Elderwood At Williamsville
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsville, New York.
- Location
- 200 Bassett Road, Williamsville, New York 14221
- CMS Provider Number
- 335326
- Inspections on file
- 23
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Elderwood At Williamsville during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with severe dementia and incapacity was inappropriately touched by another cognitively impaired resident in a common area, with the incident witnessed by staff. The victim's care plan did not address risk of victimization, and there was no immediate revision after the event. Staff recognized the incident as sexual abuse, but documentation and monitoring for ongoing safety were lacking.
A Life Safety Code survey revealed that corridor doors in a facility were not properly maintained, affecting multiple floors. Issues included doors not latching and being obstructed. Maintenance inspections were inadequate, and staff education on door operation was inconsistent. An outside contractor was hired for repairs, but some doors remained unrepaired, and the Maintenance Director responsible for the corrective plan was on leave.
A survey revealed that hazardous area doors in a facility were not self-closing and latching properly, affecting all resident use floors. Issues included stuck latches, doors needing manual engagement, and doors held open by ropes or magnets. Maintenance inspections were inadequate, and staff lacked comprehensive education on door maintenance. Despite a Plan of Correction, deficiencies persisted during a post-survey revisit.
Smoke barrier walls in a facility were found to be improperly maintained, with open and unsealed penetrations compromising their integrity. Observations during a survey and a follow-up revisit revealed that these issues affected multiple floors, despite a Plan of Correction stating they were addressed. The Maintenance Director was on leave, and the Maintenance Assistant was unaware of the deficiencies, leaving the Administrator to assume responsibility.
A Life Safety Code survey found a portable electric space heater in a facility's basement office, violating safety codes due to lack of documentation on its heating element's temperature. Despite corrective actions, a revisit revealed another heater in the same office, improperly placed near flammable materials. The facility's audit process was insufficient, and staff lacked formal education on space heater policies.
A resident with severe cognitive impairment wandered off a memory care unit without staff knowledge, exited through an unalarmed emergency door, and sustained injuries from a fall. The facility failed to apply a wander alert bracelet promptly and did not ensure functioning alarms, contributing to the resident's unsupervised exit and injury.
The facility failed to maintain adequate staffing levels, resulting in unmet resident needs and prolonged wait times for assistance. Observations and interviews revealed that call lights were often unanswered, and staff struggled to complete their duties due to high resident-to-staff ratios. Residents and families expressed dissatisfaction with the care provided, highlighting the facility's inability to meet the required minimum hours of care per resident per day.
The facility failed to ensure food and drink were palatable and served at safe temperatures, with hot foods often being lukewarm or cold, and cold foods warmer than recommended. Residents expressed dissatisfaction with meal quality, noting cold coffee, bland Salisbury steak, and warm milk. Staff acknowledged the issues, attributing them to equipment problems, but did not adequately address the deficiencies.
The facility failed to maintain food safety standards in the Main Kitchen, with observations revealing a dust-laden ceiling and a damaged wall. The Director of Dining Services did not submit a maintenance work order for these issues, and the Administrator assumed a plan was in place to address them. Inspection reports also noted dirty heat detectors. Despite awareness of these issues, necessary maintenance was not completed.
A survey found that the facility's emergency generator lacked proper maintenance, with missing documentation for diesel fuel quality testing and monthly load tests. Additionally, the emergency manual stop station was not remotely located, and key staff were unaware of its location.
A Life Safety Code survey identified improper exit signage on two resident use floors, with exit signs incorrectly indicating egress paths. On the first floor, signs in the Main Kitchen and service elevator lobby misled egress routes, conflicting with fire evacuation diagrams. In the basement, exit signs were obscured by paint, further complicating egress paths. The Director of Facilities Maintenance acknowledged the need for corrections.
The facility failed to conduct fire drills at least once per shift per quarter as required by their Fire Drill Policy. Only two drills were conducted in the second quarter of 2023 and two in the third quarter of 2024. Interviews revealed that the Maintenance Director, who was responsible for scheduling and documenting the drills, was no longer employed, leading to inadequate documentation and execution.
The facility did not maintain continuous illumination of egress pathways, as required by the Life Safety Code. On the first floor, corridor lighting was controlled by switches that, when turned off, left egress routes unlit. Additionally, the exterior lacked adequate lighting above certain exit doors, with observed inconsistencies in lighting during testing by electricians.
Two residents with severe cognitive impairments were treated in an undignified manner by a CNA, who made a fist and boxing jab motion towards one resident and pushed another in a wheelchair 'wheelie' motion. These actions were captured on video and deemed inappropriate by facility staff, highlighting a failure to uphold the dignity and respect required by the facility's policy.
A resident with limited ROM and chronic conditions was not ambulated daily as per their care plan, due to staffing shortages. Despite being on a nursing rehab ambulation program, the resident was only walked on a few occasions over a month. Staff acknowledged the issue, citing insufficient staffing as a barrier to following the care plan.
A resident with a history of urinary tract infections was observed with their foley catheter drainage bag improperly positioned above the bladder level and placed on the floor, contrary to facility policy. Staff failed to adhere to proper catheter care protocols, increasing the risk of infection. Observations and interviews confirmed the deficiency in managing the catheter and preventing infections.
The facility did not comply with emergency preparedness requirements by failing to participate in a full-scale community-based exercise in 2023, affecting all resident units. Despite being a member of the Western New York Mutual Aid Plan, the facility did not partake in any community-wide drills, and no documentation was found to support participation in any exercises. The responsibility for arranging these drills was with the Director of Maintenance, who missed the exercise in 2023.
The facility failed to submit Termination Form 105 to the NY State Department of Health CHRC program within the required 30-day period for two housekeeping aides and one CNA. The forms were submitted months late, contrary to the facility's policy and state regulations. The HR Manager, new to the position, discovered the oversight during a personnel file review.
A CNA witnessed another CNA grab a resident's arms and nose during a combative episode but did not report the incident immediately, resulting in a delay in notifying the New York State Department of Health. The resident had severe cognitive impairment and daily behavioral issues.
