Fishkill Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Beacon, New York.
- Location
- 22 Robert R. Kasin Way, Beacon, New York 12508
- CMS Provider Number
- 335750
- Inspections on file
- 24
- Latest survey
- December 26, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fishkill Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and high fall risk was not provided with adequate fall prevention interventions, despite being identified as high risk. Staff observed the resident attempting to get out of bed prior to a fall that resulted in injury, but necessary safety measures such as frequent monitoring and use of floor mats were not consistently implemented or documented. Inconsistent communication and documentation among staff contributed to the resident sustaining harm from a fall.
A resident with severe cognitive impairment suffered a fall resulting in facial and head injuries. Facility staff attempted to notify a family representative but contacted the wrong person and left only a voicemail, with no documented follow-up or attempts to reach other listed contacts. The correct representative was not informed of the incident until they visited the facility over a month later, despite the facility's policy requiring timely notification after significant changes in condition.
Two residents with cognitive impairment did not have their care plans reviewed or updated in accordance with required assessment schedules. Although goals and interventions were documented, there was no evidence that these were evaluated for effectiveness or that updates were made based on recent assessments. Staff interviews revealed inconsistencies in care plan documentation and transfer of meeting notes within the electronic medical record system.
The facility failed to test all components of the fire alarm system annually, specifically omitting hold open devices and magnetic release mechanisms, as required by NFPA standards. This was identified during a documentation review, and the Director of Maintenance acknowledged the oversight.
The facility did not ensure staff were offered the COVID-19 vaccine or provided with education on its benefits and risks. During a survey, it was found that ten staff members, including dietary aides, housekeeping staff, CNAs, LPNs, RNs, social workers, dining supervisors, and cooks, were not documented as having been offered the vaccine or educated about it. The facility's policy required offering the vaccine and posting signage, but no such signage was observed. Interviews revealed a lack of vaccine offers due to perceived disinterest and inadequate tracking of vaccine status.
The facility did not ensure that corridor doors to hazardous areas resisted smoke passage as per NFPA 101 standards. During a survey, it was found that storage room doors on one resident floor did not latch properly, with one door missing a knob and latching mechanism. The Director of Maintenance acknowledged the issue.
The facility did not ensure a safe, clean, and homelike environment in the North 2 unit, with issues such as broken tiles, a cracked wall, and a hanging curtain. A resident complained of feeling cold due to an open hallway window, despite the room thermometer reading 74 degrees. Staff were unaware of who opened the window, and the Maintenance Director cited ongoing renovations and issues with the shower drain.
The facility did not ensure that CNA performance reviews were conducted at least once every 12 months for three CNAs hired in 2017, 2018, and 2020. The Human Resource Director was unaware of the oversight, and the Assistant Administrator and Assistant Director of Nursing were unsure why the reviews were not completed. This deficiency was identified during a recertification survey.
A resident with a history of chronic conditions was mistakenly given methadone instead of their prescribed medication due to a nurse's failure to verify the resident's identity and medication details. Despite having identification methods in place, the nurse was distracted by alarms and did not follow the facility's medication administration policy, leading to the resident's transfer to a hospital for evaluation.
A facility failed to develop a comprehensive care plan for a resident with limited range of motion, specifically regarding the use of a cervical collar. Despite physician orders to monitor skin and maintain the collar, no care plan addressed these needs. Observations confirmed the resident consistently wore the collar, but the RN Unit Manager admitted the absence of specific goals and interventions. This deficiency was noted during a recertification survey.
The facility failed to ensure proper disposal of garbage and refuse, as the dumpster was left open with cardboard boxes inside, and the compactor was filled with old furniture. Old furniture, large metal containers, and debris were scattered around the dumpster. The maintenance department was responsible for this oversight, and the Director of Maintenance stated that the compactor was full and awaiting emptying, while the Food Service Director confirmed they were not responsible for the dumpster's condition.
