Ellicott Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, New York.
- Location
- 200 Seventh Street, Buffalo, New York 14201
- CMS Provider Number
- 335437
- Inspections on file
- 27
- Latest survey
- February 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ellicott Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with diabetes did not receive scheduled insulin doses or have their blood glucose monitored, leading to hospitalization for diabetic ketoacidosis. The incident was due to lapses in communication and documentation among nursing staff, with the scheduled nurse not arriving on time and the RN Supervisor not administering medications. The LPN Unit Manager incorrectly documented the resident as hospitalized, resulting in missed medication administration.
The facility failed to serve food at safe and appetizing temperatures, with meals often being cold and unpalatable. Residents reported dissatisfaction, and staff lacked awareness of safe temperature standards. The facility's policy required hot foods to be served at or above 135°F, but test trays showed significantly lower temperatures.
Structural components in the facility were not properly protected from fire, as required by the Life Safety Code. The structural support web truss system and steel beams above the lay-in style ceiling assembly were not protected to meet the minimum fire-rated building construction classification. This affected all three resident use floors in the front building. Observations revealed unrated lay-in ceiling tiles and unprotected structural steel beams and trusses. The Assistant Maintenance Director confirmed no changes had been made since the last survey.
A Life Safety Code survey identified deficiencies in corridor door maintenance across multiple floors in a facility. Doors failed to latch due to medical tape and obstructions, with maintenance staff citing ongoing keypad replacements. Additionally, a door was improperly propped open, and there were no formal checks on door functionality.
A survey revealed that four portable resident lifts in the facility were not maintained according to manufacturer's recommendations, with lapses in inspection and testing schedules. The facility's policy required adherence to state, federal, and NFPA regulations, but maintenance records were incomplete, and key personnel changes led to inconsistent maintenance practices. The Administrator expected maintenance staff to document all equipment testing, but gaps in regular inspections were identified.
A survey revealed that emergency generators at the facility were not properly maintained, with no documentation of required monthly load tests and weekly checks since November 2023. The Assistant Maintenance Director believed the former Maintenance Director performed these tasks but lacked documentation. The Administrator confirmed the absence of maintenance records, only receiving verbal updates.
The facility failed to document and perform required monthly and annual tests on the battery-powered emergency lighting in the Boiler Room. The Assistant Maintenance Director checked the light daily but did not document these checks and was not instructed to do so. The required longer battery test was never performed, contrary to the facility's policy.
The facility's fire alarm system was inadequately maintained, with incomplete annual testing of devices, lack of sensitivity testing documentation for smoke detectors, and unrepaired horn/strobe failures. The Maintenance Director and Administrator were unaware of these issues, and the facility lacked a specific maintenance policy for the fire alarm system.
A survey revealed that fire-rated doors in the facility were not inspected and tested annually as required by NFPA standards. The facility's policy indicated that the Maintenance Director was responsible for ensuring these tasks were completed, but no documentation was available to confirm compliance. Interviews indicated that only smoke barrier doors were checked during fire drills, and no formal checks were conducted on other fire-rated doors.
A Life Safety Code survey revealed that fire extinguishers in the facility were not maintained with required monthly inspections, affecting all resident use floors. The Assistant Maintenance Director, who assumed the role after the previous director left, acknowledged the oversight and noted missing documentation of checks since August. A discrepancy in the number of extinguishers was also noted.
A Life Safety Code survey revealed deficiencies in smoke barrier wall maintenance at an LTC facility. Unsealed penetrations and improper sealing materials, such as non-compliant orange expandable foam, were found on the second floor of both the front and rear buildings. The Maintenance Director acknowledged the use of non-compliant materials by an outside vendor, and the lack of regular audits contributed to these deficiencies.
The facility failed to maintain appropriate temperature levels and sanitary conditions, with air temperatures in the Harbor View unit consistently below the required range, causing discomfort for residents. Additionally, shower rooms on the City View and Harbor View units were found with dried feces on floors and chairs, indicating a lack of adherence to cleaning protocols. Staff interviews revealed confusion over cleaning responsibilities, contributing to the unsanitary conditions.
Two residents in an LTC facility did not receive necessary personal hygiene and grooming care. One resident, with multiple health issues, was not assisted out of bed or shaved despite expressing a desire for these services. Another resident, legally blind, had long, dirty fingernails and whiskers, which were not addressed by staff. Interviews revealed a lack of communication and responsibility among staff regarding the provision of these services.
The facility failed to administer enteral feeding as ordered for two residents, leading to potential nutritional deficiencies. One resident did not receive the prescribed 1600 milliliters of formula due to inconsistent feeding schedules and staff confusion over orders. Another resident's feeding tube was not connected, and the formula bag was not replaced as scheduled, resulting in missed nutrition. Facility policies for enteral feedings were not followed, compromising residents' nutritional intake.
A facility failed to manage a PICC line for a resident, who was readmitted with the catheter in their arm. There were no physician orders or care plan updates for the PICC, and staff were unaware of its presence. The dressing was soiled and lifting, posing an infection risk. The deficiency was noted as a failure to adhere to professional standards and facility policies.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease, as there was no ongoing monitoring or communication with the dialysis center. The resident's care plan lacked details about their dialysis care, and there were discrepancies in the records, such as the incorrect listing of an AV fistula. Staff interviews revealed a lack of clarity and communication regarding the dialysis process, and the Director of Nursing confirmed no education on dialysis access devices or procedures.
The facility failed to securely store discontinued medications, with boxes found in an unsecured conference room and an unlocked Nurse Manager's office. These medications, including insulin pens, inhalers, and psychotropic drugs, were accessible to staff, residents, and visitors, violating storage policies and posing a risk of unauthorized access.
A LTC facility failed to maintain an effective infection control program, as staff did not adhere to Enhanced Barrier Precautions for residents with indwelling medical devices. Instances included not wearing gowns during high-contact activities and improper glove changes and hand hygiene during incontinence care. Additionally, signage indicating necessary precautions was missing for some residents.
A survey identified a deficiency involving a portable electric space heater operating in a facility's Health Information Office without documentation ensuring its heating element did not exceed 212°F. The heater, not provided by the facility, was plugged into a power strip. Interviews revealed the facility lacked a written policy on space heater use, contributing to the deficiency.
The facility failed to comply with the 2020 Fire Code of New York State regarding carbon monoxide detection and maintenance. Observations revealed inconsistencies in the number of detectors logged and missing maintenance records. The Assistant Maintenance Director admitted to undocumented checks, and the Maintenance Director confirmed the need for weekly testing and monthly vacuuming. The Administrator expected documented testing, which was not done.
The facility failed to submit MDS assessments to CMS within the required timeframe for all reviewed residents. Delays were due to staffing shortages and incomplete sections from other departments. Key residents experienced significant overdue assessments, with staff acknowledging the issue and attributing it to being busy and waiting on other departments.
The facility failed to manage narcotic medications properly, resulting in unaccounted narcotics across four units. On the River View unit, 93 narcotic medications were missing due to a malfunctioning keypad and broken cupboard lock. Observations showed unattended narcotic reconciliation books and keys in medication rooms. An LPN was seen conducting a narcotic count alone, and records indicated numerous shifts without documented reconciliation by both outgoing and incoming nurses. Staff interviews confirmed the need for proper reconciliation to prevent diversion.
A resident with a DNR order was mistakenly given CPR due to an LPN reviewing the wrong MOLST form. The error occurred when the LPN failed to verify the resident's identity, leading to the initiation of CPR against the resident's wishes.
