neglecting to include measurable objectives and timeframes for their medical and psychosocial needs. For example, a resident with benign prostatic hyperplasia and another with epilepsy lacked appropriate care plans. Interviews revealed that staff were not adequately trained in updating care plans, contributing to these deficiencies.
A resident with a history of falls and muscle weakness experienced multiple falls over several months, but the facility failed to update the resident's care plan to reflect these incidents. Despite the facility's policy requiring care plan revisions after significant changes, the care plan was not updated following the falls, as confirmed by the DON.
The facility failed to provide meaningful activities for two residents, impacting their quality of life. One resident, who enjoyed crocheting, did not receive requested supplies, while another found the offered activities demeaning and felt isolated. The facility's activity program lacked oversight, with the Activities Director resigning without notice and interim support in place.
Two residents in an LTC facility did not receive care according to professional standards. A resident with a surgical wound did not have daily dressing changes as ordered, and an LPN documented a change that was not performed. Another resident was ordered to self-perform oral suctioning, but the facility lacked guidelines for this, and there was no evidence of vital sign monitoring during the procedure.
The facility failed to maintain proper nutritional and hydration care for two residents. One resident experienced significant weight fluctuations and vomiting due to improper tube feeding management, while another did not receive adequate fluids, leading to signs of dehydration. Staff interviews revealed issues with communication, staffing, and adherence to care plans, contributing to these deficiencies.
The facility failed to administer oxygen therapy correctly for two residents. One resident received oxygen at 2.5 liters per minute instead of the prescribed 3 liters, and their oxygen saturation was not checked every shift. Another resident was given oxygen at 3 liters per minute instead of the ordered 2 liters. Nursing staff were unclear about monitoring responsibilities, leading to inconsistent checks and adjustments.
The facility did not ensure an RN was on duty for at least eight consecutive hours daily, as required. On several occasions, staffing records showed insufficient RN coverage, with no waivers in place. Interviews with staff highlighted ongoing staffing challenges and attempts to adjust schedules, but specific reasons for the deficiencies were not provided.
A facility's medication error rate reached 22.22% when a nurse crushed and administered medications to a resident without a physician's order. The resident, with conditions including dementia, received medications that should not have been altered, according to manufacturer guidelines. Miscommunication among nursing staff led to the error, despite facility policies requiring proper medication administration checks.
The facility failed to properly label and store medications, with multiple medication carts and rooms containing drugs without open or expiration dates, and expired or discontinued medications present. Personal items were improperly stored in medication areas, and narcotic boxes were not double locked. Staff interviews revealed a lack of awareness about medication expiration dates, despite training and competency checks.
The facility failed to maintain food safety and cleanliness standards in the main kitchen and resident unit nutrition rooms. Inspections revealed debris on kitchen equipment, broken seals on coolers, and ice build-up in the freezer. Nutrition rooms had rusted equipment, broken cabinets, and dirty surfaces. Interviews indicated unclear cleaning responsibilities and a need for improved diligence.
The facility failed to properly dispose of garbage and refuse, with two trash bins not being pest and rodent-proof due to unsecured doors and a missing drain plug. Despite daily clean-up efforts, garbage waste was found around the dumpsters. The Director of Maintenance acknowledged the issues and had contacted the vendor to address the missing drain plug, but a follow-up observation showed the problem persisted.
The facility was found to be inadequately administered, failing to effectively use its resources to ensure residents' well-being. Deficiencies included failures in maintaining resident dignity, assessing medication self-administration, and ensuring a safe environment. Issues with staffing, nursing services, care planning, and medication management were identified, along with infection control and food safety concerns. The facility also lacked a robust quality assurance program, potentially compromising resident health and safety.
A resident with a history of abdominal surgery had incomplete medical records due to a failure in documenting dressing changes accurately. The resident expressed concerns about the monitoring of their incision, and it was found that an LPN marked a dressing change as completed without performing it, due to being called away for an emergency.
The facility failed to maintain a QAPI committee with all required members, including the Medical Director and Infection Preventionist, who were absent from meetings. The Director of Nursing was also serving as the Nurse Educator and was unaware that the Infection Preventionist role could not be combined with their position. The Administrator admitted to oversight regarding the Medical Director's attendance. These issues hindered the committee's ability to coordinate and evaluate performance improvement projects effectively.
The facility did not designate a qualified Infection Preventionist from October 2024 to January 2025, leading to insufficient infection control practices. The Director of Nursing, also serving as the Nurse Educator, assumed the role but was unable to manage all responsibilities effectively due to multiple roles.
The facility did not ensure survey results were accessible to residents, as they were kept in an unmarked binder near the entrance with incomplete documentation. Residents were unaware of the location, and staff interviews confirmed the absence of proper signage and documentation.
A resident with multiple health conditions fell and broke their leg due to a Certified Nurse Aide not following the care plan, which required assistance from two or more staff members. The incident was not promptly reported, revealing gaps in the facility's incident documentation and reporting processes.
A facility failed to provide a written notice of the bed-hold policy to a resident and their representative during a hospital transfer. The resident, who was transferred due to respiratory distress, did not receive the required documentation, as confirmed by interviews with staff. The facility's policy mandates written notice at the time of transfer, but this was not documented, leading to a deficiency.