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident with dementia. The investigation did not include interviews with other residents the accused staff member had cared for, despite the staff member working on different units. Both the DON and Administrator acknowledged the investigation's shortcomings.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe dementia and incapacity to make medical decisions was subjected to inappropriate sexual contact by another resident. The incident took place in a common area after dinner, where a staff member witnessed one resident touching the other's breast under their shirt. The victim was unable to communicate or react due to severe cognitive impairment, and there was no evidence of consent. The perpetrator, who also had dementia and lacked capacity for medical decision-making, did not recall the event and displayed indifference when questioned. Prior to the incident, the care plan for the victim did not address the risk of potential victimization, nor was it revised after the event to reflect the new risk. The perpetrator's care plan noted moderate cognitive impairment and behavioral concerns, with interventions to monitor interactions for appropriateness, but there was no documented history of prior inappropriate behavior. Staff interviews confirmed that the incident was recognized as sexual abuse, and immediate separation of the residents occurred. However, documentation and monitoring for the safety of the victim and prevention of recurrence were not clearly established at the time of the incident. The facility's abuse prevention policy required protection of residents from abuse and outlined steps such as increased supervision and room changes to safeguard victims during investigations. Despite these policies, the lack of a care plan addressing the victim's vulnerability and the absence of immediate, documented interventions to prevent further abuse contributed to the deficiency. Staff responses varied in their understanding of the incident, with some not recognizing the event as abuse due to the perpetrator's cognitive status, while others identified it as non-consensual sexual contact.
Corridor Door Maintenance Deficiency
Penalty
Summary
During a Life Safety Code survey, it was observed that corridor doors in a long-term care facility were not properly maintained, affecting three of the four resident use floors. Specific issues included doors that did not latch into their frames and were obstructed from closing. On the second floor, the Treatment Room door required a forceful close, and the Janitor's Closet door was obstructed by a paper towel and a decoration hanger. On the first floor, the Respiratory Therapy Office door was propped open with a garbage can, despite being equipped with a magnetic hold-open device. In the basement, the Ladies Locker Room door did not latch, and on the second floor, the door to Resident Room 222 appeared warped. The facility's computerized maintenance system indicated that fire and smoke door inspections were not specific to door locations and were not conducted frequently enough to address the issues. The last annual inspection was completed nearly a year prior, and the monthly inspection did not specify door locations. Interviews revealed that an outside contractor had been hired to repair and replace certain doors, but there was no written list of the doors included in the project. Maintenance staff recalled that Resident Room 222's door was part of the project. During a post-survey revisit, it was found that the deficiency persisted, with the Ladies Locker Room door still not latching. Staff education on corridor doors was inconsistent, with some staff members reporting no recent education on the topic. The facility's Plan of Correction indicated that corrective actions were either completed or in progress, but the Maintenance Director, who was responsible for the plan's implementation, was on leave. The Administrator was unaware that some doors had not been repaired and assumed the contractor would complete the repairs before the plan's completion date.
Plan Of Correction
Plan of Correction: N/A Corrective action for the deficient corridor doors at the Unit 2 treatment room, unit 2 janitor’s closet, unit 1 respiratory therapy office, the ladies locker room, and resident room 222 is completed or in progress by outside contractor. Education will be provided to all staff related to corridor door operation and to the maintenance team on proper operation of corridor doors. A Monthly audit will be conducted for all corridor doors. The results of this audit will be logged monthly into the TELS system. The results of this audit will be reported to the QA committee on a monthly basis. Administrator will provide the education. Monitored Monthly for 3 months in QA. Responsible Designee: Maintenance Director
Hazardous Area Doors Failing to Self-Close and Latch
Penalty
Summary
During a Life Safety Code survey, it was observed that hazardous area doors in a facility were not properly self-closing and latching into their door frames. This issue was identified across all four resident use floors, including the basement, first, second, and third floors. Specific doors, such as those to the Precautions Bins Storage Room, Oxygen Storage Areas, Soiled Utility Room, Laundry Room, Central Supply, and Maintenance Shop, were found to have various issues preventing them from closing and latching properly. These issues included stuck latches, doors needing to be pulled to engage the latch, and doors being held open by ropes or magnets. The facility's computerized maintenance system indicated that fire and smoke door inspections were not specific to door locations and were not conducted frequently enough to ensure compliance. Interviews with the Director of Facilities Maintenance and other staff revealed that some doors had been repaired by an outside contractor, but there was no written list of doors assigned for repair. Additionally, the maintenance staff had not been adequately trained on inspecting and maintaining these doors, contributing to the ongoing deficiencies. During a post-survey revisit, it was found that the deficiencies persisted, with doors on the first and third floors still not self-closing and latching. Staff interviews revealed a lack of comprehensive education on the importance of maintaining hazardous area doors, with some staff unaware of the issues or the necessary corrective actions. The facility's Plan of Correction was not fully implemented, and the absence of the Maintenance Director further complicated the resolution of these deficiencies.
Plan Of Correction
Plan of Correction: N/A Corrective action for the deficient doors located on Unit 5 precaution bin storage, Unit 2 oxygen storage area, Unit 3 oxygen storage area, Unit 1 oxygen storage area, Unit 1 soiled utility room, laundry room rear door, central supply door, and the maintenance shop area are corrected or in progress completion by outside contractor. Education will be provided to all staff related to proper door closure and to the maintenance team on proper technique for checking all interior doors. An audit will be conducted for all facility interior doors. This will be logged in the TELS system, and the results will be reported to the QA committee on a monthly basis. Administrator to provide all education and we will continue to monitor the doors monthly and annually. Monitored monthly for 3 months in QA. Responsible designee - Maintenance Director
Smoke Barrier Wall Deficiencies Persist in Facility
Penalty
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls in a facility were not properly maintained, affecting three of the four resident use floors. Specifically, the smoke barrier walls were incomplete from floor to ceiling/roof deck, lacked a 30-minute fire resistance rating, and had open and unsealed penetrations that could allow smoke passage. Observations revealed multiple unsealed penetrations above ceiling tiles on various floors, including outside resident rooms and in the MDS Office. These penetrations were noted to have wires and cables passing through them, which were not sealed, compromising the integrity of the smoke barriers. A follow-up Onsite Post-Survey Revisit found that the issue persisted on one of the floors, indicating a continuing deficiency. The facility's Plan of Correction had stated that the penetrations were sealed, but observations during the revisit showed otherwise. Interviews revealed that the Maintenance Director, who was responsible for implementing the Plan of Correction, was on leave, and the Maintenance Assistant was unaware of the penetrations. The Administrator, in the absence of the Maintenance Director, assumed responsibility for the Plan of Correction but was informed that the penetrations were sealed on the day they were identified, which was not the case.