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Unlabeled and outdated beverages were found in the nutrition and storage refrigerator, and an open parcel of flour was left unsealed on a shelf. The Cook Supervisor and Food Service Director acknowledged these lapses, citing staffing shortages as a contributing factor. The facility's policy requires proper labeling and dating of food items, which was not followed.
The facility did not ensure that two residents were offered pneumococcal immunizations or received education about them. Both residents, who were cognitively impaired and dependent on staff, lacked documentation of being offered the vaccine or receiving education. The DON, responsible for the vaccine program, admitted to not monitoring or tracking the vaccine information closely.
A resident experienced multiple omissions in the documentation of pain management medications and treatments, with no reasons provided for these omissions. The resident, who had a care plan for pain management, reported ongoing pain despite receiving some medication. The RN Unit Manager and DON acknowledged the omissions and emphasized the need for proper documentation.
The facility failed to maintain residents' dignity by serving beverages in plastic storage cups with lids, despite residents' preference for hard plastic cups. Additionally, a CNA referred to a resident with severe cognitive impairment as a "feeder," a term also found in the resident's progress notes. The CNA later acknowledged the inappropriateness of the term, and the DON confirmed it is unacceptable in the facility.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident identified as high risk for falls. The resident, who had diagnoses including cerebral infarction, aphasia, altered mental status, and severe cognitive impairment, was assessed as a high fall risk based on the facility's fall risk assessment protocol. Despite this, the resident's care profile did not reflect fall precautions, and interventions such as 30-minute safety checks and floor mats were either not implemented or not documented as required by facility policy. Staff interviews revealed that the resident was observed attempting to get out of bed prior to the fall, with half of their body hanging off the bed, but this observation did not result in additional interventions or updates to the care plan. The resident was dependent for bed mobility and transfers, and staff had varying perceptions of the resident's ability to move or self-transfer. On the night of the incident, the resident was found on the floor with injuries including a swollen eye, hematoma, and a scratch, after reportedly attempting to get out of bed to retrieve belongings. The facility's documentation and communication regarding fall risk interventions were inconsistent, with some staff unaware of the resident's increased risk and others noting that required safety measures were not in place or not documented. The facility's fall risk intervention protocol required immediate implementation of prevention measures for residents with high fall risk scores, but the resident's care plan and care profile were not updated accordingly. The lack of documentation and failure to implement or communicate appropriate interventions contributed to the resident sustaining actual harm from a fall. The deficiency was substantiated by observations, record reviews, and staff and representative interviews, which highlighted lapses in supervision, care planning, and adherence to established safety protocols.
Failure to Notify Correct Family Representative After Resident Injury
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant change in the resident's physical condition. Specifically, after a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction and altered mental status, experienced a fall resulting in injuries to the face, eyes, and head, the facility did not promptly inform the correct family representative. The initial attempt to notify was made by calling the first contact listed on the resident's face sheet, but this was not the correct representative, and only a voicemail was left. There was no documented evidence of follow-up attempts or efforts to contact other listed representatives when the initial call was not returned. Interviews with staff revealed that the wrong contact was repeatedly called, and the correct representative was not informed of the incident until they visited the facility over a month later. The care plan for the resident included interventions to ensure safety and communication, but these were not effectively implemented regarding family notification. The facility's own policy required notification of family or significant others in the event of an accident or incident, but this was not followed, as evidenced by the lack of timely and appropriate communication with the designated representative.
Failure to Review and Update Cognitive Care Plans as Required
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed, updated, and revised for two out of three residents reviewed for care planning. Specifically, one resident with severe cognitive impairment and another with moderate cognitive impairment had care plans for impaired cognition that had not been reviewed or updated in accordance with the most recent comprehensive or quarterly assessments. The care plans contained goals and interventions, but there was no documented evidence that these were evaluated for effectiveness or that goals were met, as required by facility policy. Interviews with facility staff revealed that the responsibility for updating cognitive care plans typically falls to the Social Worker, who stated that updates are supposed to occur quarterly, annually, and with any significant changes. However, discrepancies were noted between the dates of care plan reviews in the electronic medical record and the actual care plan meeting documentation. The Social Worker and DON acknowledged that care plan updates were not consistently reflected in the system, and meeting notes were not always properly transferred to the care plan documents.