A resident with respiratory conditions was found with unsupervised medications in their shared room, contrary to the facility's policy requiring secure storage. The resident's inhalers were left accessible on the bedside table, despite the facility's rule against self-administration of medications.
A resident was prescribed Estrace Vaginal Cream without a documented indication for use, contrary to facility policy and professional standards. Interviews with staff revealed that medication orders should include the reason for use, but the provider and Medical Director indicated that this information was in clinical notes, not on the order itself.
A resident experienced significant medication errors when Alprazolam was administered at incorrect times, contrary to physician orders. The resident reported that a nurse left medication unattended, and records showed multiple instances of improper timing. Staff interviews revealed a lack of awareness and failure to notify the physician, leading to the deficiency.
A facility failed to ensure the safe storage of food brought by visitors, leading to a deficiency. A resident with multiple medical conditions had outside food improperly stored in their room. Staff interviews revealed a lack of adherence to the facility's policy, with family members not educated on safe food handling and staff unaware of the food's presence. The DON was unfamiliar with the policy specifics, expecting staff to address any food-related issues.
A resident with multiple medical conditions sustained a skin tear on their hand after returning to the facility late at night. Although the wound was treated and documented by nursing staff, there was no evidence of a thorough investigation into how the resident exited and re-entered the building or whether proper leave procedures were followed. Staff interviews confirmed that required investigative steps were not taken, resulting in a deficiency for failure to investigate the incident.
Staffing Deficiency in Nursing Home
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as required by New York State Public Health Law and Regulations. From January 12, 2025, to January 17, 2025, the facility did not meet the minimum staffing standards, which require 3.5 hours of care per resident per day, with at least 2.2 hours provided by a certified nurse aide and 1.1 hours by a licensed nurse. The facility's staffing records showed that the required number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) were not scheduled on several days, and the number of Certified Nurse Aides (CNAs) was consistently below the required levels. Observations and interviews during the survey revealed that residents experienced delays in receiving care, particularly during nighttime and weekends. Residents reported that call lights could take up to an hour to be answered, and family members expressed concerns about the lack of staff, leading them to provide personal care themselves. Staff interviews indicated that the facility struggled with staffing, with some staff members working alone and unable to complete their duties effectively. The facility's staffing coordinator and Director of Nursing acknowledged the staffing challenges, citing issues such as inadequate pay structures and difficulties in recruiting staff. The facility attempted to address these issues by using travel nurses and borrowing staff from other corporate facilities, but these measures were insufficient to meet the required staffing levels. The facility's administrator also noted efforts to recruit staff, with corporate assistance beginning in January 2025.
Staffing Deficiency and Delayed Resident Assistance
Penalty
Summary
The report highlights a deficiency in sufficient and competent nurse staffing at the facility. An incident was noted where a resident's oxygen cannula was not properly placed in their nose, and the resident experienced delays in receiving assistance, particularly at night when only one staff member was on duty. This situation indicates a lack of adequate staffing to meet the needs of residents, especially during nighttime hours. Additionally, there were issues with the accuracy of reported staffing hours, as discrepancies were found between the hours reported and the actual hours worked by staff, including instances where no Registered Nurse (RN) was present. The staffing coordinator, Deprincess Golden, has been proactive in scheduling and coordinating staff to meet the required hours, but challenges remain. The facility relies on a mix of local and out-of-state agency staff, as well as travelers, to fill staffing gaps. Despite efforts to recruit and retain staff, including offering sign-on and referral bonuses and attending job fairs, the facility continues to face difficulties in maintaining consistent and adequate staffing levels. The Director of Nursing (DON) occasionally takes on assignments, which is not ideal, and there is a reliance on borrowing staff from sister facilities as a last resort.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. Observations revealed that staff did not consistently adhere to infection prevention and control practices, such as putting on and taking off personal protective equipment (PPE) or practicing hand hygiene when entering and exiting residents' rooms with transmission and enhanced barrier precautions. Additionally, personal care items in shared bathrooms were not labeled or designated for specific residents, increasing the risk of cross-contamination. Specific incidents included Resident #218's oxygen tubing lying on the floor and not being labeled, and Resident #17's urinary catheter drainage bag was observed lying on the floor. Resident #364's urinary catheter care was not maintained as ordered, with the catheter bag also lying on the floor. These observations indicate a lack of adherence to the facility's infection prevention and control policies, which require that catheter drainage bags not touch the floor and that standard precautions be followed when handling or manipulating drainage systems. Interviews with staff and residents further highlighted deficiencies in infection control practices. Resident #364 reported that staff did not wear PPE when checking their catheter and that they were not educated on how to clean it. Certified Nurse Aides were observed not performing hand hygiene or wearing PPE when required, and a Licensed Practical Nurse was seen wearing an N95 mask incorrectly. The Director of Nursing acknowledged the need for handwashing and PPE use but admitted that re-education was informal and not documented, relying on unit managers and supervisors to monitor compliance.