Plan Of Correction
Plan of Correction: N/A Corrective action for the deficient smoke barrier on unit 4 resident room 333, MDS office on unit 2, resident room 233, and in the wall between the atrium and unit 1 have been sealed. Education will be provided to the maintenance staff on the proper procedure for checking for gaps in smoke barriers. An audit will be conducted to check all smoke barriers in the facility. This will be logged in TELS and the results will be reported to the QA committee on a monthly basis. Administrator will provide education. Weekly audits for 3 months. Reviewed monthly for 3 months in QA. Responsibility Designee - Maintenance Director.
Recurring Space Heater Violation in Facility
Penalty
Summary
During a Life Safety Code survey, a portable electric space heater was found operating in the basement of a facility, specifically in the Environmental Services Office. The heater was not documented to ensure its heating element did not exceed 212 degrees Fahrenheit, violating the 2012 edition of the National Fire Protection Association 101: Life Safety Code. The Director of Facilities Maintenance was unaware of the heater's presence and stated that space heaters were not allowed in the facility. The Housekeeping/Laundry Supervisor, who shared the office, also denied knowledge of the heater's use, suggesting it might have been turned on by an employee who used the office earlier. Upon a revisit, another portable electric space heater was found plugged in and ready for use in the same office, with a second heater nearby. The heater was improperly placed close to flammable materials, and no documentation was available to confirm the heating element's temperature compliance. The Director of Environmental Services denied ownership of the heaters and had not received formal education on space heater policies since the initial survey. The Administrator was unaware of the new heaters and acknowledged that audits should have been conducted to prevent such occurrences. The facility's Plan of Correction included removing the heater and conducting in-service training on the prohibition of space heaters. However, interviews with staff revealed a lack of formal education on the matter, and the audit process was insufficiently documented. The Maintenance Director, responsible for implementing the Plan of Correction, was on leave, leaving the Administrator to oversee the process. Despite weekly audits, the Environmental Services office was not consistently checked, contributing to the recurrence of the deficiency.
Plan Of Correction
Plan of Correction: N/A Corrective action for this deficient practice was to remove the portable space heater from the Environmental Services office. A full-house audit will be conducted to check for portable space heaters. An in-service on the prohibition of portable space heaters will be conducted to staff who have offices. Ongoing compliance will be monitored by the Director of Maintenance/designee. The results of the weekly audit will be reported to the Monthly QA committee. Administrator will provide education. Weekly audits will be completed for 3 months. Audits will be reviewed Monthly in QA for 3 months. Responsible Designee - Maintenance Director
Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
The facility failed to ensure a safe environment for Resident #154, who was severely cognitively impaired and at high risk for elopement. On 7/13/2024, the resident wandered off the 2nd floor Memory Care Unit without staff knowledge, exited through an emergency stairwell door that did not alarm, and left the building. The resident subsequently tripped and fell, sustaining a 2.5 cm laceration and hematoma to the head, as well as abrasions to the midback and right knee. This incident resulted in actual harm to the resident. The facility's policies on elopement and electronic wandering security were not adequately followed. Although the resident was identified as a high risk for elopement upon admission, the care plan did not initially include interventions for elopement risk. A wander alert bracelet was not applied until after the incident, and there was no evidence that the alarms were verified as functioning at the time of the elopement. Staff interviews revealed that no alarms were heard, and the facility did not have a properly fitting bracelet available immediately after the incident. The facility's response to the incident was delayed and inadequate. Staff were unaware of the resident's absence until a visitor found the resident outside and alerted the front desk. The resident was new to the facility, and there was a language barrier that complicated identification and communication. The facility's failure to apply a wander alert bracelet promptly and ensure functioning alarms contributed to the resident's unsupervised exit and subsequent injury.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? For Resident #154, the Elopement Risk Assessment was initiated on 7/12/24 and completed on 7/17/24. The care plan was revised on 7/15/2024 to reflect that the resident was at high risk for wandering and elopement related to impaired cognition and memory. Nursing interventions were outlined on the care plan. The resident was discharged from the facility on 7/24/24 to a lower level of care. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 7/6/24, 7/13/24, 7/20/24, and 7/27/24 and were documented as functioning. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The QA Committee met on 2/12/25, to complete an assessment of causative factors and to identify an appropriate plan to prevent recurrence. It was determined that all residents have the potential to be affected by the same deficient practice. The Nursing Unit Manager(s) will complete an elopement risk assessment on all residents to identify a baseline for every individual and will be completed by 2/21/25. Any resident who is identified at risk for elopement will have their care plan reviewed to ensure their risk is identified and that an adequate care plan has been developed to ensure the resident’s environment remains free from accident hazards, that adequate supervision and assistive devices to prevent accidents are in place at that time. Preventive Maintenance Checks were completed on all Doors, Locks, and Alarms by the Maintenance Staff on 2/1/25 and 2/8/25 and were documented as functioning. All egress doors are equipped with functioning alarming devices that are easily audible by all staff in all areas of the unit, including when in a room with a closed door. The Unit Clerks will verify that all current residents have a facility issued wristband placed on their person and that hospital identification bands are removed by 2/21/25. The Administrator verified that an appropriate amount of well-fitting wander alert devices were available in the event any residents were to require this type of intervention on 2/12/25. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure that the residents’ environment remains free from accident hazards and that adequate supervision and assistive devices to prevent accidents are provided, the following measures will be implemented: All licensed nurses will be re-educated on the facility’s policies titled Elopement Risk Assessment, Electronic Wandering Security System, and Guidelines for Care Planning Wandering/Elopement High Risk Residents that outlines when elopement risk assessments are to be completed, when appropriate safety measures are to be implemented, and documented on the care plan once risk level for unsafe wandering/elopement is identified. The facility’s policy titled Preventative Maintenance Program was reviewed and remains appropriate. Maintenance Staff will be re-educated on the policy and the required weekly functionality verification of egress door alarms and door security devices. The Front Desk Receptionists, Unit Clerks, and Medical Records staff will be educated on the facility’s policy titled Resident Identification / Patient Identifiers and their responsibility of placing facility identification wrist bands upon admission to the facility to ensure residents are adequately identified in emergency situations. The facility’s assessment and minimum staffing plan will be reviewed and/or revised by the facility administrator to ensure adequate supervision and to prevent accidents. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Nursing / designee will conduct an audit of all new admissions within 24 hours of admission x 2 weeks, then weekly x 2 weeks, then monthly for a period of 2 months, to ensure Elopement risk assessments are completed as required, that appropriate safety measures have been implemented, that care plans are updated to reflect high risk residents, and that wander guard ankle bracelets have been placed when deemed necessary for residents at high risk. The Administrator, in conjunction with Maintenance staff, will conduct a monthly audit x 3 months ensuring that egress door alarms and door security devices have been checked weekly through the Preventive Maintenance Program and that are all functioning as intended. The Unit Clerks will conduct a weekly audit of all new admissions x 4 weeks, then monthly for a period of 3 months, to ensure facility identification bands are present and hospital identification bands removed for all new admissions/readmissions. The Director of Nursing will review daily staffing schedules weekly x 4 weeks, and then monthly for a period of 3 months, to ensure minimum staffing is in place to provide adequate supervision to prevent accidents. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on 3/7/25.
