Ferncliff Nursing Home Co Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rhinebeck, New York.
- Location
- 21 Ferncliff Drive, Rhinebeck, New York 12572
- CMS Provider Number
- 335405
- Inspections on file
- 25
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ferncliff Nursing Home Co Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral needs was physically abused by an LPN following an altercation over food in the dining room. The resident, after spitting at the LPN, was slapped on the cheek, resulting in redness, swelling, and emotional distress. The incident was witnessed by two CNAs, and the resident required consolation immediately afterward.
The facility did not perform the required generator fuel quality test as per NFPA standards. During a survey, it was found that documentation for the current test was missing, with the last test conducted in 2023. The Corporate Regional acknowledged the oversight and stated that the vendor would be contacted.
The facility failed to provide adequate nursing staff, resulting in delayed resident care and meal services. Staffing shortages were observed on numerous shifts, with staff interviews confirming the negative impact on resident assistance and supervision, particularly on the dementia unit. Lunch services were also delayed due to insufficient staffing.
The facility failed to adhere to food safety and infection control standards, as surveyors observed undated food items in storage and dietary aides not changing gloves between tasks. The Food Service Director was unaware of the undated items, and despite training, dietary staff did not follow the glove use policy.
A resident's representative was not informed of changes in the resident's medication regimen, including the reduction and discontinuation of Seroquel and the initiation and discontinuation of Sertraline. Facility staff interviews revealed a lack of communication and responsibility in notifying the family, with the Assistant Director of Nursing and attending physicians acknowledging the oversight.
The facility did not ensure a safe, clean, and homelike environment. A shower room had mildew and drafts, soiled linens were found on the floor, and a broken handrail posed a risk. Staff were unaware of these issues until observed during the survey.
Two residents in an LTC facility were not adequately supervised, leading to safety risks. One resident with dementia wandered unsupervised, entering other residents' rooms and attempting to open exit doors. Another resident with Huntington's Disease experienced multiple falls due to unclear care plan documentation and lack of assistance during ambulation. Staff interviews revealed challenges in managing these issues due to limited staff availability and communication gaps.
A resident with impairments and dependency on staff for self-care was observed with long, dirty fingernails on multiple occasions, indicating a failure in maintaining personal hygiene. Despite the resident's inability to manage their nails and expressing a desire for assistance, staff were reportedly too busy, leading to inconsistent care. Interviews revealed that while personal hygiene tasks were the responsibility of CNAs, there was no specific documentation for fingernail clipping, contributing to the deficiency.
A resident with intact cognition and frequent bladder incontinence did not receive appropriate treatment to restore continence. The facility failed to implement a voiding diary or toileting program as per policy, despite the resident's ability to use the bathroom prior to admission. Staff interviews revealed a lack of awareness and implementation of an incontinence care plan, with the resident only recently placed on a toileting program.
A resident with limited range of motion was observed with their foot dangling off the wheelchair pedal due to improper positioning and equipment issues. Despite evaluations for mobility, there was no documentation of proper positioning or repairs. The occupational therapist noted a malfunctioning phalange and a misaligned foot box, while a CNA observed but did not report the issue. There was no official schedule for assessing wheelchairs, leading to a deficiency in care.
A resident with severely impaired cognition experienced significant weight loss, which was not properly documented or addressed by the facility. The resident's weight was not recorded for two months, and the registered dietician did not document any interventions. Staff interviews revealed a lack of awareness and communication regarding the resident's nutritional status.
A resident with severely impaired cognition and a history of [REDACTED] was not properly positioned during meals, leading to increased coughing and gagging. Despite being dependent on staff for all activities, the resident was observed sliding down in their chair while being fed, with no interventions documented in the care plan. Staff interviews revealed a lack of evaluation for chair positioning, and only after a family request was a device added to prevent sliding.
The facility did not ensure that the means of egress was clearly marked, as the exit sign between the elevator and the recreation room on the B wing directed travel through an occupied daycare space. This was observed on one of the four resident floors, and the Director of Maintenance acknowledged the issue during an interview.
The facility did not maintain continuous illumination in the means of egress as required by NFPA 101. During a survey, it was found that turning off the wall-mounted light switches in the fifth-floor dining room also turned off all lights, including those needed for an emergency stairwell exit. This issue was identified on one of the three resident floors, and the Director of Maintenance confirmed the lights would be continuous.
Two residents experienced incidents due to inadequate supervision and maintenance in the facility. One resident, with a history of Alzheimer's and hip surgery, was bumped by elevator doors twice, causing hip pain. Another resident with severe dementia and wandering behaviors accessed a housekeeping closet due to a malfunctioning door. The facility failed to ensure proper elevator sensor function and secure the closet, leading to these deficiencies.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia, diabetes mellitus, and major depressive disorder, was subjected to physical abuse by a staff member. The incident took place in the dining room during lunch, when the resident took another resident's cake, leading to an argument with an LPN. During the altercation, the resident spat at the LPN, who then responded by slapping the resident on the right cheek. This act was witnessed by two certified nurse aides, and the resident was observed to have redness and swelling on the right cheek and was crying immediately after the incident. The resident's care plan indicated a need for ongoing redirection, monitoring, and structured activities due to behavioral symptoms and a risk of victimization related to dementia. Despite these documented needs, the staff member engaged in a physical confrontation rather than employing de-escalation or redirection techniques. The incident resulted in observable physical harm and psychosocial distress to the resident, as evidenced by immediate crying and the need for consolation by staff. Interviews with staff confirmed that attempts were made to intervene and de-escalate the situation, but the argument continued, culminating in the physical abuse. The LPN involved acknowledged the incident and expressed regret, while other staff members promptly reported the event to facility leadership. The deficiency centers on the failure to protect the resident from abuse by a staff member, contrary to facility policy and regulatory requirements.
