Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fort Hudson Nursing Center Inc during CMS and state inspections, most recent first.
The facility failed to inspect and test elevators in Building #1 according to required intervals, lacking documentation for inspections and necessary repairs. The administrator believed inspections were done but could not provide evidence. The facility also did not fully implement the Electronic Plan of Correction by the Credible Allegation Date, leading to a citation.
The facility failed to maintain adequate staffing levels, resulting in delayed call light responses and resident grievances. From December 1 to December 5, 2024, multiple shifts and units were understaffed, with significant shortages of CNAs and LPNs. Residents reported long wait times for assistance, and staff interviews confirmed that understaffing slowed care delivery. The Assistant Director of Nursing acknowledged the challenges in meeting call light response expectations due to the high number of residents requiring mechanical lifts.
The facility did not maintain exits in compliance with NFPA 101 Life Safety Code, as exit discharges in the G-wing and S-wing were not marked to clearly indicate the direction of egress travel to a public way. This was observed during a recertification survey, and the facility's administrator acknowledged the issue.
Exits in two wings were obstructed by snow and padlocks, impeding their use as required by NFPA 101 Life Safety Code. Maintenance staff shortages delayed snow removal, and staff were not trained to open the padlocks. The charge nurse was unaware of how to operate the padlock, highlighting a lack of preparedness in emergency situations.
A recertification survey revealed that the automatic sprinkler system was not installed under a cloth canopy attached to Building #3, as required by NFPA standards. The canopy, over 20 feet in length, lacked documented evidence of being fire-retardant. The facility's administrator mentioned that the canopy was installed in 2020 and they are seeking documentation from the vendor about its fire-retardant properties.
The facility did not maintain smoke barriers according to NFPA 101 standards. A hole in the G-wing east smoke barrier wall was filled with insulation but lacked proper fire protection. The Maintenance Supervisor acknowledged the issue and planned to address it.
Two residents were observed self-administering medications without documented assessments or physician orders, contrary to the facility's policy. One resident had a Proventil inhaler at their bedside, and another changed their oxygen tank and set the flow rate independently. Staff interviews revealed a lack of adherence to the facility's Medication Self-Administration Policy, which requires assessments and care plans for self-administration.
A resident's care plan in the facility failed to document the use of oxygen and nebulizer treatments, despite the resident being observed with oxygen and having orders for these treatments in the electronic health record. The resident, who was cognitively intact and had diagnoses including hypertension and atrial fibrillation, did not have these treatments included in their care plan as required by facility policy. Staff interviews confirmed the oversight, with the ADON acknowledging the expectation for the oxygen to be documented.
Two residents in the facility were found to have as-needed psychotropic medication orders without specified stop dates, contrary to policy. One resident received lorazepam for agitation multiple times without an end date, while another had an indefinite order for Risperidone despite a recommendation for a stop date. The Nurse Practitioner acknowledged the requirement for time-limited orders but did not implement it.
A resident's dietary preference to discontinue a collagen supplement, supported by a dietician's recommendation and physician's order, was not followed for 35 days due to an oversight in updating the electronic medical record. The RN unit manager acknowledged the error, and the DON expected compliance with signed dietary recommendations.
The facility failed to maintain accurate medical records for three residents, with inconsistent documentation of incontinence care, meal consumption, and supplement intake. Staff interviews revealed that documentation was not always completed in real-time, and there was confusion about documentation procedures. The facility's practices did not align with the expectations for accurate record-keeping.
The facility failed to maintain accurate and complete medical records for three residents, leading to deficiencies in documentation of care provided. A resident's incontinence care was not documented as required, and two other residents had incomplete documentation of meals, supplements, and snacks. Staff interviews revealed inconsistencies in documentation practices, and the Assistant Director of Nursing acknowledged a documentation issue.
The facility's emergency preparedness plan was found lacking provisions for earthquake, flood, or nuclear disaster, as required by New York State regulation. This deficiency was identified during a recertification survey, with no documented evidence of these provisions. The administrator acknowledged the oversight and planned to address it.