Inadequate Staffing Levels Compromise Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaint investigations and observations. The facility's staffing levels were consistently below the required minimums, with reports indicating that the average hours of care per resident per day were significantly lower than the mandated 3.5 hours. Observations and interviews revealed that call lights were left unanswered for extended periods, and residents were not receiving timely assistance with basic needs such as repositioning, toileting, and meal service. Interviews with staff members, including CNAs and LPNs, highlighted the challenges faced due to inadequate staffing. Staff reported being unable to complete their duties, such as providing showers, toileting residents, and assisting with meals, due to the high resident-to-staff ratios. The lack of sufficient staff also led to delays in medication administration and inadequate supervision of residents, particularly those with higher acuity needs or behavioral issues. Residents and their families expressed dissatisfaction with the care provided, citing long wait times for assistance and unmet care needs. The Resident Council and Ombudsman also reported concerns about staffing levels, with residents describing instances where call lights were ignored, and staff were unable to provide timely care. The facility's failure to maintain adequate staffing levels compromised the safety and well-being of its residents, as evidenced by the numerous complaints and observations documented in the report.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The following corrective actions for those residents who were found to have been affected by the deficient practice: Five complaint investigations were conducted (#NY 668, #NY 735, #NY 153, #NY 833, and #NY 434) during annual survey which ended on 1/21/25. It was determined that the facility allegedly did not ensure that there was sufficient staffing on multiple dates throughout the [AGE] year, based on the previously referenced complaints and staff/resident interviews conducted during the annual survey. No residents were affected by this deficient practice. The Social Service Director/designee will review with all residents who are alert and oriented in person and/or will contact the responsible parties of those residents with cognitive impairment, to discuss the facility's active plan to recruit and retain staff. The recruitment and retention plan will be reviewed at the next resident council meeting. The Administrator/designee will also discuss the “Ambassador program” that was created to foster relationships between management team members and new staff. The facility also has a “Manager on Duty” program to assist on weekends with staffing challenges; this includes the majority of management in the facility. Nursing leadership coverage rotates on a weekly basis, with all members of the nursing leadership team assisting with off-hour and weekend assistance. The Daily Nursing report (BIPA) is reviewed daily to ensure the number of nursing hours worked and the number of nursing staff working each shift based on census met the minimum staffing requirements. The facility will work with the Corporate Recruitment manager to discuss alternative recruitment initiatives. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/Assistant Director of Nursing ensure the health and wellbeing of the residents by having responsibility for oversight and operations of the nursing department. The DON and ADON, along with the Unit Nursing Managers, have been present on many shifts over the course of the last year. These include occasions when there were call-offs, weather-related issues, and other staffing challenges to help ensure adequate clinical specialists were on-site to provide care to the residents. The facility assessment and minimum staffing plan was reviewed and revised on 2/12/25 to include the use of a supplemental staffing agency. The Emergency Preparedness plan was reviewed on 2/12/25 to address staffing, which includes the use of a supplemental staffing agency. The facility labor disruption policy was reviewed on 2/12/25 to ensure interventions to address insufficient staffing are identified and staff will be re-educated on the process of when to activate the emergency staffing plan. When resident census changes, when staff call off or additional staff are called in to assist with staffing, the number of nursing hours worked, the number of nursing staff working each shift, and census will be updated on the Daily Nursing Report Sheets (BIPA). The Daily Nursing Report sheets along with the Facility Assessment minimum staffing ratios identified in the Facility Assessment will be compared to the daily clinical staffing sheets to ensure clinical daily schedules adequately reflect that staffing minimum hours are being achieved every shift according to the facility assessment. The Administrator, the DON, and the Staffing Coordinator will continue to review staffing daily and implement procedures to ensure sufficient staff are available to meet residents’ needs. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: To ensure that this deficient practice does not re-occur, the Administrator/Director of Nursing will provide educational training consisting of but limited to: 1. Facility policy and procedures on Facility Wide Assessment Tool consisting of the facility's clinical minimum staffing requirements. 2. Facility policy and procedures on Labor Disruption Policy and when to activate plan. 3. Facility policy and procedures on Emergency Staffing Plan and when to activate the plan. 4. Facility policy and procedures on completing and reviewing the Daily Nursing Report Sheet. 5. Nursing Managers and Nursing Supervisors will be re-educated on procedures when to notify the Administrator, Director of Nursing, and the Assistant Director of Nursing when there are vacancies and nursing call-offs that impact the facility not meeting minimum clinical staffing requirements as identified on the Facility Assessment. 6. All in-services will be completed by 3/12/2025. Nursing Unit Managers, Nursing Supervisors, and all other nursing exempt staff will be educated by the Administrator/Director of Nursing on the facility's minimum staffing numbers identified in the facility assessment and what to do if the numbers drop below the minimum requirements. This will include what to do, who to call regarding call-offs/no call no shows, and what other nursing personnel to contact to try and fill the vacancy issues when dropping below minimum staffing requirements. A new on-call schedule was developed to provide to backfill vacancies that are unable to be filled. The on-call schedule does not include the DON as the facility census is above 60. Discussions regarding recruitment and retention initiatives will be added to the monthly resident council meeting agenda for three months. Grievances will be reviewed daily for staffing concerns during morning report. The Clinical Staffing Coordinator will audit the daily staffing sheets, the daily nursing report sheets (BIPA), the facility assessment minimum staffing ratios, and the daily census daily for three months to ensure minimum staffing compliance. The Administrator in conjunction with the Director of Nursing will continue to review the facility's schedules weekly for three months to ensure sufficient staff have been scheduled to attain and maintain the highest practicable physical, mental, and psychosocial well-being of residents. With support from the Corporate Recruitment Team and Chief Operating Officer involvement, continued Recruitment meetings will take place weekly to monitor recruitment initiatives. The facility will continue to provide daily staffing needs updates to the Staffing Agency vendor to try and fill daily open shifts. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents across multiple units. During the survey, it was observed that food items were served at suboptimal temperatures, with hot foods often being lukewarm or cold, and cold foods being warmer than recommended. The facility's policy required hot foods to be maintained between 140-160 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit, but these standards were not met during meal service. Residents expressed dissatisfaction with the quality and temperature of their meals during Resident Council Meetings and interviews. They reported that food was often served cold, lacked flavor, and did not include requested condiments. Specific complaints included cold coffee, bland Salisbury steak, and warm milk. Residents also noted that the menu did not always match what was served, and there were frequent omissions of items like condiments. Staff interviews revealed awareness of the issues, with some attributing the problems to the plate warmer used on the tray line. The Registered Dietician and Assistant Director of Dining Services acknowledged that food temperatures were not within the safe range and that the milk should be kept colder. Despite these acknowledgments, the facility did not take adequate steps to address the deficiencies, resulting in continued resident dissatisfaction and potential health risks due to improper food handling.