Missing Generator Fuel Quality Test Documentation
Penalty
Summary
The facility failed to ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110 standards. During a Life Safety recertification survey, it was observed that the documentation for the current fuel quality test of the facility's generator was missing and not provided at the time of the survey. The last recorded fuel quality test was conducted in 2023, indicating a lapse in compliance with the testing schedule. This deficiency was confirmed during an interview with the Corporate Regional, who acknowledged the oversight and mentioned that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 K918 – Essential Electrical Testing and Maintenance I. Immediate Corrections The facility engaged the Emergency Generator service provider to perform fuel quality testing. Testing completed (MONTH) 7, 2025. II. Plan of Correction to Identify Other Areas Potentially Affected It was determined that all residents have the potential to be affected by the facility not ensuring that the required emergency generator fuel quality test is completed. The Director of Plant Operations will review all record and log reports to ensure required systems testing and inspection are completed as per the required code and regulations. Work completed: (MONTH) 12, 2025 III. Systemic Changes The facility maintenance record and log policy were reviewed; it was determined that no changes were needed to the policy. The Director of Plant Operations will review all required records and logs to ensure periodic testing, inspections, and services are completed as per schedule. All maintenance staff will receive in-service education, and all participants will understand the life safety issues identified, with a focus on the annual fuel testing requirements for the Emergency Generators. The Director of Plant Operations has been assigned responsibility for the education of staff. Work completed: (MONTH) 13, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that required generator annual fuel tests are completed in accordance with NFPA 101 and NFPA 110. 1. Audits will be completed by the Director of Plant Operations quarterly x 2 quarters, then complete annually thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to the QA Committee Quarterly x 2 Quarters then annually thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee
Staffing Shortages Lead to Delayed Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the staffing shortages observed during the recertification and abbreviated surveys. Specifically, the facility did not meet the minimum staffing levels outlined in their Minimum Staffing Standard Matrix on sixty-nine out of ninety-six shifts, and on nine out of thirty-two night shifts, the staffing fell below the general staffing plan documented in the Facility Assessment. Interviews with staff revealed that these shortages led to delays in resident care and meals, with some staff members being mandated to work additional shifts, which affected their ability to perform their duties effectively. Observations on the dementia unit highlighted the impact of staffing shortages, with unsupervised residents appearing confused and unable to find seats in the day room. Staff interviews confirmed that the dementia unit often operated with fewer certified nurse aides than required, which compromised the supervision and care of residents. Additionally, the lunch service on the 3rd floor was delayed, with some residents receiving their meals significantly later than others, further indicating the strain on staff resources. The report includes multiple staff testimonies describing the negative effects of working with insufficient staff, such as residents not receiving timely assistance with toileting and transfers, and meals being delayed. These deficiencies in staffing and care delivery were corroborated by the facility's own staffing records and staff interviews, which consistently pointed to a pattern of inadequate staffing levels that failed to meet the facility's documented standards.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 725 Sufficient Nursing Staff I. The Following Actions were accomplished to ensure minimum staffing levels for certified nurse aides are met on all shifts: A review of the facility-wide assessment was conducted on 3/17/25 based on the revised Medicaid CMI to re-evaluate the allocation of resources needed to care for the residents. The facility-wide assessment will provide information regarding direct care staff needs and capabilities to provide services to the residents. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the deficient practices. The facility-wide assessment conducted will re-evaluate the allocation of resources and staffing on all shifts. Corrective action will include following the minimum determined staffing levels for certified nurse aides on all shifts. III. The following systemic changes will be implemented to ensure minimum staffing levels for certified nurse aides are met on all shifts: The Administrator and Director of Nursing will provide education to the Staffing Coordinators on the importance of meeting minimum staffing requirements for all shifts. The Facility Assessment will be conducted on a routine basis by the Administrator and the Director of Nursing to review the staffing levels based on current Case Mix Index information and ADL and care needs of the residents. Any changes to the staffing levels in all shifts based on the facility assessment will be communicated to the staffing coordinator to ensure that staffing levels are maintained. When staffing levels are not at the designated levels after all resources available to the staffing coordinator will notify the Administrator and the Director of Nursing to determine additional actions needed to meet the needs of the residents’ levels determined by the facility assessment. The Administrator, along with the Director of Nursing, continuously works on hiring more C.N.A. staff for all shifts. The facility staffing levels improved over the last three months by successfully hiring more staff for all shifts. These new staff members assisted our residents needs by picking up shifts each week. Agency staff are also utilized to meet the needs if all employed staff solutions are exhausted. The facility has a plan to meet staffing requirements through an in-house recruiter who was recently hired and has helped tremendously with staff recruitment. Also, the facility has offered referral bonuses, sign-on bonuses and retention bonuses. An in-house childcare center will be opening soon and will be offered to all staff to help with recruitment and retention. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: The daily staffing is reviewed by the facilities Staffing Coordinator, Director of Nursing and Administrator to assure that the staffing levels meet the residents’ needs. These levels are reported weekly for 3 months. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing. Responsible Person: The Director of Nursing is the person responsible to ensure all of the above actions have been completed.