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by several incidents involving four residents. Resident #13 was unable to attend activities of their choice because their wheelchair could not fit through the interior doorways to the activities room, leading to feelings of exclusion. Despite expressing a desire to participate in activities like bingo, the resident was only able to access the activities room through an exterior route, which was not feasible in poor weather conditions. This situation was acknowledged by staff, who noted the difficulty in maneuvering the wheelchair through a 'rut' on the path. Resident #17 reported feeling like a burden due to staff unprofessionalism, which made them uncomfortable asking for assistance with bowel movements. The resident also noted that staff often discussed personal matters inappropriately, indicating a need for in-service training on professionalism and dignity. The facility primarily employed agency staff, and there was uncertainty about the orientation process for these staff members. Resident #62 was observed with matted, greasy hair and a malodorous presence, and expressed frustration over the delayed removal of meal trays. The resident also experienced an incident where they were locked out of a shared bathroom, resulting in incontinence while waiting for staff assistance. This incident highlighted issues with call light response times and staff attitudes, as one CNA expressed that residents should be grateful for the care provided. Additionally, Resident #364's urinary catheter drainage bag was not covered with a privacy pouch, contrary to facility policy, and was observed lying on the floor, raising concerns about adherence to dignity and privacy standards.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate. This deficiency was identified during a recertification survey for two residents who were observed with inhalers on their overbed tables without documented assessments or physician orders for self-administration. The facility's policy requires an assessment of residents' mental and physical capabilities to self-administer medications, but this was not followed for the residents in question. Resident #13, who has diagnoses including acute and chronic respiratory failure, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, was observed with Albuterol and Trelegy inhalers on their overbed table. Despite being cognitively intact and able to communicate effectively, there was no documented evidence of an assessment for self-administration capability or a physician order allowing self-administration. Interviews with the resident and nursing staff revealed that the inhalers were left at the bedside and used under nurse supervision, contrary to facility policy. Similarly, Resident #22, with diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, and anxiety disorder, was observed with an Albuterol inhaler on their overbed table. The resident reported using the inhaler as needed, with the nurse providing it from the medication cart. However, there was no documented assessment or physician order for self-administration. Interviews with nursing staff and the Director of Nursing confirmed that no residents were officially allowed to self-administer medications, and proper procedures for assessment and documentation were not followed.
Deficiencies in Facility Maintenance and Housekeeping
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across all five resident units, as observed during a recertification survey. Handrails throughout Units A, B, C, D, and G were found to be scuffed, nicked, and scraped, exposing untreated wood. In Unit A, there was insufficient hot water in residents' rooms, and a bathroom light was dimly working. Additionally, a door handle was sticking, preventing easy access. In Unit B, residents reported difficulty regulating room temperature, and in Unit C, shared bathrooms had significant buildup around toilets and in corners. Unit D had a room that was cluttered with equipment and had sticky floors, while Unit G had a valance coming off the window holder and exposed radiator tubing. Interviews with staff and family members highlighted further issues. A family representative noted persistent odors from bags left in hallways and expressed dissatisfaction with the cleanliness of floors. The Director of Housekeeping claimed that rooms were cleaned daily, focusing on high-touch areas, but acknowledged the need for more consistent spot inspections. The Director of Maintenance explained that damage to handrails and other areas was due to residents' actions and that no work orders had been received for these issues. They also mentioned ongoing projects to replace lighting and heating units but admitted that some problems, like exposed radiator piping, had not been addressed. The facility's policy required staff to complete maintenance and housekeeping work orders when issues were identified, but this process was not effectively implemented. The Director of Maintenance was aware of the handrail damage but had not taken corrective action. Additionally, the facility was working with an outside contractor to upgrade lighting, but this had not yet reached resident rooms. The lack of immediate action and communication regarding maintenance issues contributed to the deficiencies observed during the survey.
Deficiency in Grievance Process for Anonymous Submissions
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as required by regulations. During a recertification survey, it was observed that there was no designated location for residents to submit grievances anonymously, such as a secured box or drop area. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse, revealed a lack of awareness about the process for submitting anonymous grievances. The Director of Social Work, who serves as the Grievance Officer, confirmed that while grievance forms were available, there was no mechanism for anonymous submission. Residents expressed concerns during a Resident Council meeting, indicating fear of retaliation and difficulty in maintaining confidentiality when filing grievances. The Administrator acknowledged that there was no formal process for anonymous grievances, suggesting informal methods such as slipping forms under doors. The facility's grievance policy, although documented, was not effectively implemented to allow for anonymous submissions, leading to a deficiency in honoring residents' rights to voice grievances without fear.