Elevator Inspection and Testing Deficiency
Penalty
Summary
The facility failed to inspect and test the elevators in Building #1 according to the required 12-month and 5-year intervals as specified by the American Society of Mechanical Engineers booklet A17-1 Safety Code for Elevators and Escalators 2004 Edition. Specifically, there was no documented evidence that the G Wing 1 and G Wing 2 elevators, the service elevator, and the dumbwaiter were inspected and tested during the years 2022 and 2024. Additionally, necessary repairs, such as the emergency phone and lighting circuit repairs for the G Wing 1 elevator, were not documented as completed. The service elevator also required a rupture test, which was not documented as conducted. During interviews, the facility's administrator expressed belief that the inspections and tests had been conducted but was unable to provide the necessary documentation. The facility also failed to ensure that the Electronic Plan of Correction was fully implemented by the Credible Allegation Date, as there was no evidence that the G Wing 1 elevator emergency phone was repaired or that a rupture test was conducted on the service elevator. This lack of documentation and failure to adhere to the required testing schedule led to the citation during the recertification survey.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 1. Elevator inspection reports demonstrate completion every six months for the past three years for each elevator (4). Proposal for all outstanding repairs accepted on 12/10/24 and is scheduled to be completed by P(NAME) completion date of 2/3/25. 2. No other elevators exist in the building. 3. Inspection and testing schedule to be developed to assure compliance with frequency, with all results provided directly to the Director of Plant Operations for review to assure recommended repairs are addressed in a timely manner. 4. Inspection, testing and repair information will be provided to the Quality Assurance/Performance Improvement Committee on a quarterly basis for one year, with frequency to be reassessed after one year based on overall compliance with frequency and repair follow up. Responsible Party: Director of Plant Operations
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, compromising their safety and well-being. From December 1 to December 5, 2024, the facility did not meet its minimum staffing levels for Certified Nursing Aides (CNAs) and Licensed Practical Nurses (LPNs) across multiple shifts and units. This staffing shortage was evidenced by delayed call light response times, resident grievances, and complaints about low staffing levels. Observations during this period showed significant delays in call light responses, with some residents waiting over 50 minutes for assistance. The facility's staffing plan, as per the assessment dated August 28, 2024, outlined specific numbers of full-time employees required per shift. However, records from December 1 to December 5, 2024, indicated consistent shortages in staffing across various wings and shifts. For instance, on December 1, 2024, the evening shift was missing several CNAs and LPNs across different wings, and similar shortages were noted on subsequent days. These deficiencies were further corroborated by resident grievances filed between February and September 2024, highlighting issues such as long wait times for assistance, inadequate toileting support, and poor care due to insufficient staffing. Interviews with residents and staff further illustrated the impact of these staffing shortages. Residents reported long wait times for assistance, sometimes exceeding an hour, particularly during meal times when staff were occupied with other residents. Staff interviews revealed that understaffing led to slower care delivery, as staff from other units, unfamiliar with the residents, had to cover shifts. The Assistant Director of Nursing acknowledged the challenges in meeting call light response expectations, citing the high number of residents requiring mechanical lifts and the lack of adequate space to accommodate them. These factors collectively contributed to the facility's failure to maintain adequate staffing levels, directly affecting the quality of care provided to residents.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. In the absence of resident-specific corrections to be made, the Administrator and/or Director of Nursing will meet with the Resident Council to review this Plan of Correction and request feedback. 2. All Customer grievances related to call bell response times over the last 12 months will be reviewed for trend identification to determine if there are root cause issues or common time/shifts/units, etc. If identified, focused action plans will be implemented. 