Failure to Administer Insulin and Monitor Blood Glucose
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin and monitoring of blood glucose levels. Resident #202, who had a history of diabetes, end-stage renal disease, and anxiety, did not receive scheduled doses of Humalog and Lantus insulin, nor was their blood glucose monitored as per the provider's orders. This oversight led to the resident being found unresponsive with a critically high blood glucose level of 579, resulting in hospitalization for diabetic ketoacidosis. The incident occurred due to a series of lapses in communication and documentation among the nursing staff. On the morning of the incident, the scheduled nurse did not arrive on time, and the Registered Nurse Supervisor did not administer the morning medications, citing a lack of responsibility for the medication cart. The Licensed Practical Nurse Unit Manager, who arrived later, incorrectly documented that the resident was hospitalized at the time of the scheduled insulin doses, leading to the omission of critical medication administration and blood glucose monitoring. Interviews with the facility's staff, including the Director of Nursing, Physician Assistant, and Consultant Pharmacist, confirmed that the lack of insulin administration and blood glucose monitoring contributed to the resident's high blood glucose level and subsequent hospitalization. The Director of Nursing acknowledged that the facility's policies were not followed, and the Medical Director emphasized the importance of adhering to medical orders to prevent harm to residents.
Plan Of Correction
Plan of Correction: Approved March 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 202 was sent to the hospital on [DATE] and did not return to the facility. Record review was completed for resident # 202 by the Director Of Clinical Operations and findings were shared with the QAPI Committee on meeting of 3/10/25. RN Supervisor # 1 was terminated on 11/10/24. Nurse who failed to administer Insulin and failed to perform blood glucose monitoring on 10/5/25 was LPN Unit Manager # 5. LPN Unit Manager # 5 was suspended on 2/13/25 and subsequently resigned on 2/13/25. The DON was counseled by the Director of Clinical Operations regarding review of medication omissions and records review of residents sent to hospital with change in condition. A review of residents sent to hospital in the last 30 days will be conducted - review will ensure that Insulin was given and blood glucose monitoring performed if indicated. Issues noted will be immediately addressed. All residents have the potential to be affected by the deficient practice. A full house review of residents receiving Insulin and blood glucose monitoring in the last 14 days will be completed. Any omissions and or issues noted will be immediately addressed. The policies for Medication Administration, Medication Administration Documentation and Medication Errors were reviewed by the Director of Clinical Operations with no revisions required. Education will be provided to all licensed nurses and will include: 1) Medication Administration and documentation 2) Medication errors 3) Medication errors reports and protocol 4) Need to notify DON and Medical provider of any medication omissions/errors 5) Ramifications of residents not receiving Insulin and or blood glucose checks 6) Review of Protocol for notifying DON/designee of staffing call ins requiring reassignment of nurses Licensed Nurses who do not attend the scheduled Education will be removed from the schedule until education is complete. The PCC Medication Administration Audit report will be reviewed daily at morning meeting. This audit allows for review of all medication omissions for a specified time frame. Omissions noted will be addressed and medication error reports completed as indicated. This audit will continue x 8 weeks. The RN Educator/designee will conduct Insulin and Blood glucose monitoring audits of 10 residents weekly x 12 weeks. Audits will ensure that Insulin is administered and blood glucose monitoring completed as per provider order. Audits will include all shifts and will include in person observations of staff. Issues noted will be immediately addressed. Residents sent to the hospital for change in condition will be reviewed by the DON/designee daily to ensure that there are no issues related to quality of care x 8 weeks. Audits/reviews will be shared with the QAPI Committee for review and input. QAPI Committee may continue audits based on findings. Responsibility: DON
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents in the Cityview, Skyview, and Harborview units. During the survey, it was observed that food was served at suboptimal temperatures, making it unpalatable. The facility's policy required hot foods to be served at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. However, test trays showed that food temperatures were significantly below these standards, with hot foods being served as low as 72 degrees Fahrenheit. Residents expressed dissatisfaction with the food quality, stating that it was often cold, overcooked, or undercooked, and inedible. Several residents reported that their meals were consistently served lukewarm or cold, and staff were unable to reheat the food. The facility's Menu Planning and Food Service Committee had previously documented complaints about cold food, noting that food carts were left at the nurse station before being served. Interviews with staff revealed a lack of awareness regarding the safe temperature range for serving food. The Diet Technician responsible for test trays did not measure food temperatures against specific standards, focusing instead on palatability. The Registered Dietician/Food Service Director acknowledged that hot foods should reach residents at 135-140 degrees Fahrenheit, but the facility failed to meet these expectations, leading to potential food safety issues.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The registered diet technician will meet with Resident #3, #55, #63, #65, #96, #104, and #203 to address their identified concerns regarding food temperatures, meal times, and preferences. Three test trays per week will be evaluated for temperature and palatability for each meal for three consecutive weeks. Any concerns will be addressed immediately. The facility recognizes that all residents can be potentially affected by this deficient practice. The Administrator or designee will address meal times and food temperatures at each monthly food council meeting. Minutes will be documented. The “individual resident concern” response form will be completed for any resident who wishes to review their meal preferences and dislikes with the Registered Diet Technician or RD. The diet technician will review and update food preferences and dislikes for five residents per week and continue to update preferences upon each resident's scheduled review or change in condition. The facility's policy and procedure titled Food Temperature Policy was reviewed, and no changes were made. The Food Service Director will continue to provide ongoing oversight of the food service department. Broken/uninsulated food carts will be replaced for meal service to ensure holding food temperatures are maintained. All food service staff will be educated on maintaining hot and cold food temperatures under acceptable holding temperatures, including safe food temperatures/handling. Any issues noted if temperature requirements are not met will be immediately corrected. Cook and supervisors’ competencies will be completed on recording, monitoring, and maintaining food temperature. The FSD/RD or designee will review the food temperature logs daily for 30 days, then weekly for three months to assure substantial compliance is met for food safety and palatability. The Diet Technician or designee will evaluate and monitor the temperature of one tray per week for three months. Audit results will be reported to the QAPI committee for review and comment. The need for further reporting will be determined by the QAPI committee. The Administrator/designee will report outcomes from food committee meetings monthly with interventions to the QAPI committee monthly. The need for continued reporting will be determined by the QAPI committee. Responsible Party: Administrator, FSD/RD
Unprotected Structural Components in Facility
Penalty
Summary
Structural components of the facility were not properly protected from fire, as observed during the Life Safety Code survey. The structural support web truss system and steel beams located above the lay-in style ceiling assembly were not protected to meet the minimum acceptable fire-rated building construction classification. This deficiency affected all three resident use floors in the front building. The facility's construction type requires that structural components be protected by a one-hour or two-hour fire-rated barrier, depending on the specific classification. However, observations revealed that the ceiling tiles on the first, second, and third floors were comprised of an unrated lay-in ceiling assembly, and there were unprotected structural steel beams and steel web truss assemblies. During an interview, the Assistant Maintenance Director confirmed that there had been no changes to these components since the last Life Safety Code survey.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The facility had an FSES completed prior which indicated that the facility was in compliance with NFPA [PHONE NUMBER] 19 1.6.1 equivalency. However, due to the passage of time, the facility will be conducting a new FSES to be performed in accordance with CMS survey and certification memo 17-15-LSC. The FSES will be started on 3/10/25. All residents had the potential to be affected. No other life safety functions were affected. The facility will in-service the maintenance director on fire safety maintenance such as identification of any potential fire safety concerns or potential for unsafe or hazardous conditions. The Maintenance Director will be educated on the results of the FSES and on the requirement to ensure the facility is in compliance with NFPA [PHONE NUMBER] 19 1.6.1. The facility also intends to maintain compliance by utilizing an FSES for equivalency as necessary for future recertifications as applicable. An audit tool was created to ensure all items listed in the upcoming FSES are in place. Audits will be conducted monthly x4. The results of the FSES, the requirement for a passing FSES, and the results of the audits will be discussed at QAPI. The Administrator/Designee is responsible for this plan.