Failure to Report Resident Fall and Injury
Penalty
Summary
The facility failed to report an incident involving Resident #40, who fell and sustained a serious injury, in accordance with state regulations. Resident #40, who has a history of seizure disorder, morbid obesity, and bipolar disorder, required assistance from two or more staff members for personal care tasks as per their Comprehensive Care Plan. However, during an incident on October 1, 2024, the resident fell out of bed while being assisted by a single Certified Nurse Aide, resulting in a right distal femur fracture. The incident was not reported to the Department of Health as required by the facility's policy and state regulations. The facility's policy mandates that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, must be reported immediately, but not later than two hours after the allegation if it involves abuse or results in serious bodily injury. Despite this, there was no documented evidence that the incident involving Resident #40 was reported to the Department of Health. Interviews with staff revealed a lack of clarity and adherence to the reporting process, with some staff members unaware of the requirement to document incidents in the medical chart or report them to the Department of Health. The Director of Nursing and the Administrator were identified as the individuals responsible for investigating and reporting such incidents. However, interviews indicated that the Administrator only reported allegations of abuse if they were substantiated within two hours, which contradicts the regulation that requires all allegations to be reported within that timeframe. This failure to report the incident involving Resident #40 highlights a significant deficiency in the facility's adherence to state regulations and its own policies regarding the reporting of abuse, neglect, and mistreatment.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge for a resident, identified as Resident #362, who was admitted with a fracture of the femur, polysubstance abuse, and unspecified osteoarthritis. The resident was cognitively intact and required skilled physical therapy to improve functional mobility and safety. Despite reaching maximum potential in physical therapy, the resident expressed feeling unprepared for discharge and did not receive adequate discharge education or written notice of their rights to appeal the decision. The facility's policy required coordination of necessary services for a safe transition to the community, including providing written notice of discharge and appeal rights. However, the resident did not have a discharge planning meeting with Social Work, and there was no documented evidence of education or notification of the appeal process. The resident was informed by a nurse that leaving the facility would result in signing out Against Medical Advice, potentially affecting insurance coverage. The Social Worker later informed the resident of the discharge, but no appeal information was documented. Interviews revealed that the discharge was prompted by a notice of discontinuation of payment from the resident's insurance, which was not communicated effectively to the resident. The Social Work Director confirmed the insurance issue as the reason for discharge, but did not report offering an appeal. The resident signed the discharge notice without understanding their rights or the appeal process, leading to a deficiency in the facility's discharge procedures.
Incomplete PASARR Screening for Residents
Penalty
Summary
The facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission, as required by the Preadmission Screening and Resident Review (PASARR) process. Specifically, the PASARR forms for seven residents were incomplete, with missing or incorrect information regarding their mental health diagnoses. For instance, Resident #17, who was diagnosed with major depressive disorder, PTSD, and anxiety disorder, had a Level I PASARR form that incorrectly documented no serious mental illness and lacked a Level II referral. Similarly, Resident #40's PASARR form was incomplete, with unanswered questions regarding mental illness and developmental disability. Resident #60, who had diagnoses of bipolar disorder, schizophrenia, and dementia, also had a Level I PASARR form that incorrectly documented no serious mental illness and lacked a Level II referral. The Director of Social Work stated that a Level II form was not required for Resident #60 because they were admitted for rehabilitation, despite the surveyor pointing out that the resident could potentially qualify for a Level II evaluation based on their diagnoses. The facility's Corporate Social Worker had advised that a Level II evaluation was unnecessary, which was echoed by the Corporate Registered Nurse, who stated that the residents did not have a qualifying stay for mental illness. Interviews with facility staff revealed a lack of understanding and compliance with the PASARR process. The Director of Social Work and the Corporate Registered Nurse both indicated that they believed Level II evaluations were not required based on the residents' admission reasons or corporate guidance. However, the Minimum Data Set Coordinator stated that a Level II evaluation should be conducted whenever there is a qualifying mental illness diagnosis. This discrepancy in understanding and execution of the PASARR process led to the deficiency identified during the survey.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for several residents, as identified during a recertification survey and an abbreviated survey. Specifically, the care plans for seven residents did not address their medical, nursing, and psychosocial needs. For instance, one resident with diagnoses of benign prostatic hyperplasia, obstructive uropathy, tremors, generalized anxiety disorder, and constipation did not have a care plan that included these conditions. Another resident with epilepsy and seizures also lacked a care plan addressing these diagnoses. The report highlights that the facility's policy required comprehensive care plans to be developed within seven days of completing the Minimum Data Assessment, incorporating measurable objectives and timeframes. However, this was not adhered to, as evidenced by the lack of care plans for specific medical conditions and treatments. For example, a resident who was prescribed hormone cream and another who required thigh-high stockings for deep vein thrombosis prevention did not have corresponding care plans. Interviews with facility staff revealed gaps in the care planning process. A registered nurse admitted to participating in care plan meetings but was not familiar with updating care plans. The Director of Nursing stated that registered nurses were responsible for updating or creating care plans, but there was a lack of clarity and training on how to do so effectively. This lack of training and oversight contributed to the deficiencies observed in the care planning process.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised based on changing needs for a resident who experienced multiple falls. Specifically, the care plan for a resident with diagnoses of muscle weakness, pain, and a history of falls was not updated following several incidents of falls in October, November, and December 2024. Despite the resident being cognitively intact and able to communicate effectively, the care plan was not revised to reflect the falls documented in the incident reports. The facility's policy required that care plans be updated when there was a significant change in a resident's condition, such as falls. However, the care plan for the resident was only revised on 10/30/2024 and did not include updates for the subsequent falls. During an interview, the Director of Nursing stated that falls were reviewed the day after they occurred to ensure appropriate interventions were implemented, but this was not reflected in the care plan updates.