Fire Alarm System Testing Deficiency
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were tested annually, as required by the 2012 NFPA 101 and 2010 NFPA 72 standards. Specifically, the annual vendor service report for the fire alarm system for the year 2024 did not include testing of hold open devices and magnetic release mechanisms. This omission was identified during a documentation review, where it was noted that the maintenance logs lacked evidence of these components being tested. The fire alarm system was last serviced on March 25, 2024. During an interview conducted at the time of the finding, the Director of Maintenance acknowledged the oversight and stated that the vendor would be contacted to address the issue. The absence of testing for these specific devices was a clear deviation from the required standards, as outlined in the NFPA codes and New York Codes, Rules, and Regulations (NYCRR). The deficiency was based on observations, staff interviews, and record reviews conducted during the survey.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 All residents, staff, and visitors have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or designee conducted a facility-wide audit and notated where all hold-open and magnetic release mechanisms are located. On 2/12/2025, the Director of Environmental Services or designee called the vendor to perform an annual test on all door holders and magnetic release mechanisms now and on an annual basis. Testing was completed on 2/14/2025. The Director of Environmental Services or designee will update a contract with the vendor to include the annual inspection of all hold-open and magnetic release mechanisms. The contract was received and signed on 2/13/2025. On 2/14/2025, the Director of Environmental Services or designee will educate the Maintenance staff on which elements the contractor should check when performing the annual inspection. The Director of Environmental Services or designee will report the findings of the annual testing of the door holders and magnetic release mechanisms in QAPI. Responsible party: Director of Environmental Services or designee.
Failure to Offer and Educate Staff on COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the most recent COVID-19 vaccine, and provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025, where it was found that there was no documented evidence that COVID-19 vaccination was offered or that education was provided to ten staff members, including dietary aides, housekeeping staff, certified nurse aides, licensed practical nurses, registered nurses, social workers, dining supervisors, and cooks. The facility's policy, dated November 30, 2024, stated that consenting personnel would be offered the opportunity to receive the COVID-19 vaccine, and signage would be posted throughout the facility to remind personnel and residents of this offer. However, during the survey, no such signage was observed, and the facility could not provide documentation of vaccine offers or education. Interviews conducted during the survey revealed further issues. A licensed practical nurse stated they were not offered the COVID-19 vaccine and had not heard about it, although they would have consented if it had been offered. The Assistant Director of Nursing admitted to not offering the COVID-19 vaccines due to perceived lack of interest among staff, despite acknowledging the importance of staff education on vaccines. The Director of Nursing also admitted to not closely tracking vaccine status for staff and residents and was unaware of the missing signage. These inactions and lack of documentation contributed to the facility's failure to comply with the requirement to offer and educate staff about the COVID-19 vaccine.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F887 Ss=E The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Employee health nurse/ ADON is offering most recent covid 19 vaccinations with education pamphlet regarding benefits, risks and potential side effects associated with vaccine to all eligible staff members. Consent / declination forms and education are logged by Employee Health nurse/ ADON. Dietary aide #15, housekeeping #16, CNA #17, #18, #20, LPN #19, RN #21, Social work #22, Dining supervisor #23 and cook #24 have been provided education pamphlet on covid vaccine and consent/ declination logged week completed 2/25/25. All STAFF have the potential to be affected by this practice - Audit for all staff employed by the facility who are eligible for covid vaccine and are being provided with education/ information pamphlet, consent and declinations are being obtained. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Management of covid 19 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The Director of nursing will educate the assistant director of nursing/ employee health nurse on covid vaccines, providing education/ information pamphlet and proof of consent or declination. - The Assistant director of nursing/employee health nurse will ensure staff who were offered the covid vaccine were educated and documentation of refusal or consent is logged. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/ infection preventionist/ Designee will perform an Audit for all staff employed in the facility who are eligible for covid vaccine and are being provided with education/ information pamphlet, consent and declinations are being obtained. Eligible staff will be audited weekly for 3 months. Audit for new hires will be done weekly x 3 months. Any discrepancies will be reported to Administrator and immediately corrected, staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors to hazardous areas were able to resist the passage of smoke as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the kitchen storage room opposite the kitchen and the storage room within the kitchen did not latch when tested to self-close. Additionally, the storage room within the shower enclosure was missing a door knob and latching mechanism, preventing it from latching properly. These deficiencies were noted on one of the two resident floors. The Director of Maintenance acknowledged the issue during an interview conducted at the time of the findings.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or Designee adjusted the self-closing mechanisms on 2 of the 3 doors cited in order for the doors to positive latch as per NFPA 101. The Director of Environmental Services or Designee installed the new hardware (doorknob) on the 3rd of 3 doors for the storage room within the shower enclosure to ensure it has a positive latch. On 2/12/2025, the Director of Environmental Services or Designee conducted an audit of all dietary closets with self-closing mechanisms as well as the doors to all 4 storage rooms in the shower enclosures (1 on each unit) to ensure all are in working order as per NFPA 101. Those found deficient will be repaired. On 2/14/2025, the Director of Environmental Services or Designee will educate all maintenance staff on how to properly check doors for positive latch. Starting on 2/14/2025, the Director of Environmental Services or Designee will audit the 3 doors that did not self-latch weekly for 1 month (4 weeks) then monthly for 3 months to ensure the doors are self-latching. All findings will be repaired and reported in QAPI. Responsible party: Director of Environmental Services or designee.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in the North 2 unit, as observed during a recertification survey. Specific deficiencies included broken tiles in rooms X6 and X3, a cracked wall in room V1, and a hanging curtain in room S3. Additionally, the shower room had a damaged drain, and the hallway window near room V3 was left open, causing a resident to complain of feeling cold despite the room thermometer reading 74 degrees. The Maintenance Director acknowledged ongoing renovations and issues with the shower drain, attributing the problem to the weight of some residents. Interviews with staff revealed a lack of awareness regarding the open hallway window, with certified nurse aides and a registered nurse unable to identify who opened it. The registered nurse suggested it might have been opened for fresh air after care was provided but acknowledged it should have been closed. The absence of a documented work order logbook for repairs further highlighted the facility's failure to maintain a homelike environment, as required by regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 All Residents, Visitors, and staff have the potential to be affected by the deficient practice. On 2/12/2025, the Director of Environmental Services or designee repaired the curtain in room S3. On 2/12/2025, the Director of Environmental Services or designee patched the crack by the window in room X1. On 2/14/2025, the Director of Environmental Services or designee locked the windows on the corridor where V3 window is located to ensure that the window does not open and V3 does not get a draft. On 2/12/2025, the Director of Environmental Services or designee affixed the tiles in room X3 where they were coming loose. On 2/12/2025, the Director of Environmental Services or designee patched the scuffs under the window in room V1. On 2/14/2025, the Director of Environmental Services or designee hired a company to replace the floor in room X6. On 2/12/2025, the Director of Environmental Services or designee permanently affixed the drain cover to the north 2 shower drain. The Director of Environmental Services or designee will conduct monthly checks for 6 months in rooms S3, X1, X3, X6, V1, V3, and the shower room to ensure that the repairs that were made continue to hold their integrity. All findings will be discussed during QAPI.