Food Safety and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain specific food items in accordance with professional standards for food safety and infection control prevention. During the initial tour of the kitchen, surveyors observed an opened and undated container of thickened milk in the refrigerator and an opened, undated bag of powdered sugar wrapped with plastic wrap in dry storage. The Food Service Director, when interviewed, stated they were unaware that these items were not dated after opening, which was contrary to the facility's policy requiring all unused portions and open packages to be covered, labeled, and dated using the Medvantage/Freshdate labeling system. Additionally, the facility did not ensure proper use of disposable gloves by dietary aides during meal service. Three dietary aides were observed failing to change gloves after touching non-meal service objects. Dietary Aide #26 was seen using gloves to handle an ink pen, clipboard, and garbage lid before continuing meal service without changing gloves. Dietary Aide #27 used gloves to touch a door handle and refrigerator door before preparing meal trays. Dietary Aide #28 answered a phone call while wearing gloves and then continued to serve meals without changing them. The Food Service Director confirmed that all dietary staff had been trained on the policy requiring glove changes between tasks, but the aides did not adhere to this policy during the observations.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 812 Food Procurement I: Immediate Corrections - The opened undated container of thickened milk and undated bag of powdered sugar were all discarded on 2/20/25. - The Dining Service staff that were identified during observations were immediately provided with an in-service education on proper disposable glove usage on (MONTH) 14 through (MONTH) 16, 2025. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All freezers, refrigerators, and dry storage areas were inspected for any additional items that may be unlabeled or past their expiration date and holding. - All Dining Service Staff were provided in-service education on (MONTH) 25, 2025, on proper food storage procedures including importance of labelling all opened items and monitoring food expiration dates, including all dates identified as “sell-by,” “best-by,” “enjoy-by,” or “use-by.” - All Dining Service Staff were provided in-service education on (MONTH) 14 – (MONTH) 16, 2025, on proper disposable glove usage. III: The following system changes will be implemented to ensure continuing compliance with regulations: - The Administrator and Director of Food Services reviewed the policy titled, Production, Purchasing, Storage: Food and Supply Storage. There were no revisions necessary. - The Administrator and Director of Food Services reviewed the policy titled, Sanitation and Infection Control: Disposable Glove Use Policy. There were no revisions necessary. - All Dining Services Staff were provided with in-service education on the facility’s policy titled Production, Purchasing, Storage: Food and Supply Storage by the Director of Food Services. - All Dining Services Staff were provided in-service education on the facility’s policy titled, Sanitation and Infection Control: Disposable Glove Use Policy by the Director of Food Services. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: - Director of Food Services will develop an audit tool entitled, “Labeling of Food Products.” This tool will be utilized by the Dining Service Managers and will conduct daily inspection of all refrigerators, freezers, and dry storage areas to ensure all items are properly labelled, dated, and within appropriate date ranges. The audit will be conducted weekly for 3 months. - Director of Food Services will develop an audit tool entitled, “Disposable Glove Use.” This audit tool will be utilized to monitor compliance of five (5) Dining Service Staff members on Sanitation and Infection Control with Disposable Glove Use. The audit will be conducted weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement committee by the Food Service Director. Responsible Person: The Dining Director is the person responsible for ensuring all the above actions are completed.
Failure to Notify Resident's Representative of Medication Changes
Penalty
Summary
The facility failed to notify the representative of a resident about changes in their medication regimen, which is a requirement under the facility's policy. The resident, who had diagnoses including dementia, anxiety, insomnia, and Alzheimer's disease, was undergoing a gradual dose reduction of Seroquel, an antipsychotic medication, and the initiation and subsequent discontinuation of Sertraline, an antidepressant. Despite these significant changes in the resident's plan of care, there was no documentation indicating that the resident's representative was informed of these changes. Interviews with facility staff revealed a lack of communication and responsibility regarding the notification process. The Assistant Director of Nursing acknowledged that the family should have been notified by the physician, but this did not occur, partly due to the attending physician's departure from the facility. Attending Physician #2 and the Psychiatric Nurse Practitioner involved in the resident's care also did not recall notifying the family, highlighting a breakdown in the communication process within the facility's interdisciplinary team.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 580 Notification of Changes I: The Following Actions were accomplished for the residents identified in the Sample: ? Resident #400 expired on (MONTH) 13, 2024. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ? All residents have the potential to be affected by the same practice. ? The Director of Nursing/Designee will complete chart reviews of other residents with psychoactive medication changes from (MONTH) 2024 till present to ensure all resident’s family or representative were notified of any changes on psychoactive medications. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ? The Administrator and Director of Nursing reviewed the policy entitled “Psychoactive Drugs” on (MONTH) 17, 2024, and no revision is needed. ? The Licensed Nurse Educator/Designee will provide education to all licensed nurses on the existing policy for Psychoactive Drugs. ? The Attending Physician #2 was also provided one to one education by the Licensed Nurse Educator/ADON of the responsibility to notify the Resident’s family or representative of any psychoactive medication changes. ? The Medical Director will also complete the educational in-service to all medical providers. ? The Staff Educator/Designee will create a lesson plan regarding Psychoactive Medication changes. The lesson plan will be discussed with all licensed nurses to ensure compliance with the policy for Psychoactive Medication. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ? Director of Nursing/Designee will develop an audit tool entitled “Psychoactive Medication Notification of Changes.” The audit tool will be utilized to monitor compliance with family or representative notification for any psychoactive medication changes. The audits will be conducted weekly for 3 months. ? A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. Responsible: Director of Nursing is responsible for ensuring all above is completed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as observed during the recertification and abbreviated surveys. In the shower room on the 3A unit, there were black stains on the shower curtain, brown discoloration on the tiles at the base of the toilet, and black and orange stains on the tile grout in the shower stall. Additionally, a window air conditioner caused a cold draft in the room. Resident #18 reported the shower room was cold and had mildew. The Director of Housekeeping acknowledged that the shower curtain should have been replaced and the tiles needed cleaning, but they had not received any reports about these conditions. The Director of Maintenance was unaware of the issues but acknowledged the need for addressing the grout discoloration and the draft caused by the air conditioner. In another incident, soiled linens were found on the floor next to Resident #27's bed. A Certified Nurse Aide confirmed that soiled linens should be bagged and placed in a linen hamper, not on the floor. Additionally, a broken handrail with a sharp edge was observed at the entrance to the 3A dining room. The Maintenance Worker and the Director of Maintenance were not aware of the broken handrail, but the Director of Maintenance stated that handrails would be added to the list of items to check during rounds.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 584 Safe/ Clean/ Comfortable Homelike Environment I. Immediate Corrections: - The Housekeeping staff cleaned the Shower room on unit 3A. The black and orange dis-coloration along the base of the shower stall was removed. Completed 2/26/2025. - The Housekeeping staff cleaned shower curtains. Black stains on the bottom of curtain were removed. Completed 2/25/2025. - The Housekeeping staff cleaned the toilet. Discolored brown stains on tiles around the base of toilet were removed. Completed 2/26/2025. - The window air conditioner unit that was allowing cold draft to enter the shower stall was removed by the maintenance staff. Completed 2/26/2025. - The Certified Nursing Assistant picked up the soiled linen with feces that was next to the bed in Resident # 27 room. The Linen was bagged and placed in hamper. Completed 2/20/2025. - The broken handrail on the right side of the dining room entrance was repaired by the maintenance staff. Completed 2/26/2025. II. Plan of Correction to identify other areas potentially affected - The facility acknowledges that all residents have the potential to be affected by this practice. - The Director of Plant Operations will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be scheduled for correction. Completed 2/28/2025. III. Systemic Changes - All maintenance staff, housekeeping and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483.10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff. - The Policy & Procedures were reviewed, and it was determined that no changes to the policy were necessary. IV. Quality Assurance Monitoring - The Director of Plant Operations/Housekeeping will conduct audits on all rooms to ensure a homelike environment is maintained weekly x 4 weeks and then monthly for 3 months unless any significant trends are identified. Any concerns during audits will be addressed immediately to ensure compliance with standards of care or practice. - The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. Responsibility: Director of Plant Operations
Inadequate Supervision and Accident Prevention for Two Residents
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, leading to deficiencies in accident prevention. Resident #183, diagnosed with non-Alzheimer's dementia and other conditions, was observed wandering unsupervised into other residents' rooms and attempting to open exit doors. Despite having a care plan that included visual checks and engagement in activities, Resident #183 was frequently unsupervised, leading to potential safety risks. Staff interviews revealed challenges in managing the resident's wandering behavior due to their advanced dementia and limited staff availability. Resident #242, diagnosed with Huntington's Disease, experienced multiple falls over a period of time. The care plan initially required staff assistance for ambulation due to gait and balance issues. However, observations showed the resident ambulating unassisted, and there was no documentation indicating the discontinuation of the assistance requirement. Interviews with staff revealed a lack of clarity and communication regarding the resident's need for assistance, contributing to the resident's falls. The deficiencies highlight the facility's failure to provide adequate supervision and maintain a safe environment for residents at risk of accidents. The lack of consistent staff intervention and documentation regarding care plan changes contributed to the residents' exposure to potential hazards and accidents.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 689 Free of Accident Hazards/Supervision/Devices I: The Following Actions were accomplished for the residents identified in the Sample: - Resident #27 and Resident #151 were provided with a mesh stop sign on the door to prevent Resident #183 from wandering in the rooms on (MONTH) 18, 2025. - Resident #183 background interest and past occupation were reviewed by IDT and revised care plan intervention to simulate her past profession as a housekeeper. - Resident #242 was re-evaluated on (MONTH) 18, 2025, by rehab and continues to demonstrate the ability to safely perform independent bed mobility, functional transfers, and ambulation to desired locations within the unit with chorea movements. This gait pattern is consistent with long-term effects of [MEDICAL CONDITION]’s disease. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - All Unit Managers/Designee will review facility’s wanderguard list to identify residents who exhibit intrusive wandering behavior in their assigned unit(s) and will update resident’s care plan for appropriate interventions. - All residents diagnosed with [REDACTED]. This assessment will focus on any fluctuations in their gait beyond their baseline chorea movements. Based on the findings, their care plans will be updated to implement appropriate interventions. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - All licensed nurses in the facility will be re-inserviced on the facility’s Elopement Risk Assessment and Procedure Policy as it relates to the assessment of Elopement risk and initiation of Resident specific interventions such as monitoring of residents for their safety. - The Staff Development Nurse will be responsible for re-inservicing all other Licensed Nurses on the facility’s Elopement Risk Assessment and Procedure Policy. - The Staff Development Nurse will provide an inservice education to all licensed nurses, highlighting the importance of promptly notifying the rehabilitation department about any residents diagnosed with [REDACTED]. This in-service education aims to ensure early identification of ambulation fluctuation and prompt implementation of intervention. - The Director of Nursing and Administrator reviewed the facility’s Elopement Risk Assessment and Procedure Policy and the Wander Alert System Operation. No revision is necessary. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: - The Director of Nursing/Designee will develop an audit tool entitled, “Identification of Intrusive Wandering Behavior.” The audit tool will be utilized to identify residents exhibiting intrusive wandering behavior. It will also assess the immediate interventions implemented by staff and ensure that the plan of care is updated accordingly to address these behaviors effectively. The audits will be conducted weekly for 3 months. - The Director of Rehab/Designee will develop an audit tool entitled “[MEDICAL CONDITION]’s Disease – Ambulation Fluctuations.” This audit tool will be utilized to identify residents who experience falls during ambulation in the HD unit, specifically focusing on fluctuations in their gait that are not attributable to their baseline chorea movements. This approach will effectively recognize and implement appropriate interventions tailored to enhance safety and mobility. The audits will be done weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing and Director of Rehab. Responsible Person: The Administrator is responsible for ensuring all the above is completed.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Specifically, a resident with intact cognition and impairments in both upper and lower extremities was dependent on staff for self-care abilities, including personal hygiene. Despite this dependency, the resident was observed on three occasions with long and dirty fingernails, indicating a lack of proper hygiene care. The resident expressed a desire to manage their fingernails but was unable to do so due to their condition and reported that staff were too busy to assist. Interviews with facility staff revealed that personal hygiene care, including fingernail clipping, was the responsibility of certified nurse aides. However, there was no specific documentation task for fingernail clipping, leading to inconsistencies in care. A certified nurse aide admitted to not remembering the condition of the resident's nails during hygiene assistance, while an LPN stated they clipped the resident's nails when the aides were busy. This lack of consistent attention to the resident's personal hygiene needs resulted in the observed deficiency.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 677 ADL Care Provided for Dependent Residents I. The Following Actions were accomplished for the residents identified in the Sample: - Resident #27 was assessed by Licensed Unit Manager on 2/25/2025 and the designated C.N.A provided nail care, including trimming, and documented accordingly. - The C.N.A assigned to Resident #27 and the Licensed Practical Nurse #18 received in-service education on the importance of providing nail care for all residents. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have been identified as potentially affected by the same practices. - All Unit Managers will conduct direct care observations of all residents in their assigned units to ensure that fingernails are properly trimmed, cleaned and filed. - Any identified residents will be provided with nail care and will be documented accordingly. III. The following systemic changes will be implemented to ensure the deficient practice will not recur: - The Policy and Procedure titled Clinical, Activities of Daily Living Protocol and Policy was reviewed by the Administrator and Director of Nursing. No further revisions were necessary. - Nursing staff will be provided with in-service education by the Licensed Staff Educator or ADON on providing nail care and documented accordingly. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur utilizing the following Quality Assurance practice: - The Director of Nursing/designee will develop an audit tool entitled “Nail Care – Personal Hygiene.” The Audit tool will be utilized to monitor ten (10) residents per week for each unit and all new admissions to ensure that nail care is provided and documented accordingly. - The audits will be conducted weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing/Designee. Responsible: Director of Nursing is responsible for ensuring all above is completed.
Failure to Implement Bladder Management Program
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. Resident #112, who had intact cognition and required substantial assistance with activities of daily living, was frequently documented as incontinent of bladder. Despite this, the resident's care plan did not include a voiding diary or a toileting program, which are essential components of a bladder management strategy. The facility's policy required assessments and individualized re-training programs for bladder function, but these were not implemented for Resident #112. Interviews with the resident and staff revealed that the resident was not placed on a toileting schedule and was not encouraged to use the bathroom regularly, despite expressing a desire to do so. The resident reported being able to use the bathroom without accidents before entering the facility and expressed dissatisfaction with wearing pullups. Staff interviews indicated a lack of awareness and implementation of an incontinence care plan for the resident, with the Assistant Director of Nursing and a Registered Nurse both unsure why such a plan was not created. A Certified Nurse Aide mentioned that the resident was only put on a toileting program the day before the interview, indicating a delay in addressing the resident's needs.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 690 Bowel/Bladder Incontinence, Catheter, UTI I: The Following Actions were accomplished for the residents identified in the Sample: ? Resident # 112 is now on a toileting program. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ? All residents have the potential to be affected by this deficient practice. ? All new admissions will be reviewed for the past three months to ensure appropriate interventions are in place. ? Any identified resident who has a decline in continence of bladder will be placed on toileting program. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ? The Administrator and Director of Nursing reviewed the facility policy titled Clinical Bladder Management. ? There were no revisions necessary. ? All nursing staff will receive an in-service education focused on identifying residents who have recently become incontinent with bladder, as well as newly admitted residents who are incontinent with bladder. This in-service education will emphasize the importance of initiating a toileting program aimed at restoring continence to the extent possible. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ? The Director of Nursing/Designee will develop an audit tool entitled “Incontinent of Bladder – Toileting Program.” This tool will identify residents who are admitted as being incontinent with bladder, as well as residents who have recently become incontinent with bladder. It will assess whether they were promptly placed in a toileting program immediately, with the aim of restoring the resident’s continence to the extent possible. ? This audit will be conducted weekly for three (3) months. ? A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing/Designee. Responsible Person: The Director of Nursing is responsible for ensuring all above is completed.