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #53, #68, #94, #97, #131 were the impacted residents – two residents discharged (#131 & #53). The remaining 3 residents will have the director of dining services interview each of them related to the deficient practice. The director will continue to work with each of these residents to maintain their satisfaction. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be impacted by the same deficient practice. The director/designee will work with all residents. The director of social work/designee will interview all residents to determine satisfaction with their meals. The results of these interviews will be tracked and issues alerted to the dining services director/designee. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Director of Dining will provide in-service training to all dietary staff, no later than 2/28/25, to include appropriate food temperature requirements and holding time, the palatability of food, and appetizing meals. The director of dining services/designee will in-service the cooks on following the recipe, to ensure foods are prepared according to the appropriate method, ensuring taste and nutritional value. The director of dining services will educate the dietary staff on methods to keep cold food appropriately below 41 degrees, through the use of refrigeration/freezers/or ice. In order to maintain proper hot food temperatures (between 140 and 160), the team will use the newly purchased “hot plate warmer” and maintain food temperatures of hot items in the oven or steam-well. The use of the plate warmer will help to maintain proper hot food temperatures. The dietary staff will be pouring hot beverages just prior to meal service at each meal to ensure proper coffee/tea temperatures. The internal temperature of the coffee machine will be increased to improve temperatures at the time of service. The director of dining services/designee will monitor temperatures when food is ready to serve and at the end of service for resident meals. This will include hot and cold temperature checks to ensure both safe and palatable temperatures are maintained. Appropriate action will be taken if the food is not to proper temperatures – warmed up for cold food and refrigerated/chilled for items that are not cold enough. All cooks will record food temperatures to discover any variations to the required temperatures. Any issues discovered will be reported to the director of dining services/designee and issues will be corrected immediately to obtain proper temperatures. The director of dining services/designee will attend resident council, upon resident request to address any food concerns. Grievances related to food concerns will be reviewed daily in morning report and actions to address any concerns will be implemented. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Test trays will be conducted at each meal for one week, daily for 3 weeks, and then weekly for 2 additional months to observe palatability, temperature, and appearance. These observations will be provided to the Director of dining services/designee. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Deficiencies in Kitchen Maintenance and Food Safety Standards
Penalty
Summary
The facility was found to have deficiencies in the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. During an observation of the Main Kitchen, it was noted that the ceiling was covered in a layer of dark gray dust, affecting the ceiling tiles, grid, vents, sprinkler heads, and heat detectors. The Director of Dining Services acknowledged that the ceilings were not cleaned by the Dietary staff and should have been addressed by the Maintenance staff. However, a maintenance work order was not submitted, and the issue was not communicated to the current Maintenance staff after the former Director of Maintenance left the facility. Additionally, inspection reports from an outside contractor indicated that the heat detectors in the kitchen were dirty, with one detector being caked in dust and needing relocation. Further observations revealed a damaged wall behind the extinguishment hood in the Main Kitchen, with chipped and cracked paint and drywall paper peeled. The Director of Dining Services confirmed that the wall required repair and that clean dishes were stored against it. Interviews with the Director of Facilities Maintenance and the Administrator indicated that kitchen cleaning responsibilities were divided between Dietary and Maintenance staff, with deep cleaning and repairs needing to be scheduled during off-hours. Despite being aware of the issues for several months, the Director of Dining Services and the Administrator did not ensure that the necessary maintenance work was completed, leading to the continued presence of these deficiencies.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? All areas of the kitchen were thoroughly cleaned, including walls and ceilings. The areas specifically mentioned as deficient were resolved; the ceiling tile grid, the vents, sprinkler heads, and heat detectors were cleaned prior to the conclusion of the annual survey. The wall areas noted to be damaged have been repaired. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be impacted by this deficient practice. The cleanliness of the kitchen will be monitored by the director of dining services. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? A cleaning schedule will be developed collaboratively between the director of dining services and the director of maintenance to maintain cleanliness of the kitchen, specifically the ceiling which would be difficult for dietary staff to maintain. The ceiling tiles, sprinkler heads, vents, and heat detectors will be cleaned on a monthly basis and as needed to maintain the sanitary conditions of the kitchen. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Dining Services will complete environmental audits monthly for 3 months to identify any dust-laden ceilings or damaged walls. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Emergency Generator Maintenance Deficiencies
Penalty
Summary
The facility's emergency generator was found to be inadequately maintained during a Life Safety Code survey. The survey revealed that there was no documentation of annual diesel fuel quality testing for the years 2023 and 2024, with the last recorded test being in March 2022. The Director of Facilities Maintenance/Corporate was unable to provide documentation for these years and stated that the outside contractor responsible for maintenance typically handled fuel testing and documentation. Additionally, there were gaps in the generator's monthly load test records, with missing documentation for specific periods in 2024. The computerized maintenance system showed incomplete records for these tests, lacking essential details such as hour meter information. Furthermore, the survey identified that the emergency manual stop station for the generator was not located in a remote area, as required. The only stop station was found on the generator itself, and staff, including the Administrator and Director of Facilities Maintenance/Corporate, were unaware of any remotely located stop station. This lack of awareness extended to the Maintenance Assistant, who had been conducting load tests due to a vacancy in the Director of Maintenance position. The absence of a remote stop station and the lack of knowledge among key staff members about its location were significant findings in the survey.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 Corrective action for the areas found to be deficient were to obtain fuel samples on an annual basis, conduct monthly generator load tests, and add a remote emergency stop to the generator. Outside Contractor provided documentation for 2024; however, results for 2023 were not found. The remote emergency stop will be installed by outside contractors. Audits will be conducted by the Maintenance Director consisting of a monthly load test on the generator, which includes the fuel and oil checks as well as the remote emergency stop button for proper functioning. A weekly no load test will be conducted. Education will be provided to the Director of Maintenance to maintain compliance with generator regulations. The monthly testing will be recorded in the TELS system. The results of the audits will be reported to the QA committee on a monthly basis. The Administrator will provide education to the Maintenance Director. Reviewed monthly in QA for 3 months. Responsible - Maintenance Director will train the maintenance team. Maintenance Director will implement the P(NAME).