3(a). The following strategies focused on staff recruitment and retention will continue to be implemented and continually adjusted based on response to address overall staffing levels. a. Aggressive recruitment campaign, including sign on bonus, referral bonus, tuition reimbursement, etc., with addition on 1/1/25 of new social media contract service. NOTE - agency nursing, including travel nurse resources are extremely scarce in rural areas. Several contracts are in place but unable to provide actual supplemental staff. Staffing requests remain pending and unfilled. Facility will review, screen and onboard agency staff that contracted agency finds. Current staff will continue to be offered significant shift bonuses (Up to $25 per hour differentials) for hard to fill shifts. b. Continued implementation of Nurse Aide training program, including evening classes (grant funded). c. Continued mentorship programs for newly hired Certified Nursing Assistants and Licensed Practical Nurses. d. Continued tuition reimbursement program (currently sponsoring 3 Licensed Practical Nursing students’ full tuition plus stipend for living expenses while in school). e. Incentive programs for longevity, attendance and other positive promotion strategies. 3(b). The following strategies will focus specifically on call light response times: a. Educational awareness program to be implemented for all clinical and support staff emphasizing the importance of call light response promptness. b. Review and revision of morning care routines for residents identified as consistently requesting assistance at predictable times with care plan adjustments as determined appropriate. c. Incorporate all staff, including ancillary department employees, with the responsibility to respond to call bells to address those issues and request within their scope of abilities, and communicate to nursing specific needs that may exist. d. No specific policy changes are indicated as this portion of the Plan of Correction focuses on staff awareness and education, combined with objective assessment of care delivery routines. 3(c). The Facility Assessment will be reviewed and updated to more clearly assess and articulate: a. Optimal staffing levels vs. minimally appropriate levels based on acuity and related variables required for appropriate resident care. b. Appropriate staffing adjustments based on census (as current Assessment and basis for deficiency is based on 100% occupancy but facility is not operating at that level). c. Recognition of support staff, reassigned staff, and other resources routinely accessed but not evident on daily staffing sheets. 4. Overall staffing levels by unit will be summarized daily and compared to the Facility Assessment optimal and minimally appropriate levels. Summarized and reported to Quality Assurance & Performance Improvement Committee monthly for six months. Total number of new hires and terminations for Certified Nursing Assistants and Licensed Practical Nurses, and overall turnover rates to be summarized monthly and reported to Quality Assurance & Performance Improvement for six months. No fewer than 5 visual observation audits (call bell response time) on different units and/or different times of day will be conducted weekly to measure call light response time. Audits will occur weekly for 3 months, followed by 10 audits per month for three months. Audit results to be reviewed by Quality Assurance & Performance Improvement Committee, which may extend or increase frequency based on results. Responsible Party: Administrator
Failure to Mark Exit Discharges in Accordance with NFPA 101
Penalty
Summary
The facility failed to maintain exits in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition, Sections 19.2.7 and 7.7, as observed during a recertification survey. Specifically, the G-wing and S-wing exit discharges in buildings #1 and #3 were not marked to clearly indicate the direction of egress travel from the exit discharge to a public way. This deficiency was identified during observations conducted on December 5, 2024, at 2:13 PM. During an interview at 3:07 PM on the same day, the facility's administrator acknowledged the issue and indicated that the facility would assess all exit discharges and install the required signage.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. Signage installed at exit discharge locations directing travel to the public way (Route 4). (NOTE – either direction (left/right) leads to the public way) 2. All other exit discharge locations for Building #1 inspected, signage placed where necessary. 3. Maintenance staff will be provided education in the form of written notice about the requirement for directional signage at exit discharges to a public way, with signature attesting to receipt and understanding. 4. The presence of signage at exit discharge locations will be audited once per month for six months to assure it is properly located, with the results reported to Quality Assurance/Performance Improvement committee. Responsible Party: Director of Plant Operations
Obstructed Exits Due to Snow and Padlocks
Penalty
Summary
Exits in Building #1 and Building #3 were not maintained in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.10.1. Specifically, the G-wing and S-wing exit discharges were obstructed with snow and had padlocks on the gate doors, which impeded their full instant use. During observations, it was noted that the northwest and southwest exit discharges of the G-wing, as well as the four exit discharges from the S-wing, were blocked by snow. Additionally, the padlocks on the gate doors were not easily operable, as staff were not trained on how to open them. Interviews revealed that several maintenance staff were on sick leave, which contributed to the delay in clearing the snow from the exit discharge sidewalks. The Maintenance Supervisor indicated that the padlocks were designed to be twisted and broken off, but there was no documented evidence that staff were trained on this procedure. The G-wing charge nurse was unaware of how to open the padlock on the exit discharge gate door. The Administrator acknowledged the issue and mentioned plans to address the obstructions, but the report focuses on the existing deficiency and the lack of immediate action to ensure the exits were free of obstructions.