Deficiency in Resident Activity Provision
Penalty
Summary
The facility failed to ensure the provision of meaningful and accommodating activities for two residents, which impacted their quality of life. Resident #22, who was cognitively intact and diagnosed with diabetes mellitus, chronic obstructive pulmonary disease, and anxiety disorder, expressed disinterest in the activities offered and reported feeling bored. Despite requesting yarn for crocheting, an activity they enjoyed, the supplies were not provided, leading to dissatisfaction and a lack of engagement in activities. Resident #75, also cognitively intact and diagnosed with cerebral infarction, bipolar disorder, and morbid obesity, expressed feelings of loneliness and isolation. Their care plan included interventions to encourage social engagement and participation in activities, but they reported that the activities offered, such as coloring, felt demeaning. The resident's mood was affected by the recent death of their cat, and they preferred playing games on their computer, which was not adequately addressed by the facility's activity program. The facility's policy required an ongoing program to support residents' choices of activities, but the Corporate Recreation Director was unaware of Resident #22's request for yarn and could not provide documentation of activity attendance or one-on-one activities. The Activities Director had resigned without notice, and interim support was being provided, indicating a lack of continuity and oversight in the activities program.
Deficiencies in Resident Care and Treatment Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. Resident #34, who was admitted with a disrupted surgical wound, did not receive daily dressing changes as ordered by the physician. Observations revealed that the dressing was not changed for several days, and the resident expressed concerns about the lack of monitoring by the nursing staff. The Treatment Administration Record indicated that a dressing change was documented as completed by an LPN, but the dressing was not actually changed, leading to a discrepancy in care. Resident #211, diagnosed with cardiomyopathy and cancer, was ordered to self-perform oral suctioning for excessive oral mucus. However, the facility's policy did not include guidelines for self-performed oral suctioning, and there was no documented evidence that the resident's vital signs and respiratory status were monitored during the procedure. The Director of Nursing acknowledged that residents permitted to self-suction should have a doctor's order and be assessed by nursing staff, with intermittent monitoring to ensure proper procedure. The deficiencies highlight a lack of adherence to physician orders and professional standards of practice, resulting in inadequate care for the residents. The facility's failure to ensure proper documentation and monitoring of treatments contributed to the deficiencies observed during the survey.
Deficiencies in Nutritional and Hydration Care for Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and hydration for two residents, leading to deficiencies in their care. Resident #51, who was admitted with diagnoses including gastrostomy malfunction and protein-calorie malnutrition, experienced significant weight fluctuations and episodes of vomiting due to improper monitoring and adjustment of tube feedings. The facility did not consistently document weekly weights as ordered, and there was a lack of communication and follow-up between the dietitian and nursing staff regarding the resident's nutritional needs and symptoms. Resident #364, admitted with conditions such as influenza virus A and acidosis, did not receive adequate fluid intake to maintain proper hydration. Despite the facility's policy on hydration, there was no clear documentation of the resident's specific fluid needs, and staff interviews revealed a lack of awareness and adherence to providing extra fluids as required. The resident reported having to repeatedly request fluids, and observations noted signs of dehydration, such as dry skin and mucous membranes. The deficiencies in care for both residents were compounded by inadequate staffing and communication issues within the facility. Staff interviews indicated that weights and fluid monitoring were not consistently prioritized, and there was a disconnect between dietary assessments and the implementation of care plans. These failures contributed to the residents' compromised nutritional and hydration status, highlighting significant lapses in the facility's ability to meet their care needs.
Inadequate Oxygen Therapy Administration for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during the Recertification Survey. Resident #13, who was admitted with acute and chronic respiratory failure, was found to have their oxygen therapy administered incorrectly. The physician's order specified that the resident should receive oxygen at 3 liters per minute, but observations revealed that the oxygen was set at 2.5 liters per minute. Additionally, the oxygen saturation levels were not consistently checked every shift as required, with several dates missing the necessary checks. Resident #22, who was admitted with chronic obstructive pulmonary disease and other conditions, also experienced improper administration of oxygen therapy. The physician's order indicated that the resident should receive oxygen at 2 liters per minute, but observations showed that the oxygen was set at 3 liters per minute. The resident reported that they had always been on 3 liters per minute, and the Physical Therapy Aide confirmed this setting during a session. However, the Licensed Practical Nurse later identified the discrepancy and noted that the oxygen should have been set at 2 liters per minute. Interviews with nursing staff revealed a lack of consistent monitoring and adjustment of oxygen levels according to physician orders. Licensed Practical Nurses and Registered Nurses were responsible for checking and adjusting oxygen levels, but there was confusion about the frequency of these checks. The Director of Nursing confirmed that oxygen saturation should be checked every shift, but the records indicated that this was not consistently done for Resident #13. Similarly, the Director of Rehabilitation acknowledged that oxygen should be applied by nursing staff, but the Physical Therapy Aide had adjusted the oxygen settings for Resident #22.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required by regulations. Specifically, the facility's staffing records revealed that on multiple occasions between July 4, 2024, and September 28, 2024, there was no RN scheduled for the required eight consecutive hours. On July 4, 2024, an RN was present for only 7.5 hours, and on July 14, 2024, there was no RN scheduled for the full eight hours. On September 20, 2024, an RN was present for 6.75 hours, but the Director of Nursing (DON) was also in the facility for eight hours that day. The facility did not have any staffing waivers in place to justify these deficiencies. Interviews with facility staff revealed that the staffing coordinator was aware of the scheduling issues and attempted to address them by adjusting staff hours. However, the coordinator could not provide explanations for the specific dates when the RN coverage was insufficient. The Director of Nursing, who was not in the position during the time of the deficiencies, acknowledged the ongoing staffing challenges. The facility administrator also confirmed the difficulties in maintaining adequate staffing levels but was unable to provide details about the specific incidents of non-compliance. The facility's failure to maintain the required RN coverage was not addressed by any corrective actions or waivers at the time of the survey.