Failure to Conduct Timely CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were conducted at least once every 12 months, as required. Specifically, three CNAs, hired in 2017, 2018, and 2020, did not have documented performance reviews within the last 12 months. During interviews, the Human Resource Director acknowledged that unit supervisors were responsible for completing these reviews and that they should be filed in employee folders. However, the director was unaware that the reviews for these CNAs had not been completed. The Assistant Administrator was also unsure why the reviews were not conducted, and the Assistant Director of Nursing, who had previously assisted with these reviews, believed they had been completed. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F730 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: - The performance reviews for Certified nurse aide #2, #3, #4 were completed on 2/17/25. The human resource director audited all current Certified nursing assistants to ensure performance reviews in place. No additional occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Director of nursing and administrator reviewed staff performance review policy with no revisions needed. - The Director of human resources was educated on criteria that performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews. - The director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - The director of Human Resources/ designee will keep a running log of all certified nursing assistants eligible for performance review and ensure they are filed in employee folders once completed. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. - The Director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - Any discrepancies will be reported to administrator and immediately corrected. - The results of the Audit will be reported at monthly QAPI.
Significant Medication Error Due to Nurse's Failure to Verify Resident Identity
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered a medication not prescribed by their physician. The resident, who had a medical history including Chronic Hepatitis C, Diabetes Mellitus, and Liver Cirrhosis, was mistakenly given methadone, a narcotic medication, instead of their prescribed medication. This error occurred despite the presence of multiple identification methods, such as an identification band, photo identification, and room label, which were not adequately utilized by the administering nurse. The incident unfolded when a registered nurse, distracted by alarms from a tube feeding pump, administered methadone to the wrong resident. The nurse failed to follow the facility's medication administration policy, which requires verifying the resident's identity and medication details before administration. The nurse did not check the resident's identification band or photo identification and did not confirm the resident's name against the medication label, leading to the administration of methadone to the resident. Upon realizing the error, the nurse reported it to the charge nurse, and the resident was subsequently evaluated by the facility's nurse practitioner. The resident, who was alert and oriented, was transferred to a local hospital for evaluation and observation. The Director of Nursing considered this a significant medication error and initiated an investigation, confirming that all identification and medication labeling protocols were in place but not followed by the nurse.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F760 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. The nursing staff on unit where resident # 399 resides received education on medication administration, ensuring all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel, Date 2/25/25. Resident # 399 was discharged from facility on 5/8/25, and sent to ER no issues found related to medication error. All residents have the potential to be affected by this practice - Nurse #9 no longer works at the facility - 8 nurses observed during medication pass on 2/25/25. All were noted to follow the policy on verifying the resident and medications. No occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled medication administration dated 4/20/21 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on medication administration, ensuring all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel. No occurrences found. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/ Designee will perform an Audit for medication administration 5 times per week for random shift to check that all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel x 3 months. Any discrepancies will be reported to Administrator and immediately corrected, staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Lack of Comprehensive Care Plan for Resident with Cervical Collar
Penalty
Summary
The facility failed to ensure the development of a comprehensive person-centered care plan for a resident with limited range of motion, specifically regarding the use of a cervical collar. The resident, who was admitted with multiple diagnoses including fractures, was noted to have severely impaired cognition and required maximum assistance for activities of daily living. Despite the presence of a physician's order to monitor the skin and maintain the cervical collar, there was no evidence of a care plan addressing the fractures, positioning, cervical collar use, or skin integrity monitoring. Observations during the survey period confirmed that the resident consistently wore a cervical collar while in a wheelchair and in bed. However, the Registered Nurse Unit Manager acknowledged the absence of a care plan with specific goals and interventions for the cervical collar. Although an assessment documented the fractures, no new goals or interventions were added following the resident's most recent admission. This oversight was identified during the recertification survey, highlighting a deficiency in the facility's compliance with its policy on comprehensive care planning.