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. The accumulated snow (measuring 0ö to 2ö) from the preceding weather event (ending 7 a.m.) was cleared by 3 p.m. This was the last section to be cleared following a full-day continuous effort. Exterior fence gate break-away padlocks were removed. 2. All other paths of egress, including all driveways, parking lots, etc. had been cleared as part of the full day response; identified areas were the last to be addressed but not overlooked. All other exterior fence gates were inspected and break-away locks removed where found. 3. All maintenance staff responsible for snow clearing will be made aware of the requirement to keep all areas of egress cleared of any obstruction; and to notify the Director of Plant Operations if additional resources are necessary during or following a snow event (when snow is the potential impediment). This information will be provided in written form by the Director of Plant Operations, with signature acknowledging receipt and understanding. Maintenance of egress routes will be included in new employee onboarding education. Fence gates will remain free of locking devices – alternative gate hardware requiring two hand function (non-locking) will be evaluated for potential installation. 4. Following any snow event for the next 3 months, egress paths will be visually inspected by the Director of Plant Operations (or as delegated) on no less than 2 hour intervals during and after the event to ensure paths are cleared in a timely manner. On a monthly basis for six months, an audit of all discharge exits will be inspected on a weekly basis to assure no obstructions exist. The results of this audit and the snow clearing audit will be reported to the Quality Assurance/Performance Improvement committee monthly. Responsible Party: Director of Plant Operations
Deficiency in Sprinkler System Installation Under Canopy
Penalty
Summary
During a recertification survey, it was observed that the automatic sprinkler system was not installed in accordance with the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition Section 8.15.1. Specifically, automatic sprinkler protection was absent at an exit discharge under a cloth canopy attached to Building #3. The canopy, which is greater than 20 feet in length, was found at the exit discharge nearest to the basement of Building #1. There was no documented evidence that the canopy fabric is fire-retardant. The facility's administrator stated that the canopy was installed in 2020 and they are in the process of contacting the vendor to obtain documentation regarding the fire-retardant nature of the canopy fabric.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. Canopy attached to Building #3 to be replaced with approved fire-retardant material. 2. Other building areas where a canopy is in use and subject to this standard will be inspected to ensure appropriate fire-retardant product is in use where exterior sprinklers do not exist. 3. Documentation will be maintained demonstrating fire-retardant materials are in use when installed. 4. Once the correction is made, no further monitoring is indicated. Completion status will be reported to the Quality Assurance/Performance Improvement committee. Director of Plant Operations
Failure to Maintain Smoke Barriers as per NFPA 101
Penalty
Summary
The facility failed to maintain smoke barriers in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition. Specifically, the G-wing east smoke barrier wall in Building #1 was not continuous from the floor to the underside of the roof and through all concealed spaces, and the fire-resistance rating was not maintained as required. During observations, a 12-inch by 12-inch hole in the smoke barrier wall was found filled with insulation but not fire-protected. This deficiency was confirmed during an interview with the Maintenance Supervisor, who acknowledged the issue and stated that they would address the fire sealing of the space in the G-wing smoke barrier wall.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 1. G wing east smoke barrier wall penetration will be sealed using appropriate fire seal. Due to the location of this area, it is not accessible for hand-application and specialized equipment is required. NOTE – this penetration was from original construction and is located above a series of pipes and conduits offering no means of direct access. 2. All smoke barrier walls in building #1 (identified as G and D wings) will be inspected to identify any other penetrations lacking appropriate fire protection. 3. All maintenance staff will be informed of the requirements for smoke walls and fire protection sealant in written form, with signature attesting to receipt and understanding. Existing standards for new work resulting in penetrations will be included in education. 4. Director of Plant Operations will verify all smoke barrier walls have been visually inspected and report the findings to Quality Assurance/Performance Improvement committee. New work resulting in penetrations to smoke walls will be visually inspected at completion; any remaining penetrations will be reported through Safety Committee. Responsible: Director of Plant Operations