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to ensure its medication error rate did not exceed 5%, resulting in a 22.22% error rate during a medication pass observation. This deficiency was identified when a registered nurse crushed and administered medications to a resident without a physician's order to do so. The resident, who was admitted with diagnoses including muscle weakness, depression, and dementia, was observed receiving crushed medications that were not supposed to be altered, according to manufacturer recommendations. The medications included Eliquis, Metoprolol Tartrate, Lotrel, Calcium Vitamin D3, Omeprazole, and Tradjenta, none of which had orders to be crushed in the Medication Administration Record. The error occurred despite the facility's policy requiring medications to be administered as per orders and checked three times for accuracy. Interviews revealed a miscommunication between nursing staff regarding the administration route, with one nurse advising another to crush the medications, contrary to the facility's policy and the manufacturer's instructions. The Director of Nursing confirmed that there should have been a physician's order for crushing medications and that medications not suitable for crushing should not have been prescribed without an alternative order.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that multiple medication carts and rooms contained medications without open or expiration dates, including albuterol inhalers, insulin vials, and nasal sprays. Additionally, expired and discontinued medications were found in the medication carts and refrigerators. Personal items such as a telephone charger and clothing were improperly stored in medication areas, and narcotic boxes were not double locked as required. Interviews with nursing staff revealed a lack of awareness regarding the labeling and expiration of medications after opening. A Registered Nurse and a Licensed Practical Nurse admitted to being unaware of the shortened expiration dates for certain medications. The Director of Nursing stated that it was the responsibility of the medication nurse to maintain the cleanliness and orderliness of the medication cart, and that all nurses received training and competency checks for medication administration. However, the survey findings indicated that these procedures were not consistently followed, leading to the observed deficiencies.
Food Safety and Cleanliness Deficiencies in Kitchen and Nutrition Rooms
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in multiple areas, including the main kitchen and resident unit nutrition rooms. During the initial inspection, several issues were observed, such as a rolling toaster and meat slicer with significant debris, broken seals on coolers, and a walk-in freezer with ice build-up preventing the door from closing properly. Additionally, the kitchen floor was dirty, and the Accutemp steamer had dirt and debris. Follow-up inspections revealed persistent issues, including wet and improperly stored pots and pans, a rolling toaster with debris, and a meat slicer with debris. The chemical sanitizer concentration in the three-sink system was also found to be higher than the recommended range. In the resident unit nutrition rooms, further deficiencies were noted. The G unit nutrition room had an out-of-service ice machine that was rusted and potentially hazardous, with broken cabinet doors and dirty counters. The B/C unit's nutrition room had similar issues with broken cabinet doors and dirty counters, while the A/D unit's nutrition room had dirty counters and door seals on the refrigerator and freezer. Interviews with the Director of Food Services and the Director of Housekeeping revealed a lack of clarity regarding cleaning responsibilities and acknowledgment of the need for improved diligence in maintaining cleanliness and equipment functionality.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a recertification survey. Two out of three trash bins were not pest and rodent-proof, with the doors not fully closed and the drain plug unsecured. Specifically, garbage waste was found around the dumpsters, with the right dumpster missing a drain plug and the left dumpster's side door left open. During an interview, the Director of Maintenance acknowledged responsibility for the dumpsters and the surrounding area, noting that despite daily clean-up efforts, refuse continued to litter the ground. They also confirmed awareness of the missing drain plug and had contacted the vendor to address it. A follow-up observation revealed the side door of the dumpster was still open, which the Director of Maintenance had to close manually, indicating a need for better awareness among staff to ensure the doors are closed after disposing of garbage.
Inadequate Administration and Resource Utilization
Penalty
Summary
The facility was found to be inadequately administered, failing to effectively use its resources to ensure the highest practicable well-being of its residents. This was determined during a recertification survey, which included observations, interviews, and reviews of various records and reports. The administration's lack of effective oversight and planning was evident in multiple areas, affecting all 39 residents sampled. These deficiencies included failures in maintaining resident dignity, assessing residents' ability to self-administer medications, and ensuring a safe, clean, and homelike environment. The survey identified numerous specific regulatory failures, such as the facility's inability to provide sufficient staffing, competent nursing services, and a comprehensive person-centered care plan for each resident. Additionally, the facility failed to ensure residents were free from abuse and neglect, report injuries from unknown sources, and provide safe and appropriate discharges. There were also significant issues with medication management, including unnecessary medications, medication errors, and improper storage of drugs and biologicals. Further deficiencies were noted in the facility's infection control practices, food service safety standards, and the completeness and accuracy of medical records. The facility also lacked a robust quality assurance program, as evidenced by the administrator's admission of system failures and attempts to correct them. These widespread deficiencies highlight the facility's failure to meet professional standards and regulatory requirements, potentially compromising the health and safety of all residents.