Corridor Door Maintenance Deficiencies
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 multiple floors in both the front and rear buildings. On the second floor of the front building, the corridor door to the kitchenette failed to latch due to medical tape covering the strike plate, as noted by the Assistant Maintenance Director. Similarly, on the first floor of the rear building, the kitchenette door did not latch because medical tape was holding the latch inside the door, as explained by a registered nurse. Both instances were attributed to ongoing maintenance work involving the replacement of battery-powered keypad code locks. Further observations revealed additional issues with corridor doors. On the first floor of the rear building, the door to the Assistant Director of Nursing's office, equipped with a self-closer, was propped open by a large box, contrary to the Maintenance Director's statement that doors should not be held open. Additionally, on the first floor of the front building, the Janitor's Closet door next to the Kitchen did not latch due to a security plate obstruction, with the Assistant Maintenance Director unable to confirm when the plate was installed. It was also noted that there were no formal checks on corridor doors, and maintenance staff only addressed issues logged by staff.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The medical tape on the corridor door to the kitchenette on the second floor of the front building was removed to allow the door to latch into its door frame. The medical tape on the corridor door to the kitchenette on the second floor of the rear building was removed to allow the door to latch into its door frame. The large box by the door to the Assistant Director of Nursing’s Office was removed to allow it to self-close and latch. The security plate on the corridor door to the janitor's closet next to the kitchen was adjusted to allow it to latch into its door frame. An audit was conducted of the facility's corridor doors to ensure doors latch into door frame and that they are not obstructed from closing. The Maintenance Director and maintenance staff were educated on the requirement to ensure corridor doors latch and corridor doors are not obstructed into its frame in accordance with NFPA 101. The Maintenance Director will conduct a monthly audit of all facility corridor doors. The audit will be monthly for 4 months. Results of the audits will be reviewed at QAPI. The Maintenance Director is responsible for the plan.
Deficiency in Maintenance of Patient Care Related Electrical Equipment
Penalty
Summary
During a Life Safety Code survey, it was found that patient care related electrical equipment (PCREE) in the facility was not properly maintained according to the manufacturer's recommendations. Specifically, four portable resident lifts, identified as Brand A, Brand B, Brand C, and Brand D, were not inspected and tested as required. The facility's policy stated that such equipment should be maintained in accordance with state, federal, and National Fire Protection Association (NFPA) regulations, and that testing and maintenance should follow the manufacturer's service manual recommendations. However, observations revealed that the lifts had either outdated inspection stickers or no inspection stickers at all, indicating lapses in the required maintenance schedule. The facility's preventative maintenance documents showed that maintenance checklists from each manufacturer's owner's manual were used, but these were only completed up to August 2024. Interviews with the Assistant Maintenance Director revealed that monthly inspections were not consistently performed after a maintenance assistant left the facility in mid-2024. The Assistant Maintenance Director admitted to inspecting the lifts only when complaints were made or when lifts were returned to their designated units, rather than following a regular preventative maintenance schedule. Additionally, the Maintenance Director, who had been in the position for less than two weeks, was unaware of the specific inspection schedules for the lifts as indicated by the stickers. The Administrator confirmed that preventative maintenance should be conducted according to the manufacturer's recommendations and expected maintenance staff to document all equipment testing. However, the departure of key maintenance personnel in mid-2024 led to a gap in the regular inspection and maintenance of the lifts. This lack of consistent maintenance and documentation resulted in the facility's non-compliance with the required standards for maintaining patient care related electrical equipment.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 The Maintenance Director thoroughly inspected all 4 facility lifts per manufacturer specifications found in the Manufacture User Manual and those found in the Maintenance Safety Inspection Checklist of each to ensure safe proper working order. A certified technician was scheduled to inspect Brand A lift. All lifts had the potential to be affected. An audit of other PECREE items was conducted to ensure safe proper working order and compliance with Manufacture User Manuals inspection requirements. The Administrator, Maintenance Director, and maintenance staff were educated on the requirement to establish, maintain and document Portable Patient-Care Related Electrical Equipment (PCREE) inspection and testing per each equipment’s specific Manufacturer User Manual and any Maintenance Safety Inspection Checklists found in those manuals, including utilizing certified technicians when required. The Maintenance Director will begin to utilize PECREE stickers to note inspections on each lift. A PECREE audit tool that mirrors the Manufacturer’s Maintenance Safety Inspection Checklist will be utilized by the Administrator to audit PECREE documentation to ensure compliance. The Administrator will scan and email the PECREE audit to the Corporate Regional Administrator every month for review. The Corporate Regional Administrator will review the PECREE audit and the maintenance PECREE documentation in-person each quarter. The Administrator will audit the PCREE documentation weekly x 4 and then monthly x 3. The Corporate Regional Administrator will review the PECREE audit monthly x 3. The Corporate Regional Administrator will review the PECREE audits and documentation in person quarterly x 2. The results of the audit will be reported at the monthly QAPI meeting. The Corporate Regional Administrator is responsible to ensure compliance.
Emergency Generator Maintenance Deficiency
Penalty
Summary
During a Life Safety Code survey, it was found that the emergency generators at the facility were not properly maintained, as required by the facility's policies and procedures. Specifically, there was no documentation of the required monthly load tests and weekly checks for the generators since November 2023. These generators are crucial as they provide emergency backup power to all resident use floors in both the front and rear buildings of the facility. The facility's policy, revised in February 2020, mandates regular maintenance and testing to ensure compliance and functionality of the backup power system. However, the records reviewed during the survey showed a lack of documentation for these critical maintenance activities. Interviews conducted during the survey revealed that the Assistant Maintenance Director believed the former Maintenance Director was performing the necessary checks and tests, but there was no documentation to support this. The Assistant Maintenance Director mentioned that they had taken over the maintenance tasks after the former Maintenance Director left, but they only started documenting their observations recently. Despite claiming to have performed generator load tests and communicated the results to the corporate maintenance department, the Assistant Maintenance Director could not provide any logs or records during the survey. The Administrator also confirmed that they had not received any documentation regarding generator maintenance, only verbal updates, and acknowledged the expectation for maintenance activities to be documented.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Both backup generators were run on full load for 30 minutes each to ensure working order. The run was documented, including automatic power transfer in under 10 seconds. Additionally, the Maintenance Director visually inspected both generators and documented the results of the inspection. All residents had the potential to be affected; however, no loss of power actually occurred at the facility. Subsequently, both generators were run under full load for 30 minutes, and a visual inspection was performed, with both generators found to be fully functional. The Administrator, Maintenance Director, and maintenance staff were educated on the requirement to perform 30-minute load tests every 20 to 40 days and weekly inspections of all generators, and to maintain written records of all the maintenance, inspections, and load tests performed, ensuring that those records are readily available. An EES Generator documentation audit tool will be utilized by the Administrator to review documentation for both the monthly 30-minute load test and weekly inspection. The Administrator will scan and email the Corporate Regional Administrator the audit log every month for review. The Corporate Regional Administrator will review all generator documentation in-person each quarter. The Administrator will audit the EES generator documentation weekly for 4 weeks and monthly for 4 months. The Corporate Regional Administrator will review the EES Generator documentation audit tool monthly for 6 months and review the documentation in person quarterly for 2 quarters. Responsible Party: Corporate Regional Administrator
Failure to Document and Perform Required Emergency Lighting Tests
Penalty
Summary