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents could safely self-administer medications when clinically appropriate, as evidenced by observations and record reviews during a recertification survey. Two residents, identified as Resident #35 and Resident #168, were involved in this deficiency. Resident #35, who has diagnoses including Spina Bifida, morbid obesity, and paraplegia, was observed with a Proventil inhaler on their overbed table without documented evidence of an assessment for their ability to self-administer medications. Additionally, there was no physician order allowing self-administration, and the care plan did not include documentation for self-administration. Despite a physician order indicating the inhaler could be kept at the bedside, the Medication Administration Record stated that medications should not be left at the bedside, highlighting a discrepancy in the facility's adherence to its own policies. Resident #168, with diagnoses of chronic obstructive pulmonary disease, end-stage renal disease, and chronic systolic heart failure, was observed changing their oxygen tank and setting the flow rate independently. Similar to Resident #35, there was no documented assessment or physician order for self-administration of medications, and the care plan lacked documentation for self-administration. Interviews with facility staff, including a Certified Nurse Aide, LPN, and RN, revealed that residents were not permitted to change their own oxygen tanks or adjust flow rates, as oxygen is considered a medication. The staff acknowledged that residents should be assessed for self-administration and self-regulation of medications, but no such assessment was documented for Resident #168. The facility's Medication Self-Administration Policy, dated September 2017, requires staff and practitioners to assess each resident's mental and physical abilities to determine the appropriateness of self-administering medications. However, the facility failed to adhere to this policy for both residents involved in the deficiency. Interviews with the Assistant Director of Nursing confirmed that a care plan and assessment should be in place for residents to self-administer medications, but these were not completed for the residents in question.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Residents #35 and #168 were assessed for safety in self-administering associated medication (inhaler and oxygen respectively) with medical orders provided if indicated and care planned accordingly. #35 medication is no longer left at bedside. #168 is not allowed to self-regulate oxygen or change tank per facility policy. 2. All resident medication administration records will be reviewed to identify orders which allow medication(s) to be left at bedside, and corresponding self-administration assessments. No other residents were identified which had medications at bedside without corresponding assessments and medical orders. All residents on oxygen reviewed to identify any resident that was independently changing supply or adjusting flow rates independently – no other residents identified. 3. All medical providers and Registered Nurses (RNs) will be re-educated on facility policy regarding self-administration of medication for residents, including assessment, medical orders and care planning requirements. No policy changes were indicated following review. 4. All new medication orders stating “self-administration” identified during the pharmacist’s monthly medication regimen review process will be reviewed to assure appropriate protocols (including assessment, medical order and care plan) are followed. Review to consist of 100% new orders for 3 months; and no less than 50% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance and Performance Improvement Committee based on overall compliance with policy. Responsible Party: Director of Nursing
Deficiency in Comprehensive Care Plan Documentation
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the care plan for a resident did not document the use of oxygen and a nebulizer, despite the resident being observed with oxygen in place and having an order for oxygen and nebulizer treatments in the electronic health record. The resident was admitted with diagnoses including hypertension, paroxysmal atrial fibrillation, and supraventricular tachycardia, and was cognitively intact, able to understand and be understood by others. The facility's policy required a written care plan to be developed upon admission and reviewed within 48 hours, with completion by the first care plan meeting within 14 days. However, the care plan dated 11/21/2024 lacked documentation of the resident's oxygen use, despite an order for continuous oxygen and nebulizer treatments being present in the electronic health record. Interviews with facility staff, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed the absence of the oxygen care plan and indicated that registered nurse unit managers were responsible for updating care plans. The Assistant Director of Nursing acknowledged the expectation for the oxygen to be included in the care plan.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #334 care plan was updated to include resident’s use of oxygen and a nebulizer. 