Improper Exit Signage and Egress Path Indication
Penalty
Summary
During a Life Safety Code survey, it was observed that required exit signs did not correctly indicate the egress path on two of the four resident use floors, specifically the basement and first floor. On the first floor, an illuminated exit sign in the Main Kitchen was mounted perpendicular to the exit stairway, with both left and right chevrons lit, misleadingly indicating egress through the service elevator or mop closet. A paper sign on the exit stairway door incorrectly stated 'This is no longer an exit,' contradicting the fire evacuation diagram that showed the exit stairway as the primary egress route. Additionally, in the dish wash area of the Main Kitchen, an exit sign incorrectly indicated egress through the dish machine alcove and service elevator lobby, conflicting with the fire evacuation diagram. Further observations on the first floor revealed an exit sign in the service elevator lobby without chevrons, suggesting an incorrect path through a solid wall. In the lobby outside the Atrium, an exit sign incorrectly lit only the chevron pointing into the Atrium, despite both the Atrium and main entrance being valid egress routes. In the basement, an exit sign above double doors in the Boiler Room had chevrons coated with white paint, obscuring the correct egress path. These discrepancies in exit signage were acknowledged by the Director of Facilities Maintenance/Corporate, who noted the need for corrections to align with the appropriate egress routes.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Corrective action for the deficient exit signs in the kitchen stairway door, the kitchen dish wash area, basement service area, lobby outside of the atrium, and the double doors in the boiler room have been adjusted and are functioning properly. A full building audit will be conducted to verify the accuracy of all facility exit signs; this will be monitored through the TELS system. Education for the maintenance staff will be provided on exit signs operation. Ongoing compliance will be monitored by the Director of Maintenance and reported to the QA committee on a monthly basis. The Administrator will provide education; we will review our tasks in our computerized maintenance system. Exit signs will be checked monthly for 3 months in QA. Responsible designee - Maintenance Director. Policy and Procedure will be reviewed as part of the P(NAME).
Failure to Conduct Required Fire Drills
Penalty
Summary
The deficiency identified during the Life Safety Code survey was the failure to conduct fire drills at least once per shift per quarter, as required by the facility's Fire Drill Policy. The policy, approved in June 2023, mandates that fire drills be scheduled by the Director of Maintenance, Nurse Educator, or a designee to ensure staff preparedness in the event of a fire. However, a review of fire drill reports revealed that only two fire drills were conducted during the second quarter of 2023 and two during the third quarter of 2024, failing to meet the requirement of one drill per shift per quarter. Interviews with facility staff, including the Director of Facilities Maintenance and the Registered Nurse Infection Preventionist Nurse Educator, highlighted issues in the scheduling and documentation of fire drills. The Maintenance staff was primarily responsible for planning the drills, but it was sometimes a joint effort with the Education staff. The Administrator confirmed that the Maintenance Director was responsible for maintaining fire drill documentation, but the individual in that role during 2023 and 2024 was no longer employed at the facility, contributing to the lack of proper documentation and execution of the required fire drills.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Corrective action for the deficient practice is to conduct monthly fire drills as required. The Director of Maintenance and Nursing Educator will be educated on the requirements for completion on each shift (days, evening, nights) every quarter. An audit will be conducted on a monthly basis for completion of that month’s drill, verification that drill was during proper shift, and the next month’s drill shift is planned. Ongoing compliance will be monitored by the Director of Maintenance and logged in the TELS system. The results of the audit will be reported to the QA committee, for both the current and following month for continued compliance. The Administrator will provide the education and review Policy and Procedure with staff. Maintenance Director will perform Monthly Audits and Drills Presented in QA for 3 months. Responsible Designee - Maintenance Director
Inadequate Illumination of Egress Pathways
Penalty
Summary
The facility failed to maintain continuous illumination of egress pathways, as required by the Life Safety Code. On the first floor, the corridor lighting in the Administrative wing was controlled by two light switches, and when these were turned off, no lighting remained on between the reception desk and the west end, which forked into two corridors. This area, approximately 96 feet in each branch, served as egress routes between the west stairway and the main entrance, as indicated by illuminated exit signs. This lack of continuous illumination could impede safe evacuation in the event of an emergency. Additionally, the exterior of the facility lacked adequate lighting above certain exit doors. Specifically, there was no light fixture above the C Stairway exit door, with the closest light being approximately six feet away, and no light fixture above the Physical Therapy exit door, with the closest light being a pole light approximately 25 feet away. During a second observation before sunrise, it was noted that the closest lights to these exits were not lit at certain times, although inside lighting was visible through the glass doors and walls. The Director of Facilities Maintenance indicated that new pole lights had been added and electricians were testing the exterior lighting, which may have caused the observed inconsistencies.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 Corrective action for the deficient areas of lighting was performed by outside vendor. Contractor installed wall pack lights with 2 bulbs above affected doors. The first-floor administrative corridor will have seven corridor lights which will be wired to be on at all times. The exterior lighting issues at both the C stairway exit and the physical therapy exit have been corrected. Education will be provided to the Director of Maintenance to maintain compliance with proper lighting throughout the facility, as required by this regulation. A weekly audit will be completed to check for illumination throughout the inside and exterior of the facility. Any deficient lighting systems will be entered into the TELS system and corrected at that time. The results of the audit will be reported to the QA committee on a monthly basis. This will be monitored monthly in QA for 3 months. Administrator will provide education to the Maintenance Director and maintenance team. Responsible Designee: Maintenance Director
Inappropriate and Undignified Treatment of Residents by CNA