Deficiency in Wheelchair Positioning and Maintenance
Penalty
Summary
During a recertification survey, it was found that the facility failed to ensure proper positioning and equipment for a resident with limited range of motion in their lower extremities. The resident, who was independent in cognition and had a diagnosis that included decreased muscle strength, was observed multiple times with their foot dangling off the foot pedal of their wheelchair. Despite being evaluated for wheelchair mobility to increase strength for self-propelling, there was no documentation of an assessment for proper positioning or necessary repairs to the wheelchair. The occupational therapist noted that the wheelchair's phalange was not functioning correctly, causing the foot pedal to swing out and making it difficult for the resident to keep their foot in place. Additionally, the left foot box was out of position and required fixing. A certified nurse aide observed the issue but did not report it, and the occupational therapist confirmed that there was no official schedule for assessing wheelchairs or documented audits. This lack of communication and documentation contributed to the deficiency in providing necessary care and equipment for the resident.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 688 Increase/Prevent Decrease in ROM/Mobility I. The Following Actions were accomplished for the residents identified in the Sample: - The wheelchair for Resident #36 was repaired first thing in the morning on (MONTH) 27, 2025. - Certified Nurse Aide #14 received an education on the importance of promptly reporting broken wheelchair to their immediate supervisor to ensure that repairs are initiated without delay. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - The Director of Rehab/Designee will identify all residents utilizing bariatric wheelchairs. This will specifically focus on foot pedals that show signs of increased wear and tear resulting from the weight of the foot pedal support. - Any identified deviations will be promptly reported to the Support Services for immediate repair and provide appropriate intervention or change existing intervention. III. The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - All Nursing Staff will be provided with an in-service education for promptly reporting any broken wheelchair to their immediate supervisor. This ensures that necessary repairs are initiated without delay, thereby maintaining resident’s functional status. - The Occupational Therapist will continue to monitor the foot pedals of residents using bariatric wheelchairs, as these experience increased wear and tear due to the extent of weight put on them. During quarterly screenings, the Occupational therapist will document assessment findings to ensure proper positioning in wheelchair and address necessary adjustments or interventions. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: - The Director of Rehab/Designee will develop an audit tool entitled “Bariatric Resident - Wheelchair Positioning.” This audit tool will be utilized to monitor residents who use bariatric wheelchairs focusing on foot pedals that exhibit wear and tear. It will help identify those requiring repairs or additional devices to maintain their functional mobility. Additionally, the tool will ensure that all necessary documentation regarding resident’s wheelchair positioning is reflected in the resident’s chair. The audit will be conducted weekly for three (3) months. - The Support Services Director/Designee will develop an audit tool entitled “Wheelchair Reporting and Repair.” This tool will be utilized to assess whether the staff have properly followed the facility’s procedure for reporting broken wheelchairs and to verify that repairs were completed in a timely manner. Responsible Person: The Administrator is responsible for ensuring all above is completed.