2. All current resident medication administration records will be reviewed for orders for oxygen and/or nebulizer treatments and their care plans were reviewed to ensure comprehensive care plans are in place. New admissions with oxygen orders will have their care plan reviewed as described in #4 below. 3. All Registered Nurses will be re-educated on the requirement and associated time frames to develop care plans for oxygen and/or nebulizer treatments. No changes to the relevant policies were indicated. 4. All new physician orders [REDACTED]. 100% review of new orders for 3 months; no less than 75% for the next 3 months; frequency to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results (actual threshold of compliance will influence the decision to continue audits beyond 6 months). Responsible Party: Director of Nursing
Failure to Implement Time-Limited PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was managed and monitored to promote or maintain their highest practicable mental, physical, and psychosocial well-being. Specifically, two residents were identified during a recertification survey as having as-needed psychotropic medication orders without specified stop dates, contrary to the facility's policy and procedure. Resident #59, who was admitted with dementia, anxiety disorder, and depression, had an order for lorazepam to be administered as needed for agitation, but the order lacked an end date. The medication was administered multiple times over November and December 2024 without a specified stop date. Similarly, Resident #86, also diagnosed with dementia, anxiety disorder, and depression, had an order for Risperidone to be given as needed for agitation/anxiety, with the order documented as indefinite. Despite a pharmacy consultant's recommendation to apply an end date, the Nurse Practitioner disagreed, citing concerns about the medication not being renewed. This lack of adherence to the requirement for time-limited as-needed psychotropic medication orders was acknowledged by the Nurse Practitioner during an interview, indicating awareness of the Centers for Medicare and Medicaid requirement.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Residents #59 and #86 Medication Administration Orders were corrected to ensure 14 day limits were included as required for their as-needed (PRN) [MEDICAL CONDITION] medication orders. 2. All current resident medication administration orders were reviewed for as needed [MEDICAL CONDITION] medications to ensure 14 day stop dates are in place. 3. All medical providers re-educated on requirement that [MEDICAL CONDITION] medications given on an as needed basis must have an end date specified in the order not to exceed 14 days, along with other policy requirements. All nurses who have the potential to enter orders (Registered Nurses, Licensed Practical Nurses) will be re-educated on the requirements in [MEDICAL CONDITION] medication order entry. 4. All new orders for “as needed” [MEDICAL CONDITION] will be audited weekly from medical provider order summary, in addition to the pharmacist’s drug regimen review process (on admission and monthly) which will identify any non-conforming order. Any pharmacist finding and recommendation pertaining to as needed [MEDICAL CONDITION] medications will be brought to the direct attention of the Director of Nursing or her designee. Results of the reviews will be reported to the Quality Assurance & Performance Improvement Committee; 100% of new as needed [MEDICAL CONDITION] orders will be reviewed for compliance with policy for 6 months; frequency of audit to be re-evaluated at 6 months by Quality Assurance & Performance Improvement Committee based on audit results. Responsible Party: Director of Nursing
Failure to Discontinue Collagen Supplement as Ordered
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences and physician's orders were followed, resulting in a deficiency. Specifically, a resident had a dietician's recommendation, signed by a physician, to discontinue a collagen supplement. Despite this, the supplement continued to be administered for 35 days after the recommendation. The resident was cognitively intact and had expressed a desire to discontinue the supplement, which was agreed upon by the provider. However, the order to discontinue was not processed in the electronic medical record, leading to continued administration. The deficiency was identified during a recertification survey, where it was found that the order to discontinue the collagen supplement was only present in the paper record and not updated in the electronic system. The Registered Nurse unit manager responsible for processing new orders acknowledged the oversight and confirmed that the order was missed in the electronic record. The Director of Nursing stated that they expected dietary recommendations signed by the provider to be followed and discontinued as ordered.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Resident #82 Medication Administration Record [REDACTED]. Responsible Registered Nurse self-identified that when she had followed up with the resident, the resident had clarified they didn't ask for a discontinuation of the Collagen order, but rather a change in administration time. This Registered Nurse followed through on the resident's request, but failed to update the medical provider of this resident's request, nor get a refreshed order based on the resident's request, as defined in policy. 