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of Certified Nurse Aide #10 towards two residents. Resident #46, who had severe cognitive impairment due to conditions such as cerebral infarction and dementia, was subjected to undignified treatment when Certified Nurse Aide #10 made a fist and a boxing jab motion towards them. Additionally, the aide wheeled Resident #46 into a corner, leaving them facing the wall in a common area. This behavior was observed on video footage and was described as inappropriate and potentially intimidating, especially given the resident's cognitive deficits. Resident #81, who also had severe cognitive impairment due to dementia and Parkinson's disease, was similarly mistreated. Certified Nurse Aide #10 was observed pushing Resident #81 in their wheelchair with the front wheels lifted off the ground, performing a 'wheelie' motion. This action was captured on video and was considered unsafe and undignified, as it could have caused fear or harm to the resident. The comprehensive care plans for both residents indicated that they required assistance with mobility and had potential for mood or behavior alterations, necessitating a respectful and supportive approach from staff. Interviews with facility staff, including the Human Resource Manager, Certified Nurse Aide #11, Activity Leader #1, and the Director of Nursing, confirmed that the actions of Certified Nurse Aide #10 were inappropriate and did not align with the facility's dignity policy. The staff emphasized that residents, particularly those with cognitive impairments, should not be subjected to actions that could be perceived as threatening or disrespectful. The facility's policy on dignity requires that all interactions with residents focus on maintaining and enhancing their self-esteem and self-worth, which was not upheld in these instances.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Residents #46 and #81 were both interviewed by the Director of Social Services to ensure they are being treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality at the time of the incident. Both residents appeared to have no negative impacts from the facility self-reported occurrences, which include no behaviors that would have implied they had concerns with abuse or dignity. #46 has been discharged. #81 does have cognitive impairment, and their legal representative was notified and interviewed, and no concerns were reported. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. The Director of Social Work/designee(s) will interview all residents and/or responsible representatives (if the resident is unable to participate) to ensure they are treated with respect and dignity and are receiving care in a manner and in an environment that promotes their quality of life and recognizing their individuality. Any reports of not being treated with respect and dignity will be investigated and reported as required. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The nurse educator will re-educate all staff on the facilities Resident Rights and Dignity policy to ensure each resident is treated with respect and dignity and receive care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Monthly at the resident council meeting, the topic of dignity will be reported on, to maintain resident expectations for the treatment received from staff, while a resident within the facility. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Director of Social Work/designee will conduct 15 quality of life/dignity interviews with the residents or resident representatives (3 residents per unit) for a period of 3 months. Any reports of not being treated with respect and dignity will be investigated and reported as required. Results of the interviews will be submitted to the QA committee for review. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Failure to Provide Daily Ambulation for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to maintain or improve their mobility. Specifically, the resident, who was cognitively intact and required supervision for ambulating, was not ambulated daily as recommended in their care plan. The resident had diagnoses of lymphedema and chronic pain syndrome and was on a nursing rehab ambulation program that required stand-by assistance for walking 10 to 15 feet with a rolling walker. However, records showed that the resident was only walked on a few specific dates over a month-long period, contrary to the daily ambulation plan. Interviews with the resident and staff revealed that the resident expressed concern about not being walked regularly, fearing a loss of mobility. Staff members, including a Certified Nurse Aide and the Registered Nurse Unit Manager, acknowledged that due to staffing shortages, the ambulation program was not consistently implemented. The Director of Rehabilitation and the Director of Nursing both stated that they expected staff to follow the care plan, which included daily ambulation for the resident. The failure to adhere to the care plan was attributed to insufficient staffing, which hindered the ability to provide the necessary care to maintain the resident's mobility.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #51 was reassessed by therapy to ensure there was no decline in residents' ROM or abilities, which revealed there were no changes in ADL abilities. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents who are care-planned for an ambulation program are at risk for the same deficient practice. All residents with an ambulation program will be reviewed to ensure ambulation programs are appropriate and being completed as planned. Any adjustments required to the plan will be made at that time. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure residents receive appropriate treatment to prevent decline, the facility’s Ambulation Program policy was reviewed, and no changes were identified to be needed. All nursing staff responsible for implementing and overseeing ambulation programs will be re-educated on the facility's policy. The therapy department will provide a weekly list to the nursing department indicating what residents are care planned for an ambulation program. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? Unit Managers will conduct weekly audits for 1 month, then monthly audits for a period of 2 months, verifying that ambulation programs are being implemented. Audits will include documentation review, as well as resident interviews. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Improper Catheter Care and Infection Control Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in managing the catheter and preventing urinary tract infections. The resident, who had a history of urinary tract infections and other urinary conditions, was observed with their foley catheter drainage bag improperly positioned above the level of the bladder, which is against the facility's policy. The drainage bag was also placed on the floor, and the tubing was kinked, both of which pose infection control risks. During multiple observations, staff members were seen placing the drainage bag in incorrect positions, such as on the wheelchair handle or armrest, and even directly on the floor. These actions were contrary to the facility's policy, which requires the drainage bag to be hung below the bladder level to ensure proper urine flow and prevent backflow, which can lead to infections. Interviews with staff, including certified nurse aides and registered nurses, confirmed that the drainage bag was not handled according to the established procedures. The facility's medical director and infection preventionist highlighted the increased risk of infection due to improper handling of the catheter drainage system. The staff's failure to adhere to proper catheter care protocols, such as ensuring the drainage bag was not touching the floor and was positioned correctly, contributed to the resident's risk of developing another urinary tract infection. The deficiency was identified through observations, interviews, and record reviews conducted during the standard survey.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 53 was evaluated by the medical provider and noted to be free from infection or signs of UTI. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents utilizing a foley catheter are at risk for the same deficient practice. A full house audit was completed on 2/10/25 to ensure all Foley drainage bags were kept below the residents’ bladder with tubing free of kinks and not placed on the floor. There was no further deficient practice noted. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The facility’s policy titled Catheter Daily Care (Indwelling) was reviewed and no changes are necessary. All nursing staff will be re-educated by the Infection Preventionist on proper care and placement of foley bags and tubing to ensure residents who have an indwelling (Foley) catheter receive the appropriate care and services to manage catheters. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Unit Managers will complete weekly observation audits x 4 weeks, then monthly x 2 months ensuring all foley drainage bags are properly placed below the bladder, that the drainage bag is properly secured before and after transfers, that there is no obstructed urine flow from improperly placed tubing, and that the drainage bag or tubing is not touching the floor. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Failure to Participate in Required Emergency Preparedness Exercise