Incomplete Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident, as evidenced by an incomplete Treatment Administration Record. The resident, who was cognitively intact, had a history of abdominal surgery with complications and expressed concerns about the monitoring of their incision. An observation revealed that the resident's abdominal dressing had not been changed as per the documented schedule, with the dressing dated two days prior to the observation. The deficiency was further highlighted during interviews, where it was revealed that a Licensed Practical Nurse (LPN) had documented the completion of the dressing change on a specific date, but the procedure was not performed. The LPN admitted to marking the treatment as done with the intention of returning to complete it, but was called away for an emergency. The Director of Nursing confirmed the discrepancy and took disciplinary action against the LPN upon discovering the issue.
Failure to Maintain Required QAPI Committee Members
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee with the participation of all required members, including the Director of Nursing, Medical Director or designee, Administrator, and Infection Preventionist. The facility's QAPI plan outlined that the committee should meet monthly and include various key personnel, but a review of meeting attendance records from July 2024 through December 2024 revealed that the Medical Director or designee did not attend any meetings, and the Infection Preventionist was absent from all meetings. This lack of participation hindered the committee's ability to coordinate and evaluate performance improvement projects effectively. Interviews with facility staff revealed further issues contributing to the deficiency. The Director of Nursing, who was also serving as the Nurse Educator, stated that there had been no one available to fulfill the role of Infection Preventionist, and they were attempting to promote a nurse to the Assistant Director of Nursing role, assuming the nurse had the necessary certification. The Administrator admitted to being unaware that the Infection Preventionist role could not be combined with the Director of Nursing role and acknowledged that the Medical Director's absence from the meetings was due to a failure to sign in, despite attending. These oversights and misunderstandings contributed to the facility's failure to maintain a properly functioning QAPI committee, as required by regulations.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the Infection Prevention and Control Program from October 2024 to January 2025. This deficiency was identified during a recertification survey, where it was observed that the facility did not have a designated individual fulfilling the role of Infection Preventionist. The Director of Nursing, who was also serving as the Nurse Educator, stated that they had assumed the role of Infection Preventionist but were unable to effectively manage all responsibilities due to their multiple roles. This lack of a dedicated Infection Preventionist led to insufficient infection control practices among the staff. The facility's policy on Antibiotic Stewardship, revised in July 2024, indicated that the Infection Preventionist should oversee the program with input from the Medical Director, Consultant Pharmacist, Director of Nurses, and Administrator. However, the absence of a designated Infection Preventionist meant that these responsibilities were not adequately fulfilled. The Director of Nursing acknowledged the challenge of managing infection control duties alongside their other responsibilities, indicating a gap in the facility's infection prevention and control measures.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent Federal/State survey were posted in a location that was easily accessible to residents, visitors, and other individuals. During a resident council meeting, four residents expressed that they were unaware of where the Department of Health Survey results were located. An observation revealed that the survey results were kept in a black binder near the entrance area, but there was no prominent sign indicating the contents of the binder. Additionally, the binder contained incomplete documentation regarding survey results from the past three years. Interviews with facility staff further highlighted the deficiency. A receptionist stated that reports regarding survey results were sent directly to the Administrator and were not kept at the front desk. The receptionist was unaware of the location of the survey results and confirmed the absence of a sign indicating their availability. The Administrator acknowledged that a sign indicating the availability of survey results had been removed and stated that they would replace it. The Administrator also admitted that the binder lacked survey results for specific dates, which they intended to rectify.
Neglect Leads to Resident Injury Due to Care Plan Violation
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall and injury. A Certified Nurse Aide did not adhere to the resident's comprehensive care plan while providing personal care, leading to the resident falling from their bed and sustaining a broken leg. The resident, who had a history of seizure disorder, morbid obesity, and bipolar disorder, required significant assistance with activities of daily living and was dependent on two or more staff members for tasks such as rolling in bed and personal hygiene. The incident occurred when the resident was being assisted by a single Certified Nurse Aide, contrary to the care plan's requirement for assistance from two or more staff members. During the care, the resident rolled too close to the edge of the bed and fell, resulting in a right distal femur fracture. The resident was on a blood thinner, Eliquis, and had additional injuries, including a head strike and a bleeding toe laceration, necessitating hospital evaluation. Interviews with facility staff revealed gaps in incident reporting and documentation. The Director of Nursing and Administrator were responsible for reporting incidents to the Department of Health, but there was inconsistency in how incidents were documented and reported. Staff were educated on abuse and neglect annually, but the incident highlighted a failure to follow the care plan and report the incident promptly, as required by facility policy and regulations.