During a Life Safety Code survey, it was found that the battery-powered emergency lighting in the Boiler Room of the facility was not tested monthly for 30 seconds and annually for 90 minutes as required. The facility's policy, created in December 2020, assigns the Maintenance Director the responsibility of ensuring that maintenance staff are trained and perform routine preventative maintenance tasks, including testing emergency lighting. However, there was no documentation of these tests being conducted. The Assistant Maintenance Director stated that they checked the emergency light daily using a broom handle but did not document these checks and were not instructed to do so. Additionally, they never performed the required longer test of the battery. The Administrator expected all equipment testing by maintenance staff to be documented, which was not the case here.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The emergency lighting identified in the boiler room was comprehensively tested for 90 minutes to ensure proper function and to bring the facility back in compliance with testing requirements per NFPA 101. The testing of the emergency lighting was added to the emergency lighting test log book. An audit of the facility was completed and only one emergency light is in the facility. An audit was conducted of the emergency lighting testing log book to ensure all other emergency lighting tests are up to date in accordance with NFPA 101, specifically that ensuring that the emergency lighting will be tested 30 seconds monthly and 90 minutes annually and documentations of the tests will be added to the log book. The Maintenance Director and maintenance staff were educated on this NFPA requirement and on facility policy titled Maintenance-Preventative to ensure 30 second testing monthly and 90 minute testing annually and to keep documentation in the logbook. Testing is scheduled in accordance with NFPA 101. Audits on the testing log book will be conducted monthly x4 by the maintenance director. Results of the audit will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility's fire alarm system was found to be inadequately maintained during a Life Safety Code survey. The survey revealed that not all fire alarm system devices were functionally tested annually, as required. Specifically, a review of the Fire Alarm Inspection and Test Reports from an outside contractor showed that only half of the system's devices were tested on two separate dates, with some devices only receiving a visual inspection and others not tested at all. Additionally, there was no documentation of sensitivity testing for smoke detectors, and some smoke detectors lacked addresses, indicating they were non-addressable and required sensitivity testing. The Maintenance Director, who had been in the position for less than two weeks, was unaware of these issues. Further findings included the failure of four horn/strobe devices during testing, which had not been repaired or replaced. The facility lacked documentation from the fire alarm system manufacturer regarding the need for sensitivity testing and had no policy or procedure specific to the maintenance of the fire alarm system. Interviews with the Maintenance Director and the Administrator confirmed the absence of necessary documentation and awareness of the system's deficiencies. The facility's fire alarm system issues affected all resident use floors in both the front and rear buildings.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Documentation was obtained on which exact smoke detectors were fully addressable and which were conventional, and all conventional detectors had sensitivity testing conducted on 2/24/25. The four horn/strobes that failed in the 2/7/24 fire inspection report were replaced on 2/24/25. The 21 heat detectors, the one duct detector, and one remote annunciator will be inspected/tested. A review of all fire alarm inspection and testing reports was conducted to ensure all fire alarm system components have been inspected, tested, and maintained per all applicable codes. The Maintenance Director was educated on the NFPA requirement to ensure the fire alarm system is maintained and tested at required intervals, including sensitivity testing and fire alarm system devices functional testing. The policy and procedure was reviewed again, and no changes were made. An audit tool was created to ensure proper scheduling is completed for all required testing and inspection and to ensure that any failed devices are repaired or replaced. Audits on the testing log book will be conducted monthly x4 by the Maintenance Director. Results of the audit will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Failure to Maintain Fire-Rated Doors as per NFPA Standards
Penalty
Summary
During a Life Safety Code survey, it was found that fire-rated doors in the facility were not maintained according to the National Fire Protection Association (NFPA) requirements. Specifically, the fire-rated door assemblies were not inspected and tested annually as required by the NFPA 80: Standard for Fire Doors and Opening Protectives. This deficiency affected all resident use floors in both the front and rear buildings of the facility. The facility's policy titled 'Maintenance - Preventative' indicated that the Maintenance Director was responsible for ensuring routine preventative maintenance tasks, including fire door inspections, were performed timely. However, there was no documentation available to confirm that these inspections were conducted. Interviews with the Assistant Maintenance Director revealed that while smoke barrier doors were checked monthly during fire drills, no formal checks were performed on other fire-rated doors. The maintenance staff only addressed door-related issues when noted in the maintenance logs. The Administrator believed that the former Maintenance Director had been conducting regular checks, but no documentation was available to support this claim. The facility lacked a specific policy and procedure for the maintenance of fire doors beyond the general preventative maintenance policy.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 An inspection of the facility’s fire rated doors was completed using NFPA 80 guidelines. All inspections of the facility’s fire doors were reviewed and any issues were addressed. Education was provided to the Director of Maintenance and the maintenance staff regarding fire safety code NFPA 80 and the requirement to ensure fire rated door assemblies are maintained, inspected, and tested annually. An audit tool was created to ensure all fire doors remain up to date with annual inspections in accordance with NFPA 80 code. Audits will be conducted monthly x4 by the maintenance director. Results will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Fire Extinguisher Maintenance Deficiency
Penalty
Summary
During a Life Safety Code survey, it was observed that portable fire extinguishers in the facility were not maintained as required, specifically lacking monthly inspections. This deficiency affected all three resident use floors in the front building and both resident use floors in the rear building. The facility's policy, created in December 2020, assigns the Maintenance Director the responsibility for ensuring that maintenance staff are trained and perform routine preventative maintenance tasks, including monthly fire extinguisher checks. However, several fire extinguishers across different floors had tags indicating missed inspections for various periods between June 2024 and December 2024. The Assistant Maintenance Director, who took over after the former Maintenance Director left, acknowledged the oversight and stated that they had instructed the maintenance staff to conduct monthly checks using a paper tablet. Despite this, they were unable to locate any documentation of these checks since August. Additionally, there was a discrepancy in the number of fire extinguishers recorded, with the facility having 51 extinguishers plus one spare, while the contractor's report listed 52. The Assistant Maintenance Director was aware of a missing tag in the smoking area and had contacted a vendor to replace it.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 A monthly inspection was performed on all 52 fire extinguishers in the facility to ensure the facility is up to date in accordance with NFPA 10. A review was completed on the requirements for the facility’s fire extinguishers to ensure annual inspections had occurred as well. The monthly extinguisher checks will be recorded on the tag attached to the extinguisher and on the monthly log. The Maintenance Director and the maintenance staff were educated on the requirement and facility policy “maintenance-preventative” to ensure the fire extinguishers are inspected monthly and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. An audit tool was created to ensure required inspection intervals are adhered to by the Maintenance Director. Audits will be conducted monthly for 4 months. Results of the audit will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Deficiencies in Smoke Barrier Wall Maintenance
Penalty
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls in a long-term care facility were not properly maintained, leading to deficiencies in fire safety. The smoke barrier walls on the second floor of both the front and rear buildings were found to have unsealed penetrations, which compromised their ability to resist the passage of smoke. Specifically, a penetration in the smoke barrier wall at the resident lounge measured two inches wide by three inches high, with a white wire running through it. The Assistant Maintenance Director was unaware of this penetration, and the Maintenance Director identified the wire as a telephone line installed by an outside vendor. Additionally, other penetrations were found with improper sealing materials, such as orange expandable foam, which was not typically used by the facility's maintenance staff. Further observations revealed that the smoke barrier walls had been compromised by the use of non-compliant materials. A small cluster of yellow wires outside the shower room and a wire outside resident room 242 were improperly sealed with orange expandable foam, which was not fire-rated. The Maintenance Director acknowledged that the foam might have been used by an outside vendor, as the facility had previously purchased a non-compliant product, Brand A Fire Block Foam FB-Foam, which was not suitable for rated construction. The lack of regular audits of smoke barrier walls by maintenance staff contributed to the oversight of these deficiencies.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The unsealed penetration through the smoke barrier wall at the resident lounge on the second floor of the rear building was sealed. The penetration noted in the smoke barrier wall outside of the shower room on the second floor of the rear building was sealed properly and orange foam was removed. The penetration noted in the smoke barrier wall outside of resident room 242 was properly sealed and the orange foam was removed. The penetration noted in the smoke barrier wall outside of resident room 209 was properly sealed and the orange foam was removed. An audit was conducted throughout the rear and front buildings to ensure no other penetrations noted in the smoke barrier walls. The maintenance director and the maintenance staff were educated on the Smoke Barrier requirement in accordance with NFPA 101 and on facility policy “maintenance-preventative” that smoke barriers are to be inspected monthly. The policy and procedure were reviewed and no changes were made. An audit tool was created to ensure inspections on smoke barriers are completed timely. The Maintenance Director will audit one unit of smoke barrier walls monthly for 5 months in both buildings. Results of the audits will be reviewed at QAPI. The Maintenance Director is responsible for the plan.