Penalty
Summary
The facility failed to comply with emergency preparedness requirements as outlined in Appendix Z of the State Operations Manual. Specifically, the facility did not participate in a full-scale community-based emergency preparedness exercise in 2023, affecting all five resident units. The facility's Emergency Preparedness Manual, reviewed by the Administrator and Assistant Administrator in 2024, stated that the facility would conduct two separate exercises annually, including a community-based full-scale exercise. However, there was no evidence of participation in such an exercise in 2023. Interviews with the Assistant Administrator and Administrator revealed that the facility was a member of the Western New York Mutual Aid Plan but did not participate in any community-wide drills offered in 2023. The Administrator indicated that the responsibility for arranging participation in these drills fell to the Director of Maintenance, who missed the exercise in 2023. Although the Administrator believed there was a loss of power drill involving community partners in 2023, no documentation could be found to support this. Additionally, the Administrator mentioned that the facility likely activated their Emergency Preparedness Plan during a regional blizzard in 2022, but could not recall any activation in 2023. The lack of documentation and participation in required exercises led to the deficiency under 42 CFR 483.73-Emergency Preparedness.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 Corrective action for the deficient practice is to conduct two community-based disaster drills on an annual basis understanding only one is necessary. As participants in the Western New York Mutual Aid plan, the facility is due again in (MONTH) 2025 for an annual drill and will participate in two community-wide drills prior to 10/2025. The Director of Maintenance, Nursing Educator, and Administrator will keep these events in a logbook. The task will also be scheduled in the TELS maintenance program. The Director of Facilities Maintenance for ElderWood LLC will educate the Administrator as well as the Director of Maintenance and Nursing Educator on the requirements for two community-based disaster drills. The schedule and plan for facility inclusion in the two drills will be brought to the QA meeting on a monthly basis, and compliance will be documented at the time of both events. In the event the facility is unable to participate in either of these scheduled events, the facility will determine within 30 days a new date for the missed event to meet this requirement. Policy will be reviewed in Monthly QA for 3 months. Responsible Designee - Maintenance Director
Failure to Timely Submit Termination Forms for CHRC
Penalty
Summary
The deficiency identified during the Standard survey was the failure to submit the Termination Form 105 to the New York State Department of Health Criminal History Record Check (CHRC) program within the required thirty-day period after an employee was reassigned or terminated. This issue affected three out of twelve personnel files reviewed. Specifically, the facility did not submit the required termination forms for two housekeeping aides and one certified nurse assistant within the stipulated timeframe. The policy and procedure titled Criminal History Record Check, last modified in April 2024, required the Human Resources Professional to complete the Subject Individual Termination Form for CHRC via the Health Commerce System website within 30 days of a staff member's termination. The personnel records revealed that Housekeeping Aide #1 and Housekeeping Aide #2 received a Pending Denial letter, with their last working days in March 2023, but their Termination Forms were not submitted until May 2023. Similarly, Certified Nurse Aide #8, who did not work in the facility, had a Hold in Abeyance letter dated June 2024, but the Termination Form was not submitted until August 2024. During an interview, the Human Resources Manager, who assumed their position in May 2023, stated they were unaware of the delay in submitting the forms until they conducted a personnel file review. The manager acknowledged that the Termination Form for Certified Nurse Aide #8 should have been submitted by July 2024.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The deficient practice has been corrected as required by regulation. The CHRC active roster review shows compliance at this time. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. The CHRC active roster review shows compliance at this time and no recent issues have been identified. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Human resource manager will in-service the recruitment coordinator on the CHRC policy, and the procedure/timing related to removal of terminated employees from the CHRC list. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? An audit of the CHRC active roster will be conducted every 28 days, over the course of the next six months to ensure that only current employees are active. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Failure to Report Alleged Abuse Immediately
Penalty
Summary
The facility failed to ensure that all alleged violations, including abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than two hours after the allegation was made. Specifically, a Certified Nurse Aide (CNA) witnessed another CNA grab a resident's arms, shake them, and later grab the resident's nose and shake their head during a combative episode. This incident was not reported to the Director of Nursing or the Administrator immediately, resulting in a delay in reporting the alleged abuse to the New York State Department of Health as required by policy. The resident involved had diagnoses including dementia, major depressive disorder, and high blood pressure, and was documented to have severely impaired cognition with daily physical and verbal behaviors directed toward others. The incident occurred during a care routine when the resident became combative. The witnessing CNA did not report the incident until the following day, which was a violation of the facility's policy that mandates immediate reporting of such incidents. Interviews with staff confirmed that the incident should have been reported right away to initiate an investigation and ensure resident safety.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility did not ensure that all alleged allegations of abuse were thoroughly investigated for one resident. Specifically, the facility failed to complete a thorough investigation into an allegation of staff-to-resident physical abuse. The investigation did not include interviews or monitoring of other residents the accused staff member had cared for. The Director of Nursing admitted to not interviewing other residents because it was a memory care unit, and the residents were not considered reliable historians. The Administrator also acknowledged that other residents should have been interviewed to determine the potential impact on them. Resident #1, who had diagnoses including dementia, major depressive disorder, and high blood pressure, was reported to have been physically abused by Certified Nurse Aide #2. The incident was reported to the New York State Department of Health, but the investigation was incomplete as it did not include interviews with other residents. The facility's abuse policy did not specifically include interviewing other residents, which contributed to the incomplete investigation. Additionally, it was found that Certified Nurse Aide #2 had worked on different resident units in the facility, further emphasizing the need for a more comprehensive investigation.
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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