Failure to Provide Written Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a transfer to the hospital. Specifically, the deficiency involved a resident who was transferred to the hospital due to respiratory distress. The facility's policy required that a written notice specifying the duration of the bed-hold policy be provided at the time of transfer, but there was no documented evidence that this notice was given to the resident or their representative. During interviews, it was revealed that the nurse responsible for the transfer did not follow up on the bed-hold issue after notifying the family verbally. The Director of Nursing outlined the expected procedures for hospital transfers, which included notifying the family and providing necessary paperwork, but the written notice of the bed-hold policy was not part of the documented process. This oversight led to the deficiency as the facility did not comply with the regulatory requirement to inform the resident and their representative in writing about the bed-hold policy.
Medication Storage Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, identified as Resident #13, who was observed with medications unsupervised in their room. Resident #13, who shared a room with another resident, had an Albuterol inhaler and a Trelegy inhaler left on their bedside table, accessible to both themselves and their roommate. This was contrary to the facility's policy, which required medications to be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. Resident #13 was cognitively intact and had diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Despite the resident's ability to understand and communicate, the facility's Director of Nursing confirmed that no residents were permitted to self-administer medications. The inhalers were left on the bedside table throughout the day and were sometimes stored on the medication cart at night, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Document Indication for Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, as evidenced by the lack of an indication for the use of Estrace Vaginal Cream prescribed to Resident #27. The resident, who was admitted with diagnoses including urinary tract infection, unspecified dementia, and major depressive disorder, had a physician order for Estrace Vaginal Cream without a documented indication for its use. The facility's policy required that medication orders include a clinical indication, and the consultant pharmacist's review did not identify this omission as an irregularity. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, revealed that medication orders should include the reason for use, and if missing, staff should contact the provider to obtain it. However, the provider and Medical Director indicated that the indication for use was documented in clinical notes rather than on the order itself. This discrepancy led to the deficiency, as the medication was administered without a documented indication, contrary to professional standards and facility policy.
Significant Medication Errors in Alprazolam Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Alprazolam, a medication used to treat anxiety. The resident, who had intact cognition and could communicate effectively, reported that the night nurse administered Alprazolam at incorrect times and left medication unattended, instructing the resident to take it or not. The Medication Administration Record and physician's orders indicated that Alprazolam was to be given three times a day at specific times, but there were multiple instances where the medication was administered either late, early, or too close to the previous dose, violating the prescribed schedule. Interviews with the Director of Nursing and Licensed Practical Nurses revealed that the facility's policy required medications to be administered according to the physician's orders and that any deviations should be reported to the physician. However, the staff involved were unaware of the errors in administering Alprazolam, and there was no documented evidence that the physician was notified or that the resident was monitored for side effects. This lack of adherence to medication administration protocols led to the deficiency identified during the recertification survey.
Deficiency in Safe Storage of Outside Food for Resident
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of foods brought to residents by families and other visitors, leading to a deficiency in preventing food-borne illness. Specifically, Resident #52, who was cognitively intact and had medical conditions including a unilateral inguinal hernia with obstruction, hepatomegaly, and type 2 diabetes mellitus, had food brought from outside that was not labeled or discarded according to the facility's policy. During an observation, it was noted that Resident #52 had raw hotdogs in their dresser and a Tupperware container with rice at their bedside, which had been brought by a family member earlier that day. Interviews with staff and family members revealed a lack of adherence to the facility's policy regarding the handling of outside food. Family Member #1 reported that staff on the G unit did not ask to place the food in the refrigerator, unlike the previous D unit. Additionally, the family member had not received any education on the facility's policy for safe storage of outside food. Licensed Practical Nurse #1 was unaware of the food in the resident's room, and Registered Nurse #1 stated that staff were expected to inspect and store outside food properly. The Director of Nursing admitted to not knowing the specifics of the policy and expected staff to notify supervision if there were any problems with food in residents' rooms.
Failure to Investigate Resident Injury and Unsupervised Exit
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of a thorough investigation into an alleged incident involving a resident who sustained a skin tear on their right hand. The resident, who had diagnoses including type 2 diabetes mellitus, nicotine dependence, and schizophrenia, was cognitively intact and able to communicate effectively. On the night of the incident, the resident reported injuring their hand on the front door while returning to the facility at 11:00 PM. Documentation by nursing staff confirmed the presence of a new skin tear, and the wound was treated and reported to the provider. Despite the facility's policy requiring all accidents and incidents to be thoroughly investigated, including completion of an incident/accident report with detailed circumstances, there was no documented evidence that a comprehensive investigation was conducted. Staff interviews revealed that neither the supervisor nor the nurse who treated the resident inquired about how the resident exited or re-entered the building, nor did they determine whether the required Out on Pass Agreement was completed. The supervisor acknowledged not starting an investigation and only completed the incident form and skin assessment. Further interviews with the Director of Nursing and other staff confirmed that the expected protocol of immediate investigation was not followed. The resident could not recall who allowed them to leave or re-enter the facility, and staff were unaware of who facilitated the resident's movements. The lack of a documented investigation into the circumstances of the incident and the resident's unsupervised exit and re-entry constituted the deficiency.
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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