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F656 ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. What corrective actions will be accomplished for the resident found to have been affected by the deficient practice: - Nurse manager #10 was educated on identification of residents who have splints, braces, casts, immobilizers or cervical collars. Including care plan initiation, appropriate measurable goals and interventions to ensure residents identified have limited range of motion or potential for in place. - The resident #37 care plan was developed to specifically state limited range of motion due to cervical collar for c2 fracture on 2/24/25. How the facility will prevent occurrence from happening to other residents having the potential to be affected by same deficient practice: - All Residents have the potential to be affected by this practice. Any resident with splint, brace, cast, immobilizer or cervical collar, medical records were audited to ensure limited range of motion or potential for was care planed with appropriate goals and interventions. No occurrences found. This audit was completed by the DON/ADON on 2/25/25. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The policy titled, “Comprehensive care” was reviewed by the Director of Nursing and Administrator on 2/25/25. No changes indicated. - The Director of Nursing/Designee will educate the Unit Managers, Supervisors, administrator and Charge Nurses on the policies “Comprehensive care” completed 2/25/25. - The Director of Nursing/Designee will educate the Unit Managers, Supervisors, administrator and Charge Nurses on identification of residents who have splints, braces, casts, immobilizers or cervical collars. Including care plan initiation, appropriate measurable goals and interventions to ensure residents identified have limited range of motion or potential for in place. How facility plans to monitor performance to make sure the solutions are sustained: - To ascertain the effectiveness of the education an audit was developed. - DON/Designee will audit all new admission care plans with splint, brace, cast, immobilizer or cervical collar to ensure limited range of motion or potential for x 30 days then weekly x 2 months. - The Director of Nursing/Designee will perform chart Audit weekly on 10% of resident population care plans to ensure residents with splint, brace, cast, immobilizer or cervical collar to ensure limited range of motion or potential for was added to care plan x 3 months. Any discrepancies noted will be immediately rectified and re-education will be provided to appropriate licensed person by Director of Nursing/Designee. - The results of the Audit findings will be reported at monthly QAPI by the DON/designee for trending and analyzing for no less than 3 months or until the facility demonstrates sustained compliance as determined by committee.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. The facility's policy required all garbage and rubbish containers to have tight-fitting lids and to be kept covered when stored. However, during an observation, the dumpster was found open with cardboard boxes inside, and the compactor was filled with old furniture and left open. Additionally, old furniture, large metal containers, and debris were scattered on the ground around the dumpster. Interviews revealed that the maintenance department was responsible for ensuring the dumpster was closed and the area was free of garbage. The Director of Maintenance stated that the compactor was full, and they were waiting for the company to empty it, which would not happen until later. They also mentioned that the large metal containers were donations awaiting pick-up, and the old furniture was on the ground due to ongoing renovations. The Food Service Director confirmed that they were not responsible for the dumpster's condition and had reported concerns to the Maintenance Director.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. - 2/14/2025: The Director of Environmental Services or designee called the contracted sanitation company to empty and return the open-top construction container. - 2/24/2025: The Director of Environmental Services or designee will dispose of the debris that was around the overfilled open-top construction container. - 2/14/2025: The Director of Environmental Services or designee called the contracted sanitation company to repair/replace the cover for their recycling container so the facility can keep them closed. - 2/14/2025: The Director of Environmental Services or designee will begin educating all Maintenance, Housekeeping, and Dietary staff on ensuring that the 8-yard recycling container stays covered as well as the door for the compactor stays closed. - 2/14/2025: The Director of Environmental Services or designee will educate the Maintenance department on not overfilling the open-top container. - The Director of Environmental Services or designee will perform monthly checks on the open-top construction container to ensure it is not overfilled. The findings will be rectified and discussed during QAPI for 6 months. - The Director of Environmental Services or designee will perform weekly checks at random times and days to ensure that the cover for the recycling bin is being closed after being utilized. The findings will be rectified and discussed during QAPI for 6 months. Responsible party: Director of Environmental Services or designee.