Failure to Monitor and Address Resident's Nutritional Status
Penalty
Summary
The facility failed to monitor and address the nutritional status of a resident, leading to a significant weight loss that was not properly documented or managed. The resident, who had severely impaired cognition and was dependent on assistance for activities of daily living, experienced a 7.5% weight loss over three months and a 13% weight loss over four months. Despite these changes, the resident's weight was not recorded for the last two months, and there was no evidence that the weight loss was addressed by the registered dietician or other staff members. The resident's comprehensive care plan aimed to maintain a weight of 135 pounds +/- 3%, but the resident's weight dropped from 134.4 pounds to 116.8 pounds over a four-month period. The registered dietician had not documented any nutritional notes or interventions since August 2024, and the nursing staff failed to obtain and record the resident's weight in the subsequent months. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's weight loss and the absence of recorded weights, indicating a breakdown in the facility's monitoring and documentation processes.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 692 Nutrition/Hydration Status Maintenance I: The Following Actions were accomplished for the residents identified in the Sample: - Resident #93 had their most current weight obtained on 2/27/25. This was reported to the Registered Dietitian and recommendations were made and carried out. - An IDCP team meeting was held on 3/21/25 with Resident #93 family to discuss the anticipated progression of the resident’s [MEDICAL CONDITION]’s Disease, which is impacting the resident’s appetite and contributing to ongoing weight loss. Resident’s family has decided to place her on Palliative Care due to progression of [MEDICAL CONDITION]’s Disease. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - All residents’ weight from (MONTH) 2024 to present will be reviewed to ensure that the most recent and accurate weights will be obtained and will be reported to the Dietician. Any recommendations will be implemented promptly. - All residents identified as experiencing weight loss over the past four months will be reviewed to ensure that appropriate documentation and care plan interventions are in place to address their weight loss. Concurrently, the medical provider will be notified to incorporate any recommendations into the resident’s care plan, ensuring that proper documentation and interventions are implemented effectively. - All residents identified as experiencing weight loss will also be reviewed weekly by the IDCP team during weekly weight management meetings to ensure ongoing monitoring and support for residents’ nutritional needs are maintained. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - The Director of Nursing and Dietitian will conduct a review of the facility’s current process for obtaining and recording residents’ weights and re-weights. This review will be communicated to all Nursing Staff as an education in-service to ensure that weight is recorded or reported promptly and accurately. - The Administrator will provide in-service education to the Dietitian to ensure that weight loss is addressed promptly and effectively. This includes ensuring all relevant documentation is accurately recorded in the residents’ charts and that interventions to manage weight loss are implemented without delay. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: - The Dietician or Designee will develop an audit tool entitled, “Timely Recording of Weights/Re-Weights.” This audit tool will be used to monitor the weight of twenty (20) residents on a weekly basis for a duration of three (3) months. This process aims to ensure that weights and re-weights are recorded and reported in a timely manner. - The Director of Nursing or Designee will develop an audit tool entitled “Addressing Weight Loss Timely.” This audit tool will be utilized to review the weights of five (5) residents identified as experiencing weight loss during the weekly IDCP team weight management meetings. The audit tool will monitor whether dietary notes or medical provider recommendations regarding weight loss have been properly documented and addressed. This audit will be conducted weekly for three (3) months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Registered Dietitian. Responsible Person: The Administrator is the person responsible for ensuring all the above actions have been completed.
Failure to Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to ensure that a resident with severely impaired cognition and a history of [REDACTED] received appropriate positioning during meals, as per professional standards of practice. The resident, who was dependent on staff for all activities of daily living, including eating, was observed multiple times sliding down in their chair while being assisted with feeding. Despite the resident's diet being downgraded to pureed consistency with honey thickened liquids due to increased coughing and gagging, there were no interventions documented in the care plan regarding proper positioning during meals. Interviews with staff revealed that the resident had not been evaluated by occupational or physical therapy for chair positioning during feeding, and no devices were initially used to prevent the resident from sliding down. The Registered Nurse Unit Manager acknowledged the difficulty in feeding the resident and the lack of an upright position during meals. An Occupational Therapist confirmed that a screen for positioning had not been requested, although devices were available to assist with proper positioning. It was only after a family request and subsequent evaluation that a device was added to help prevent the resident from sliding down in the chair.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F684 Quality of Care I. Immediate Corrections - The Director of Rehab conducted a complete and thorough investigation into the resident’s plan of care regarding their positioning in the wheelchair during mealtimes. The Occupational Therapist assessed the resident during lunch on 2/27/2025 and added a positioning wedge under the front end of the cushion to help prevent them from sliding down in the wheelchair. - The CNA was educated regarding the positioning wedge and how to ensure the resident was properly positioned in the wheelchair. The nurse and RN supervisor were also provided with an in-service on the use of the device. II. Plan of Correction to identify other areas potentially affected - The Director of Rehab reviewed all residents in the facility positioning during mealtimes to ensure all were safely and appropriately positioned and all positioning devices (have orders and) were included in the comprehensive care plans. - In-service was also provided to all CNAs assigned to each resident. Respectfully, no other residents were identified to have been affected at this time. III. Systemic Changes - The policy for positioning was reviewed and found to be compliant with the regulations. The licensed nurses, CNAs, and licensed therapists were educated on the updated policy and the need to ensure all devices are in place in the care plans to reflect the condition of the residents. A copy of the lesson plan and attendance sheets will be kept on file for validation. IV. Quality Assurance Monitoring - The Director of Rehab/designee will perform monthly audits for the positioning of residents during mealtimes on all units x 3 months, then quarterly thereafter to ensure residents are properly positioned, any positioning devices are in place, and care plans are accurate and reflect the services required by the residents. Any outstanding issues will be corrected on site by the auditor. - All audit findings will be reported to the Administrator and QA committee. Responsible Party: Director of Rehab/Designee
Incorrect Exit Signage in Egress Path
Penalty
Summary