Inadequate Temperature Control and Unsanitary Conditions in Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by inadequate housekeeping and maintenance services. Specifically, the air temperatures in the Harbor View unit were consistently below the required range of 71 to 81 degrees Fahrenheit, with temperatures recorded as low as 66.7 degrees Fahrenheit. Residents and staff reported feeling cold, with some residents wearing multiple blankets and winter clothing indoors. The maintenance staff acknowledged issues with the heating system, including thermostats set below the required temperature and obstructions affecting heat distribution. Additionally, the facility did not adhere to its cleaning and disinfecting policies, resulting in unsanitary conditions in the shower rooms on the City View and Harbor View units. Observations revealed dried brown debris, identified as feces, on shower floors and chairs, which were not cleaned between uses. Staff interviews confirmed that the responsibility for cleaning was not consistently followed, leading to potential infection control issues and a failure to provide a homelike environment. The facility's policies on maintaining a homelike environment and cleaning procedures were not effectively implemented, contributing to the deficiencies observed. Staff members, including CNAs and housekeeping aides, were unclear about their responsibilities, resulting in inadequate cleaning and maintenance practices. The Director of Nursing and other management staff acknowledged the issues but did not ensure compliance with established protocols, leading to the observed deficiencies.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Maintenance adjusted the thermostat in Resident Rooms #136 and #133. Maintenance also adjusted the thermostat that controls the common area on Harbor View and City View units. The shower chair and shower room floor on the City View unit and Harbor View unit were cleaned and disinfected per policy. The equipment was removed from the stall. An audit was conducted to ensure the temperatures in other areas of the facility are within a range of 71 degrees to 81 degrees Fahrenheit. All shower rooms on all other units in the facility were checked to ensure shower equipment and shower rooms were clean; no other areas of concern were identified. The maintenance director and maintenance staff were educated on maintaining the temperature in the facility rooms within the range of 71 degrees to 81 degrees Fahrenheit. All CNA staff will be educated on the policy/procedure for cleaning and disinfecting reusable items between resident use. All housekeeping staff will be educated regarding the policy/procedure for cleaning shower rooms. The maintenance director will audit one unit for temperatures weekly for 4 weeks, then monthly for 3 months, including 4 resident rooms. The DON/Designee will audit shower room shareable equipment on one unit to ensure that they are clean and without debris/bodily fluids weekly for 4 weeks, then monthly for 3 months. The Director of Housekeeping will audit one unit's shower rooms to ensure floors are clean and without debris/bodily fluids weekly for 4 weeks, then monthly for 3 months. Audit findings will be reported to the QAPI committee for review. Responsible Person: DON
Deficiency in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents were affected by this deficiency. Resident #39, who had diagnoses including osteomyelitis, gastrostomy, and atrial fibrillation, was observed to have a long, unkempt beard and was not gotten out of bed on multiple days. Despite expressing a desire to be shaved and to get out of bed, staff did not offer these services, citing reasons such as the resident's pressure sore and lack of a chair. The resident's care plan indicated a need for assistance with transfers and personal hygiene, but these needs were not met. Resident #96, who had diagnoses including a fracture of the orbital floor, major depressive disorder, and osteoarthritis, was observed with long, jagged, and dirty fingernails, as well as long whiskers on their face and chin. The resident, who was legally blind, expressed discomfort with their whiskers and difficulty manipulating food due to their nails. Despite this, staff did not offer to shave the resident or provide nail care during morning care. The resident's care plan required assistance with personal hygiene, but these services were not adequately provided. Interviews with staff revealed a lack of communication and responsibility regarding the provision of personal hygiene care. Certified Nurse Aides and Licensed Practical Nurses acknowledged the importance of offering shaving and nail care for dignity and infection control reasons, yet these services were not consistently offered or provided. The Director of Nursing and other supervisory staff indicated that these deficiencies were not in line with the facility's policies and expectations for resident care.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 All staff involved with caring for resident #39 and #96 were counselled regarding ADL Care. Resident #96’s facial hair was trimmed and his fingernails were cleaned, trimmed, and filed. Resident #39’s facial hair was shaved. A wheelchair with offloading cushion was also provided for resident for opportunity to be out of bed. Care plans for residents #39 and #96 were reviewed and revised regarding ADL care and OOB schedule as indicated. All Residents in the facility will be reviewed and ADL rounds performed to ensure nail care and shaving were offered and performed where warranted. The facility will conduct a review on all other residents to ensure they are gotten out of bed per Care Plan. The ADL Policy was reviewed by the Regional Nurse with no revisions required. All CNA’s and Licensed Nursing Staff will be educated by the RN Educator/Designees on policy/procedure for ADL care, including nails and facial hair/grooming. Education will also include the need to get residents out of bed per the Care Plan. DON/Designee will perform ADL audits on five residents per unit weekly x 4 weeks then bi-weekly x 2 months. These audits will include that Facial Hair is trimmed, nails are cleaned and residents are gotten out of bed per policy and Care Plan. Audit findings will be reported to the QAPI committee for review. Responsible Person: DON
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that residents with feeding tubes received the appropriate treatment and services as ordered by the physician, leading to potential complications. For Resident #39, the facility did not administer the prescribed amount of enteral feeding. Observations revealed that the resident's tube feeding was not consistently running as ordered, and the nursing staff did not hang the required amount of formula to meet the resident's nutritional needs. Interviews with nursing staff indicated confusion regarding the feeding order, and it was noted that the resident was not receiving the full 1600 milliliters of formula as prescribed, which was necessary to meet their caloric and protein requirements for wound healing. Resident #147 also did not receive the prescribed enteral feeding as ordered. Observations showed that the resident's feeding tube was not connected, and the formula bag was not replaced as scheduled. The Medication Administration Record lacked documentation of the volume infused, and interviews with nursing staff revealed that the formula bag was not checked or replaced during the evening shift. This oversight resulted in the resident not receiving the necessary nutrition from the enteral feeding. The facility's policies and procedures for enteral feedings and physician orders were not followed, leading to these deficiencies. Nursing staff were unaware of the volume of formula in the bottles and did not adhere to the prescribed feeding schedules. The Director of Nursing and Registered Dietician confirmed that the residents were not receiving the feeding according to the provider's orders, which compromised their nutritional intake.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensed Nurses assigned to residents #39 & 147 on days cited in the SOD were counseled regarding administration of tube feedings and correct documentation. Resident #39 was assessed by medical provider; no adverse effect was noted due to not receiving tube feeding. Resident #147 was assessed by medical provider; no adverse effect was noted due to not receiving tube feeding. A review of physician orders [REDACTED]. #39 and 147 were completed by the RD with no issues noted. A full house review of residents receiving tube feedings was performed to ensure that tube feeding is administered per MD order and that administration record has documentation of administrations; no other areas of concern were identified. The Enteral Feeding Policy was reviewed by the Director Of Clinical Services with no revisions required. All licensed nurses will be reeducated by the RN Educator, in conjunction with RD, regarding tube feed administration, how to utilize feeding pump(s), rechecking for accuracy and correct documentation of tube feeding administered. RN Educator/Designee will conduct weekly Tube Feeding audits of all residents receiving tube feedings x 8 weeks to ensure tube feed was administered, infusing correctly and documented correctly per provider’s order. Issues noted will be immediately addressed. Audit findings will be reported to the QAPI committee Monthly for review. Responsible Person: DON