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety, as observed during a recertification survey. During an initial tour of the kitchen, surveyors found several unlabeled 4-ounce cups filled with white, brown, and thickened yellow liquids in the nutrition and storage refrigerator. These liquids were dated 2/4 and 2/10, respectively, and were identified by the Cook Supervisor as [MEDICATION NAME] milk, prune juice, and smoothies. The Cook Supervisor acknowledged that the [MEDICATION NAME] milk and prune juice were outdated and should have been discarded after three days, but they remained in the refrigerator due to staffing shortages over the weekend. Additionally, an open parcel of all-purpose flour was found on a shelf, unsealed and undated, contrary to the facility's policy. The Food Service Director confirmed that the [MEDICATION NAME] milk and prune juice should have been labeled and discarded after three days, and the flour should have been sealed. The facility's policy, dated 6/26/2028, requires that dry foods be removed from their original packaging, labeled, and dated, and that beverages be dated when opened and discarded after three days. These lapses in food storage practices were in violation of the facility's own policies and professional standards for food service safety.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F812 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. All outdated food identified was immediately removed and discarded. Audit of all food was performed to ensure food is stored in accordance with professional standards for food service safety. Cook supervisor #11 was educated on food receiving and storage. No additional occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Food receiving and storage was reviewed by Director of Dietary and Administrator on 2/28/25, with no revisions needed. - The Director of Dietary food services was in-serviced on dating, discarding and storage of consumable items. - The Director of Dietary/designee will educate all dietary staff on dating, discarding and storage of consumable items. - The Director of Dietary/designee will audit to ensure all foods are dated and properly discarded daily x 1 month, then weekly x 3 months. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Dietary/Designee will perform an Audit to ensure all foods are dated and properly discarded daily x 1 month, then weekly x 3 months. Any discrepancies will be reported to Administrator and immediately corrected. The results of the Audit will be reported at monthly QAPI.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey for two residents. Resident #9, who had a diagnosis of [DIAGNOSES REDACTED], was cognitively impaired and dependent on staff for daily activities. There was no documented evidence that this resident or their representative received education about, was offered, or declined the pneumococcal vaccine. Similarly, Resident #50, with a diagnosis of [DIAGNOSES REDACTED] and severe cognitive impairment, also lacked documentation of being offered the vaccine or receiving education about it. The Director of Nursing, who also served as the Infection Preventionist, acknowledged during an interview that they were responsible for the vaccine program and documentation of each resident's vaccine status upon admission. However, they admitted to not closely monitoring the pneumococcal vaccines for residents and failing to track the vaccine information. This oversight led to the deficiency, as the facility did not adhere to its policy of offering pneumococcal vaccinations to all residents to prevent the spread of infectious disease and mitigate associated risks.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F883 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Residents #9 and #50 were reviewed and offered education to resident or primary advocate on pneumococcal vaccine with documentation provided that residents #9 and #50 received pneumococcal vaccine in house on 2/19/25. All residents have the potential to be affected by this practice - Audit for all residents residing in the facility who are eligible for pneumococcal vaccine and are being provided with education/information pamphlet, consent and declinations are being obtained. No additional issues found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Pneumococcal vaccine was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/infection preventionist will educate the unit managers and charge nurses on pneumococcal vaccines, providing education/information pamphlet and proof of consent or declination. - The director of nursing/infection preventionist will ensure residents who were offered the pneumococcal vaccine were educated and documentation of refusal or consent is logged. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/infection preventionist/Designee will perform an Audit for all residents residing in the facility who are eligible for pneumococcal vaccine and are being provided with education/information pamphlet, consent and declinations are being obtained. Eligible residents will be audited weekly for 3 months for long term residents. Audit for new admission will be done weekly x 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Omissions in Pain Management Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan for pain management. Specifically, there were multiple omissions in the medication and treatment administration records for medications and treatments related to pain management for a resident. The resident, who was admitted with diagnoses including pain, had a comprehensive care plan that documented potential and intermittent pain related to activity level, with instructions to monitor for pain, administer medication as ordered, and monitor the effectiveness of medications. However, the Treatment Administration Record showed omissions for a prescribed cream on several dates, and the Medication Administration Record also had omissions for other pain medications, with no documented evidence explaining the reasons for these omissions. During interviews, the resident expressed experiencing pain and stated that they had received some pain medication but were still in pain. The resident later mentioned that their pain management was overall effective with the prescribed medications but believed they were in pain due to overexertion in therapy. The Registered Nurse Unit Manager acknowledged the omissions and stated that the medication nurse should have documented the reasons for not administering the medications. The Director of Nursing confirmed the expectation of no omissions in the medication or treatment administration records and stated that if a medication was not administered, the reason should be documented.