2. All resident records on the unit (B wing) where the Registered Nurse was entering medical orders and made the above error to be reviewed to ensure any written recommendations made by an ancillary service during the prior three months (including Registered Dietician, therapy, psychiatry, or specialist consultants--Orthopedics, Cardiology, Neurology) to ensure there is a corresponding medical order that is properly executed. 3. All licensed nurses responsible for transferring recommendations to medical orders will be provided with a policy overview of the procedure for transferring clinical recommendations to properly executed medical orders. There is no policy change indicated as this deficiency is directly related to a single order that was not completed by one employee, who self-identified the error. 4. On a daily basis (defined as every day), the night shift licensed nurse will conduct a 100% audit (visual review) of all new orders obtained during the prior 24 hours, to include written recommendations which are to be transferred to a written medical order. The results will be provided to the Director of Nursing (or designee) daily (which means daily; or the next day after a weekend). Errors, if identified, are raised to the attention of the Registered Nurse Supervisor who is in communication with the Director of Nursing or her designee and will be addressed immediately, or at the most appropriate time based on the nature of the error found (i.e. prior to the advent of additional error). A summary of the audit results will be provided to Quality Assurance & Performance Improvement monthly, with frequency to be re-evaluated after six months. As the nightly audit is being reviewed by the Director of Nursing or her designee (the assistant director of nursing) on a daily, or near daily basis, monthly reporting to Quality Assurance and Performance Improvement Committee is appropriate. In the event the Director of Nursing identifies trends or clusters of errors, correction actions will be implemented immediately. Responsible Party: Director of Nursing
Inconsistent Documentation of Resident Care
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for three residents. For one resident, the facility did not document incontinence care as required. The resident had a care plan that included a toileting schedule, but the documentation was inconsistent, with some entries missing or duplicated. Interviews with staff revealed that documentation was not always completed in real-time, and there was confusion about where and how to document the care provided. For two other residents, the care provided by Certified Nurse Aides was not consistently documented, particularly regarding the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. The care plans for these residents included specific dietary interventions due to their medical conditions, such as severe protein-calorie malnutrition and potential for weight loss. However, the documentation of meal and supplement intake was incomplete or missing on several occasions, indicating a failure to accurately record the care provided. Interviews with nursing staff highlighted a lack of oversight and verification of documentation completion. Licensed Practical Nurses and Registered Nurses were expected to check the electronic medical record dashboard for task completion, but this was not consistently done. The Assistant Director of Nursing acknowledged the documentation issues, emphasizing the expectation that care should be documented as ordered, but the facility's practices did not align with these expectations.
Deficiency in Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, leading to deficiencies in documentation of care provided. For one resident, the facility did not document incontinence care as required. The resident had a care plan that included a toileting schedule, but the task log showed inconsistencies and missing entries for when care was performed. Interviews with staff revealed that documentation was not always completed in a timely manner, and there was confusion about where and how to document the care provided. Two other residents also experienced issues with documentation. Certified Nurse Aides did not consistently document the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. The care plans for these residents included specific dietary interventions, but the Point of Care Response History showed incomplete or missing documentation for several dates. Interviews with nursing staff indicated that there was an expectation for documentation to be completed, but it was not consistently checked or verified. The lack of proper documentation was acknowledged by the facility's Assistant Director of Nursing, who noted that there was a documentation issue. The failure to accurately document care provided to residents, including toileting and nutritional intake, was a significant deficiency that was identified during the recertification survey. This deficiency highlights the need for improved processes and oversight to ensure that all care provided is accurately recorded in accordance with professional standards.