Failure to Manage PICC Line for Resident
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically concerning the management of a peripherally inserted central catheter (PICC). Resident #16, who was readmitted to the facility with a PICC in their left upper arm, did not have physician orders or assessments for monitoring the PICC, including arm circumference, external length, dressing changes, and flushes. Additionally, the comprehensive care plan for the resident did not include interventions related to the PICC. Observations and interviews revealed that the PICC dressing was dated over a month prior and was soiled and lifting, indicating a lack of attention to the catheter. Both Registered Nurse #2 and Licensed Practical Nurse #1 Unit Manager were unaware of the PICC's presence, and there were no orders or care plan updates for it. The lack of attention to the PICC was acknowledged as an infection risk by the staff. Interviews with the Physician's Assistant and the Director of Nursing highlighted the expectation that the admitting nurse should have entered orders and updated the care plan for the PICC. The absence of these orders and updates was recognized as putting the resident at risk for infection, as the PICC required regular flushing, assessment, and dressing changes. The deficiency was noted as a failure to adhere to professional standards of practice and the facility's policies.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #16 was assessed by medical provider; no adverse effect was noted due to lack of PICC line/site monitoring and care. On 2/11/25, orders were initiated for PICC line assessment, monitoring arm circumference, external length, dressing changes and PICC line flushes. The comprehensive care plan was developed for PICC line on 3/10/25. Nurses who completed admission assessments and weekly skin checks for resident #16 will be counseled by the DON regarding accurate assessments and documentation of PICC lines. All other residents with PICC lines were reviewed to ensure there are physician orders [REDACTED]. All other residents with PICC lines will be reviewed to ensure that comprehensive care plan includes peripherally inserted central catheter. All licensed nurses will be reeducated by the RN Educator regarding PICC line monitoring/care, [MEDICATION NAME] fluids, physician’s order and Care plan initiation. This will also include monitoring for arm circumference, external length, dressing changes, and flushes. Accuracy of New admission assessments for PICC lines will be stressed. All Registered Nurses will have a competency completed for PICC line dressing change and flush administration. DON/Designee will conduct PICC line audits of all residents with PICC lines weekly x 8 weeks to ensure all orders related to central catheters have been initiated including monitoring, flushing, care plan initiation and observation of PICC line dressing to ensure they are intact and dated. Audit findings will be reported to the QAPI committee for review and input. Responsible Person: DON
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as evidenced by the lack of ongoing monitoring and communication with the dialysis center. Resident #16, who had diagnoses including type II diabetes, end-stage renal disease requiring hemodialysis, and a history of methicillin-resistant staphylococcus aureus, did not receive proper assessments of their dialysis access site upon leaving and returning from hemodialysis. The facility's policy required assessments and communication with the dialysis center, but these were not conducted, and the resident's care plan did not include necessary details about their dialysis care. The facility's records showed discrepancies, such as the incorrect listing of an AV fistula as the resident's access device, when in fact, the resident had a perma-cath in their chest. Nurses documented monitoring of an AV fistula/graft, which the resident did not have, indicating a misunderstanding or misreading of the resident's orders. Additionally, there was no documentation of pre and post-dialysis evaluations in the electronic medical record, and the Dialysis Communication Book intended for communication between the facility and the dialysis center was not utilized. Interviews with staff revealed a lack of clarity and communication regarding the dialysis process. Registered Nurse #2 and the Unit Manager acknowledged the absence of necessary documentation and communication with the dialysis center. The Director of Nursing and the Administrator confirmed that there was no education provided on dialysis access devices or procedures, and they expected better communication and documentation practices. The deficiency highlights a significant gap in the facility's adherence to professional standards of practice for residents requiring dialysis.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Provider order for ongoing monitoring of [MEDICAL TREATMENT] site for resident #16 was initiated on 2/11/25 including the correct type of [MEDICAL TREATMENT] site (Permacath). Licensed staff on resident unit were counseled regarding accurate and ongoing monitoring of [MEDICAL TREATMENT] sites. Resident #16’s [MEDICAL TREATMENT] communication book was updated with current medication list and advance directives. Unit staff were counseled regarding [MEDICAL TREATMENT] communication book and policy/procedure in relation to utilization of the communication book with each [MEDICAL TREATMENT] appointment. All residents receiving [MEDICAL TREATMENT] have the potential to be affected. A full house review of all residents receiving [MEDICAL TREATMENT] will be completed to ensure that [MEDICAL TREATMENT] sites are correctly identified and have ongoing monitoring. Review will also include [MEDICAL TREATMENT] communication binders. Any issues will be immediately addressed. The [MEDICAL TREATMENT] policy was reviewed by the Regional Director of Clinical Services with no revisions required. All licensed nurses will be re-educated by the RN Educator regarding [MEDICAL TREATMENT] policy and procedures including accurate and ongoing monitoring of [MEDICAL TREATMENT] sites and consistent communication between the facility and [MEDICAL TREATMENT] Centers. Staff included in scheduling and preparing the residents for their appointments will be reeducated on ensuring all binders are sent with the resident to [MEDICAL TREATMENT] with proper paperwork. The RN educator will perform 5 [MEDICAL TREATMENT] audits weekly; audits will ensure accurate and ongoing monitoring of [MEDICAL TREATMENT] sites and consistent communication between the facility and [MEDICAL TREATMENT] Centers. Any issues noted will be immediately addressed. Audit findings will be reviewed monthly by QAPI committee until the committee determines that compliance has been attained. Person Responsible: DON