The facility failed to ensure that the means of egress was clearly marked to indicate the direction of travel to the nearest exit. Specifically, the exit sign with directional arrows between the elevator and the recreation room on the B wing indicated a path of travel through a separate occupied space, the daycare. This issue was observed on one of the four resident floors during a survey conducted on February 25, 2025, at 1:55 PM. The Director of Maintenance acknowledged the incorrect signage during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 K293 – Exit Signage I. Immediate Corrections The facility removed the directional arrow on the exit sign installed between the elevator and recreation room on the B wing indicating the path of travel through the Daycare Center. Work completed (MONTH) 12, 2025 II. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for the same deficiency. None were identified. Work completed: (MONTH) 14, 2025 III. Systematic Changes The facility maintenance and repairs were reviewed; it was determined that no changes were needed to the policy. The Director of Plant Operations will provide in-service education to all maintenance staff. All participants will understand the safety issues with NFPA Life Safety Code 2012 7.10.2, with a focus on exit signs, maintenance, and inspections. Work completed: (MONTH) 14, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that exit and directional signs are displayed in accordance with NFPA Life Safety Code 2012 7.10.2. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee
Failure to Ensure Continuous Illumination in Egress Pathway
Penalty
Summary
The facility failed to ensure continuous illumination in the means of egress as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the wall-mounted light switches in the fifth-floor dining room, when turned off, extinguished all lights in the room. This room contained an emergency stairwell exit, which should have been continuously illuminated. This deficiency was noted on one of the three resident floors. During an interview, the Director of Maintenance acknowledged the issue and stated that the lights in the rooms would be continuous.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 K281 – NFPA 101 Illumination of Means of Egress I. Immediate Corrections: The manual operated wall mounted light switches in fifth floor dining room were removed, allowing all lights in the room to be on continuously. Work completed (MONTH) 4, 2025. II. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Plant Operations inspected all areas throughout the facility for the same deficiencies. No additional instances of non-compliant were found. Work completed (MONTH) 6, 2025. III. Systemic Changes The Policy relating to Illumination of Means of Egress was reviewed and it was determined that no changes were needed to the policy. All maintenance staff will be provided with in-service education by the Director of Plant Operations on the policy relating to Illumination of Means of Egress with a focus on the importance of ensuring that Illumination of the Means of Egress were installed and maintained in accordance with 7.8. Work completed: (MONTH) 6, 2025. IV. QA Monitoring The Director of Plant Operations will develop an audit tool to verify that Means of Egress were installed and maintained in accordance with 7.8. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee
Inadequate Supervision and Maintenance Lead to Resident Incidents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents for two residents, leading to incidents involving elevator doors and access to a housekeeping closet. One resident, with a history of Alzheimer's Disease and right hip surgery, experienced two separate incidents where they were bumped by elevator doors, causing pain and discomfort to their right hip. Despite the resident's severe cognitive impairment and history of hip replacement, the facility did not ensure that the elevator sensors were functioning properly or that the incidents were promptly reported to the Director of Support Services for maintenance intervention. Another resident, with severe dementia and a history of wandering behaviors, was found inside a housekeeping closet due to a malfunctioning door striker plate. The resident, who was at high risk for elopement, was able to access the closet because the door could not close and lock properly. This incident occurred despite the resident's known wandering behaviors and the facility's policy to maintain a safe environment free from accident hazards. The facility's failure to maintain a safe environment and provide adequate supervision resulted in these incidents. The lack of communication and timely reporting of the elevator incidents to the appropriate maintenance personnel further contributed to the deficiency. Additionally, the unsecured housekeeping closet posed a significant risk to the resident with wandering behaviors, highlighting the need for proper maintenance and monitoring of facility areas to prevent similar occurrences.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 F689: Free of Accidents, Hazards, Supervision, Devices I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 had a pain assessment completed on 1/31/25 which indicated he did not have any pain. Resident #1 receives a pain screen completed every shift and has PRN APAP ordered that can be administered if needed. Resident #3 is non-ambulatory, requires extensive assistance from staff for ADL care/mobility (since last readmission on 12/17/24), and is no longer an elopement risk. His elopement assessment was updated on 1/31/25, along with his comprehensive care plan to reflect the changes in his medical status and low elopement risk. II. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. Specific to resident #1, a work call was placed to Otis to have the elevator sensors inspected and cleaned, which was completed on 1/15/2025. House-wide education is in progress for all staff on reporting accidents and incidents through the appropriate chain of command, ensuring notification is made to the highest-level supervisor in the facility. Nursing Supervisors have been re-educated to immediately notify the Director of Support Services, or designee, via phone and email if an accident/incident occurs involving equipment that is not maintained by nursing. Specific to resident #3, all locked housekeeping closet doors have been checked, with no other striker plates found to be loose or otherwise malfunctioning, which could lead to recurrence. III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Routine maintenance/cleaning of the elevator sensors have been added to the Otis monthly preventative maintenance schedule. Incident and Accident Reports (I&As) are discussed the business day following the occurrence during the Interdisciplinary Team (IDT) morning meeting/clinical meeting. This ensures that follow-up has been communicated and completed. The Director of Nursing Services will complete an audit weekly for 12 weeks of all I&As to ensure no follow-up is omitted or missed during the IDT's review. Results will be presented to the QAPI committee monthly. The Director of Support Services, or designee will conduct audits twice daily to ensure locked housekeeping closets are secure and no other striker plates were loose, malfunctioning, or presented danger to residents. These audits will be completed for a period of at least 90 days post incident, seven days a week. Results will be presented to the QAPI committee monthly. Education is in progress with all nursing staff on Incident & Accident notification process for significant occurrences. This training will also be included in new care member orientation for all new staff. IV. How will corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of the locked housekeeping door audit and the I&A audit are given to the Director of Support Services and Director of Nursing Services, respectively, for review, and are also presented to the QAPI committee monthly. The QAPI committee will determine when substantial compliance has been achieved, and when the audits can be discontinued, frequency changed, or if they should continue as currently scheduled. V. The date for correction and the title of the person responsible for correction of each deficiency? Date Certain - 3/17/2025 Person Responsible - Director of Support Services
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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