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F684 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Nurse manager #10 and the nursing staff on unit where resident #15 resides received education on medication administration, ensuring all medications are signed for in MAR/TAR and no omissions present, Date 2/25/25. Resident #15 was discharged from facility on 2/20/25, no issues related to noted omissions found. All residents have the potential to be affected by this practice - All residents MAR/TAR were audited on 2/25/25 for omissions, no occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled medication administration dated 4/20/21 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on medication administration, ensuring all medications are signed for in MAR/TAR and no omissions present. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/Designee will perform an Audit for medication administration 5 times per week for random shift to check for omissions x 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
Dignity Violation: Inappropriate Beverage Service and Terminology
Penalty
Summary
The facility failed to maintain residents' dignity by serving milk and water in plastic storage cups with lids across four units. Observations during the survey period revealed that residents were consistently served beverages in these cups, despite their preference for hard plastic drinking cups. During a Resident Council Meeting, all ten residents expressed their dissatisfaction with the storage cups, preferring the hard plastic ones. The Food Service Director admitted to using storage cups due to portioning needs and was unaware that this practice was inappropriate. The facility had a limited number of hard plastic cups, which were primarily stored in the main dining room, and there was a delay in receiving new orders of these cups. The Director of Rehabilitation also noted the difficulty residents faced using the storage cups and had discussed this issue with the Director of Nursing. Additionally, a Certified Nurse Assistant (CNA) referred to a resident with severe cognitive impairment and dependency on eating assistance as a "feeder" during an interview. This terminology was also found in the resident's progress notes. The CNA acknowledged the inappropriateness of the term after the interview and had previously received in-service training on dignity. The Director of Nursing confirmed that the term "feeder" is unacceptable in the facility and should not be used in verbal communication or clinical documentation.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F550 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. The residents observed drinking out of plastic cups on unit 4 of 4. Facility immediately removed plastic storage cups for drinking use from 4 of 4 units. Supply order of tumbler cups for all units. Residents updated on tumbler cup order through resident council and are pleased with solution - all residents will be provided with tumbler cup for each meal. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The director of dietary/designee will audit to ensure that plastic drinking cups will no longer be used for drinking. - Tumbler cups have been purchased for all residents. - A small emergency supply of additional tumbler cups was ordered to ensure they are always available. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed - The Director of dietary/Designee will audit 2 random meals per day to ensure tumblers are provided to nursing staff for each meal 5 x per week x 1 month, then weekly for 3 months. Any discrepancies will be reported to administrator and immediately corrected. The results of the Audit will be reported at monthly QAPI. 2. Certified nursing aide #7, the nursing staff and social worker on unit where resident #26 resides received education on resident rights and dignity specifically on the term “feeder” as being unacceptable and the correct language for residents who require assistance for feeding, Date 2/25/25. Resident care plan adjusted to reflect current levels of assistance required updated on 2/24/25. All residents have the potential to be affected by this practice - All residents requiring assistance with feeding during meals were observed during weeks 2/25/25 to 2/28/25 for use of improper terminology when assisting a resident with feeding, no occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Resident Rights was reviewed by Director of Nursing and Administrator on 2/24/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on assisting residents with meals with dignity and ensuring the correct terminology is used to identify the level of assistance the resident requires. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The DIRECTOR OF NURSING/DESIGNEE will audit progress notes of 5 residents who need assistance with meals weekly x 1 month, then monthly x 3 months to ensure proper terminology is used. The Director of Nursing/Designee will perform an Audit for Dining Room Observation during meal time to observe for appropriate terminology during meals. Random meal times during random days will be observed for 5 meals per week for 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.
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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