Improper Storage of Discontinued Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were securely stored in accordance with State and Federal Laws. During a standard survey, it was observed that two full boxes containing discontinued prescription medications for 22 residents were located in an unsecured first-floor conference room. These medications included insulin pens, inhalers, antipsychotic injectables, antibiotics, antidepressants, anxiolytics, anticonvulsants, diuretics, corticosteroids, antihypertensives, and vitamin supplements. The boxes were unlabeled, unsealed, and easily accessible, posing a risk of unauthorized access. Additionally, a full box of discontinued prescription medications for 32 residents was found in an open and unlocked Nurse Manager's office on the second floor. The medications included psychotropic drugs, antidepressants, antihypertensives, diuretics, and inhalers. The Nurse Manager admitted that the office door was not always locked, allowing potential access by residents. The Director of Nursing and other staff members were unaware of the proper storage procedures for discontinued medications, leading to their improper storage in unsecured locations. Interviews with the Director of Nursing, a pharmacist, and other staff members revealed a lack of awareness and adherence to the facility's medication storage policy. The Director of Nursing stated that discontinued medications should be kept in locked medication rooms or their office until pharmacy pickup. However, the medications were instead placed in unsecured areas like the conference room and Nurse Manager's office, which were accessible to staff, residents, and visitors. This failure to secure discontinued medications violated the facility's policy and posed a risk of unauthorized access and potential medication errors.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 All boxes of discontinued medications listed in the SOD were returned to the Pharmacy on 2/12/2025. All Licensed Nurses were counseled by the Education Nurse on 2/12/25 regarding appropriate medication storage in medication rooms & carts. All residents have the potential to be affected. All medications were collected from medication rooms, conference room, and all U.M Offices and promptly returned to the Pharmacy. DON/ADON/UM will educate nursing staff on proper return of discontinued medications. Discontinued medications should be stored in the locked medication rooms on each unit. The Pharmacy is to be notified of the need for discontinued meds pick up no more than biweekly. Education of LPN and RN nursing staff regarding Medication Storage with expected completion on or before 4/2/25. The Unit managers will spot audit medication rooms and carts on a daily basis to ensure appropriate medication storage. Any issues noted will be addressed. Weekly Medication Room audits will be conducted x 8 weeks by ADON/DON/UM to ensure expired medications are returned to the Pharmacy timely. Audits will ensure that discontinued medications are not stored in unlocked areas including conference, medication rooms, and UM offices. All findings will be reported to the QAPI Committee for review and comment. The DON will be responsible for the correction and monitoring.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions for residents requiring such measures. Resident #39, who was on Enhanced Barrier Precautions due to a history of clostridium difficile, was observed receiving medication and parenteral feed administration through a gastrostomy tube without the administering nurse wearing a gown. Additionally, during incontinence care, staff failed to change gloves or wash hands before handling clean items, and soiled linens were placed directly on the floor without a barrier. Resident #96, who was dependent on staff for toileting hygiene, was observed receiving incontinence care without proper glove changes or hand hygiene being performed by the staff member. The staff member placed soiled linens directly on the bed and floor without a barrier, which was acknowledged as cross-contamination and an infection control issue. The staff member admitted to not following proper procedures, which was confirmed by interviews with other staff members who emphasized the importance of these practices to prevent the spread of germs. Residents #119 and #139, both requiring Enhanced Barrier Precautions due to indwelling medical devices, did not have appropriate signage indicating such precautions. Staff were observed performing high-contact activities, such as emptying a foley catheter and flushing a cholecystostomy tube, without wearing gowns. Interviews revealed that staff were either unaware of the precautions or did not notice the signage, indicating a lack of adherence to the facility's infection control policies.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Signage that indicated Enhanced Barrier Precautions were placed at doorways to resident #119 and #139 on 2/13/25. Resident #39 was assessed by medical provider; no signs/symptoms of adverse effects related to lack of PPE worn were present. Resident #96 was assessed by medical provider; no signs/symptoms of adverse effect related to lack of PPE worn were present. Certified Nurse Aide #5 was counselled and re-educated regarding infection control practices and expectations of hand hygiene and glove changing protocols in regards to providing incontinent care. Certified Nurse Aide #6 was counselled and re-educated regarding infection control practices and expectations of hand hygiene and glove changing protocols in regards to providing incontinent care as well as policy/procedure for soiled linen handling/transport. Nursing Supervisor Registered Nurse #5 was counselled and re-educated regarding infection control practices and expectations of proper PPE for Enhanced Barrier Precautions when handling medical equipment involving bodily fluids. All residents on precautions have the potential to be affected; UM’s rounded their units to identify potential concerns related to infection control practices. Concerns identified were addressed and corrected. The Infection Preventionist and unit managers will update and maintain a list of residents on EBP precautions for each unit. All Licensed Nurses and CNA’s will be educated by the RN Educator regarding infection control practices in regards to enhanced barrier precautions, PPE, hand-hygiene policy/procedures, and soiled linen handling/transport. This will include the prevention of transmission of communicable diseases, gowning during [MEDICATION NAME] administration through a percutaneous endoscopic gastrostomy tube along with the proper changing of gloved. Education will also include proper use of barriers and handling of soiled linen, urine drainage bags, cholecystostomy tubes and coordinating signage when applicable. All nurse management and IP nurse will be educated regarding policy/procedure for signage placement for those residents on precautions. Infection Preventionist/designee will audit 10 residents on EBP precautions weekly x 8 to ensure staff are adhering to policy/procedure regarding PPE use, glove changing, and hand hygiene for care rendered. Audit findings will be reviewed monthly by QAPI committee until the committee determines that compliance has been attained. Infection Preventionist/designee will audit all residents’ rooms on EBP precautions weekly x 8 weeks to ensure appropriate precaution signage and PPE isolation bins are present. Audit findings will be reviewed monthly by QAPI committee until the committee determines that compliance has been attained. Person Responsible: DON
Deficiency in Space Heater Use and Documentation
Penalty
Summary
During a Life Safety Code survey, a deficiency was identified involving the use of a portable electric space heater in a facility. The heater was found operating in the Health Information Office on the first floor of the rear building. It was plugged into a power strip and producing heat, but there was no documentation to confirm that its heating element did not exceed 212 degrees Fahrenheit, as required by the 2012 edition of the National Fire Protection Association 101: Life Safety Code. The heater was not provided by the facility, and the Medical Records Department Director believed it belonged to a co-worker. Interviews conducted during the survey revealed that the facility did not have a written policy on the use of space heaters. The Maintenance Director stated that electric portable space heaters were allowed in non-resident rooms if the heating element did not exceed the maximum temperature. However, the Assistant Maintenance Director could not find specific information from the manufacturer's manual regarding the heater's maximum temperature. The Administrator mentioned that space heaters were not allowed in resident rooms and could only be used in common areas if monitored by staff. Despite these statements, the lack of documentation and a clear policy led to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The identified space heater and power strip were removed from the facility. An audit was conducted of all staff offices to ensure no other space heaters were in use. Education was provided to the Director of Maintenance and maintenance staff on the NFPA 101 code regarding space heaters and that the facility does not allow space heaters. All staff with offices will be educated that space heaters are prohibited in the facility. An audit tool was created to ensure staff offices remain free of space heaters by the maintenance director. Five staff offices will be audited weekly x4 then monthly x3. Results will be reviewed at QAPI. The Director of Maintenance is responsible for the plan.