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Residents #21, #144, and #171 documentation will be reviewed by the Registered Nurse Manager, with a summary assessment documented on their toileting or nutritional intake (based on nature of identified missing documentation). Missed documentation of this type cannot be accurately recreated in a retrospective manner, and a summary of the resident's status based on the Registered Nurse assessment is appropriate to substitute in this manner. 2. All residents on a specific toileting program or identified as high risk nutritionally requiring meal intake monitoring will be reviewed to assure their plan is appropriate and the documentation is substantially complete. If found to be insufficient, a summary assessment will be conducted and documented on their toileting or nutritional status by the Registered Nurse. See further explanation under #1 above. 3. The following corrective measures will be implemented: a. Toileting documentation – Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements of clinical task documentation. Within the last hour of each scheduled shift, the Licensed Practical Nurse (charge nurse) will review all task documentation that is outstanding via electronic reporting and communicate findings to assigned CNAs. Information will be provided to Registered Nurse Manager, who will provide ongoing counseling and education as necessary on the units. b. Intake Recording – Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements for intake monitoring and documentation. Hand-held devices (tablets) will be deployed in the dining areas for documentation at each meal. Charge Nurse will maintain a list of residents on intake monitoring, validating documentation completeness and accuracy during and after each meal. No documentation policy changes were indicated. In the event the charge nurse is unable to perform the audits at the end of their shift, they will first do a verbal check in with the aides; and second, if necessary, will report to their Nurse Manager or Supervisor they were unable to complete this task. 4. Registered Nurse Unit Managers will audit (visually review of documentation in electronic health record) compliance for no less than 4 days per week (using a 24 hour report) for 3 months, and 2 days per week for 3 months to determine compliance, with results reported monthly to Quality Assurance & Performance Improvement. In the event any particular unit(s) find continuing compliance issues, the findings will be reviewed with the Director of Nursing (or designee) to determine if increasing frequency of review is indicated (vs. isolated performance issue). Frequency of audits will be reevaluated after 6 months by Quality Assurance & Performance Improvement committee. Frequency of auditing may be increased at any point by the quality assurance and performance improvement committee based on audit results. Responsible Party: Assistant Director of Nursing for Quality and Education
Emergency Preparedness Plan Lacks Key Provisions
Penalty
Summary
The facility failed to comply with Disaster and Emergency Preparedness requirements as outlined by New York State regulation. Specifically, the facility's emergency preparedness plan did not include provisions for earthquake, flood, or nuclear disaster. This deficiency was identified during a recertification survey, where it was noted that there was no documented evidence of such provisions in the plan. During an interview, the facility's administrator acknowledged the absence of these provisions and indicated an intention to add them.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Disaster Plans developed for Earthquake, Flood and Nuclear events and made part of the Comprehensive Emergency Management Plan. 2. All-Hazard Risk Assessment will be updated to include these required disaster plans; and will be reviewed to identify any other risk which may pose more than a theoretical or nominal risk to ensure plans are developed. 3. Employees will be notified via general information update (email) of the Comprehensive Emergency Management Plan additions, with a copy provided for review. Further education on these plans will be incorporated into annual facility training exercises and disaster drills based on their relative priority as determined by the facility’s risk assessment (previously assessed at ‘low risk’). Families or representatives will be provided an annual overview of the Comprehensive Emergency Management Plan. This information is not detail - plan specific, but a general overview of the facility's emergency response assessment, planning, etc. 4. The development of the respective policies are complete, and have become part of the Comprehensive Emergency Management Plan. Ongoing compliance with this deficiency - which is specifically the absence of these plans - will be reviewed annually as part of annual All Risk Assessment and Comprehensive Emergency Management Plan review. Responsible Party: Administrator
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Nursing homes near Fort Edward
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines At Glens Falls Ctr For Nursing & Rehab | 3.6 mi | ★★★★★ | 15 | 0 |
| Washington Center For Rehab And Healthcare | 5.7 mi | ★★★★★ | 11 | 0 |
| Glens Falls Center For Rehabilitation And Nursing | 7.5 mi | ★★★★★ | 0 | 0 |
| Warren Center For Rehabilitation And Nursing | 8.5 mi | ★★★★★ | 21 | 0 |
| Wesley Health Care Center Inc | 16.3 mi | ★★★★★ | 0 | 0 |
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