Non-Compliance with Carbon Monoxide Detector Maintenance
Penalty
Summary
The facility was found to be non-compliant with Section 915 of the 2020 Fire Code of New York State, which mandates carbon monoxide detection in buildings with fuel-burning appliances and requires ongoing preventative maintenance of these detectors. During a building tour, it was observed that the facility had fuel-burning appliances on the first floor and resident sleeping rooms on the second and third floors. Single-station battery-operated carbon monoxide detectors were present on all three floors. However, the facility's policy required these detectors to be inspected periodically, at least annually, and the manufacturer's instructions specified weekly testing and monthly vacuuming to maintain functionality. The facility's records showed inconsistencies in the number of carbon monoxide detectors logged, ranging from four to six, while the Assistant Maintenance Director confirmed there were seven detectors in total. The logs for April, May, June, and July 2024 were missing, and the Assistant Maintenance Director admitted to checking the detectors periodically without documentation. The Maintenance Director, who had been in the position for less than two weeks, acknowledged the need for weekly testing and monthly vacuuming based on the manufacturer's instructions. The Administrator expected all equipment testing by maintenance staff to be documented, which was not done in this case.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 The affected three (first, second, and third floors) of three resident use floors in the front building were tested and vacuumed to ensure they were in good working order and dust free condition. An audit was conducted to ensure the facility is in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors tested weekly and cleaned/vacuumed monthly, as recommended/required per the manufacturer and up to date. The policy and procedure was reviewed with no changes made. An inventory list of all carbon monoxide detectors was created as a result of this audit. There are carbon monoxide detectors located on all 3 resident use floors of the front building. The maintenance director and maintenance staff was educated on the Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. The maintenance director will audit all the carbon monoxide detectors monthly x4 to ensure testing is completed timely. Audit findings will be reported to the QAPI committee for review. Responsible Person: Director of Maintenance
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and electronically submit encoded, accurate, and complete Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe for all 26 residents reviewed. Specifically, the MDS assessments for several residents were not submitted within 14 days after the assessment completion date, and others were not completed within 14 days following their Assessment Reference Date. This deficiency was identified during a standard survey conducted on February 13, 2025. The facility's policy, dated October 2019, requires that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. However, the facility did not adhere to these timeframes, resulting in significant delays. For instance, Resident #14's Quarterly MDS was due by December 31, 2024, but remained incomplete as of February 13, 2025, which was 44 days past the required completion date. Similarly, Resident #103's Annual MDS was due by December 30, 2024, and was 43 days overdue. Other residents also experienced delays in the submission of their MDS assessments. Interviews with facility staff revealed that the delays were attributed to staffing shortages, particularly in the social work department, and the need for additional training for a newly hired MDS Coordinator. The Registered Nurse responsible for MDS coordination acknowledged the late submissions and cited being busy and waiting on other departments to complete their sections as reasons for the delays. The Administrator and Regional Director of Clinical Reimbursement were aware of the overdue assessments and attributed the delays to staffing issues, indicating that they were doing what they could to manage the situation.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Resident #103/14/4/5/9/14/17/18/28/30/47/63/67/82/103/109/125/132 overdue MDS were completed on 3/3/25. Resident 6 and 78 were completed on 3/4/25. Resident 118 was completed on 3/5/25. Resident 110 was completed on 3/6/25. Resident #66 overdue MDS was completed on 2/25/25. Resident #122 was reviewed to ensure accuracy on 1/19/25. Resident #135 was reviewed to ensure accuracy on 2/28/25. All residents have the potential to be affected by this deficient practice. MDS(s) were reviewed for all residents related to compliance with MDS transmission timeframes. Areas identified will be assessed and corrected. The policy and procedure for MDS transmission was reviewed by the VP of Clinical Reimbursement and no changes were made. MDS Coordinator will be educated on RAI manual timeframes for transmission by the VP of Clinical Reimbursement. MDSC will review MDS assessment(s) for timely submission. Any identified will be submitted to QIES. MDS coordinator will review the MDS List “Completed,” “Export Ready” list within PCC twice a week for completed MDS(s) that are awaiting submission. Regional Director of Clinical Reimbursement will submit an audit related to MDS completion date and transmission on all residents including looking at the Assessment Reference Dates (ARD), completion date, submission due date for MDS weekly x4, biweekly x2, and monthly x3. All findings will be reported to the QAPI Committee for review and comment. Responsible party: DON
Narcotic Management Deficiencies Across Multiple Units
Penalty
Summary
The facility failed to provide adequate pharmaceutical services and maintain proper drug records, resulting in unaccounted narcotic medications across four units. On the River View unit, 93 narcotic medications were missing, and the keypad to the medication room was malfunctioning, allowing access via employee swipe badges. Additionally, the lock on the narcotic cupboard was broken, and the issue was not addressed until after the medications went missing. Observations revealed that narcotic reconciliation books and keys were left unattended in medication rooms on both the River View and Sky View units. Licensed Practical Nurse #1 was observed conducting a narcotic reconciliation alone on the City View unit, contrary to the facility's policy requiring two nurses to perform the count together. The facility's records showed numerous shifts across all units where narcotic reconciliation was not documented as completed by both the outgoing and incoming nurses. Interviews with staff, including the Director of Nursing and a consultant pharmacist, confirmed that narcotics should be reconciled every shift to ensure accurate counts and prevent diversion. The facility's failure to adhere to its Controlled Substance Management policy, which mandates proper storage and reconciliation of narcotics, contributed to the discrepancies in narcotic counts. The lack of consistent documentation and adherence to procedures for narcotic reconciliation and key management posed a risk of medication diversion and compromised the facility's ability to account for controlled substances accurately.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 LPN #1 and LPN #3 were placed on administrative leave, then thereafter were counseled regarding the Controlled Substance Management Policy. LPN #3’s counseling emphasized that the off-going shift nurse must remain on the unit with the keys until the on-coming nurse arrives and a narcotic count is performed with both nurses and documented in the Narcotic Book(s). It was also emphasized that keys are to be kept with the nurse on shift at all times and cannot be left unattended in the medication room or anywhere else at any time. LPN #2 was counseled to report the off-going nurse leaving before counting off narcotics to supervision right away. The provider assessed residents whose narcotics were missing to ensure there are no adverse effects as a result of the missing medication. Education was provided on the process of handing off keys and signing of narcotics in relation to not leaving the unit prior to having a relief, ensuring all signatures are in place and match the narcotic count. No residents were affected by the deficient practice. All narcotics on the units were audited and accounted for; no other issues were identified. The Controlled Substance Management Policy and Medication Administration policy were reviewed by the DON; no revisions required. All licensed nurses will be educated on the Controlled Substance Management Policy and Medication Administration policy with emphasis placed on the shift-to-shift count process with key hand off and expectation that the off-going nurse is to remain on the unit with keys on their person until the oncoming nurse arrives and count is performed – keys are not to be left unattended at any time. Medication competency with licensed nursing staff will be completed to ensure compliance. Unit Managers/Designee will conduct audits on the Narcotic reconciliation book on their assigned unit weekly for 4 weeks, then bi-weekly for 2 months. The audit will ensure that medication reconciliation records have two nurse signatures for each shift-to-shift count with no missing entries. Unit Managers/Designee will monitor 1 shift count on each shift twice weekly for 2 weeks, then weekly for 4 weeks to ensure the off-going nurse and oncoming nurse are counting narcotics appropriately, handing off keys appropriately, and documenting. Audit findings will be reported to the QAPI committee for review monthly. Responsible Person: DON
Failure to Honor Resident's Advance Directives
Penalty
Summary
The facility failed to honor the advance directives of a resident, leading to the initiation of cardiopulmonary resuscitation (CPR) against the resident's documented wishes. The resident, who had a Medical Orders for Life Sustaining Treatment (MOLST) form indicating Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, was mistakenly subjected to CPR. This error occurred because the Licensed Practical Nurse (LPN) involved reviewed the wrong resident's MOLST form, leading to the incorrect assumption that CPR was appropriate. The incident unfolded when a Certified Nurse Aide found the resident unresponsive and notified the LPN. The LPN, without verifying the resident's identity or the correct MOLST form, initiated CPR. The error was compounded by the fact that the LPN assumed the room was occupied by only one resident and did not confirm the resident's identity through the electronic medical record, as per facility protocol. This oversight resulted in the resident receiving CPR, which was contrary to their expressed wishes. The facility's investigation revealed that the LPN had mistakenly reviewed the MOLST form of the resident's roommate, leading to the inappropriate initiation of CPR. The error was not identified until after the paramedics arrived and the resident was pronounced deceased. Interviews with facility staff, including the Director of Nursing and the Medical Director, confirmed that the resident's advance directives were not honored due to this human error.
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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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