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 Fulton Commons Care Center Inc during CMS and state inspections, most recent first.
The facility failed to maintain sufficient nursing staff to meet resident needs, particularly on weekends, as identified in a recent survey. The Payroll-Based Journal indicated low weekend staffing, resulting in a One Star Staffing Rating. The Facility Assessment's staffing plan was not met, with several units having fewer LPNs and CNAs than required. Interviews revealed ongoing staffing shortages and challenges in hiring and retaining staff.
The facility failed to maintain a two-hour fire resistance barrier in ceiling assemblies on all resident floors, as observed during a recertification survey. Unsealed openings around electrical wires and conduits were found in the ceiling assemblies within electrical closets, despite documentation indicating a UL listed fire resistive ceiling tile assembly. The Life Safety Director acknowledged the issue and stated that appropriate fire stopping material would be used to seal the openings.
A recertification survey found that a common shower room was locked and inaccessible due to a leaking issue from a compromised floor seal, requiring floor replacement. The Director of Maintenance confirmed the shower room had been closed since 2023. Additionally, the emergency generator enclosure showed signs of corrosion with holes around rusted areas, acknowledged by the Life Safety Director.
A resident with intact cognition was not invited to their care plan meeting, despite facility policies encouraging resident participation. The resident, who has no known family, expressed a desire to be involved. Staff interviews confirmed the oversight, acknowledging the resident's right to participate.
A cognitively intact resident with Paranoid schizophrenia and Depression requested a transfer to another facility, but the LTC facility failed to implement an effective discharge planning process. Despite a Physician's Order and Psychiatry Consultations recommending discussions about nursing home options, no documented evidence of such discussions was found. Staff interviews revealed a lack of communication and responsibility, with the Social Worker not meeting the resident due to perceived confusion, and the Discharge Planner being unaware of the resident's request.
A resident with impaired hearing did not receive their hearing aids as per the Physician's order due to a transcription error in the Medication and Treatment Administration Records. The oversight led to the nursing staff being unaware of the need to recharge and apply the hearing aids, resulting in the resident experiencing communication difficulties.
A facility failed to ensure proper medical supervision for a resident with Schizophrenia, Anxiety Disorder, and Depression. Despite a psychiatrist's recommendations for behavior therapy and counseling, a Nurse Practitioner did not document agreement or implement these recommendations. The resident's primary physician was unaware of these recommendations, and the necessary physician orders were not entered, leaving the resident without the recommended psychological support.
A resident with serious mental health diagnoses did not receive necessary behavioral health services as recommended by a psychiatrist. Despite expressing feelings of depression and hopelessness, the resident was not referred for behavior therapy or counseling. The facility's staff failed to document and follow through on the psychiatrist's recommendations, resulting in a lack of necessary care.
A facility failed to accurately document and reconcile Oxycodone tablets for a resident, leading to a discrepancy in the controlled substance record. The pharmacy delivered 56 tablets, but the record inaccurately showed 46 received and 41 available, while 50 were actually present. Nursing staff did not identify the error during shift change reconciliation, despite the resident's need for pain management due to osteomyelitis and a stage 4 pressure ulcer.
The facility was cited for a deficiency in the illumination of egress paths in resident congregation spaces. During a survey, it was found that manual light switches in resident lounges and the chapel could completely turn off all lights, violating continuous illumination requirements. The Life Safety Director confirmed the issue, acknowledging that the current setup allowed for complete lighting shutdown in these areas.
Staffing Deficiencies Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, as identified during a Recertification Survey conducted from December 15 to December 23, 2024. The deficiency was noted across all seven units reviewed, with specific issues related to low weekend staffing levels. The Payroll-Based Journal (PBJ) Staffing Data Report for Quarter Three of 2024 indicated excessively low weekend staffing, resulting in a One Star Staffing Rating. The facility's staffing plan, as outlined in the Facility Assessment, was not adhered to, with several instances of insufficient Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) on duty during weekends. The Facility Assessment, updated in June 2024, documented the required staffing levels for each unit, which were not met on numerous occasions. For example, Unit 1 East was found to have only one LPN on several weekends, despite the requirement for three LPNs during the 7:00 AM to 3:00 PM shift. Similar staffing shortages were observed in other units, with some units having only three CNAs instead of the required five. These staffing deficiencies were consistent and repeated, indicating a systemic issue within the facility's staffing practices. Interviews conducted during the survey revealed that the facility's staffing coordinator acknowledged the ongoing staffing shortages, particularly on weekends, and noted that the use of an agency had not resolved the issue. The Director of Nursing Services was unaware of the facility's low weekend staffing rating in the PBJ and admitted to challenges in hiring and retaining staff. The facility administrator also acknowledged the difficulty in attracting and retaining nursing staff, which contributed to the failure to meet the staffing levels outlined in the Facility Assessment.
Plan Of Correction
Plan of Correction: Approved January 24, 2025 F 725 – Sufficient Staffing The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: Immediate corrective action of the discrepancy between staffing levels and the facility assessment could not be completed as the staffing levels for the time period of (MONTH) 1, 2024 through (MONTH) 30, 2024 cannot be altered. All Incident reports and grievance logs were reviewed for the time period of (MONTH) 1, 2024 through (MONTH) 30, 2024 to ascertain if there were any reports or grievances as a result of the alleged deficient practice. There were no residents identified as harmed or affected as a result of this deficient practice. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. An audit tool will be created and a retrospective review (10% audit) will be completed reviewing the staffing levels of licensed nurses and certified nursing assistants for the months of (MONTH) 2024 through (MONTH) 2024 to determine any shifts of excessively low staffing in conjunction with the facility assessment. After identification, all incident reports and grievance logs for the same time period will be reviewed to ascertain if there were any reports or grievances as a result of the alleged deficient practice. The Facility Assessment will be reviewed and adjusted to reflect the actual staffing of the units for licensed nurses and certified nursing assistants. The Director of Nursing in conjunction with the Staff Scheduler will review staff levels weekly prior to the following work week to ensure adequate staffing levels on each unit based on acuity and facility needs. Person responsible: Director of Nursing C) Systemic Changes to ensure the deficient practice will not recur: The facility has implemented the following process in an effort to recruit staff especially Certified Nursing Assistants: - Agency contracts are in place - Staff members are offered overtime - Qualified walk-ins are hired immediately after the interview process with an emphasis towards weekend staffing levels - A full-time recruiter is on staff to assist the facility with staffing needs - The facility is offering sign-on bonus and referral bonus - The facility hosts job fairs and open houses - Staff are offered flexible schedules - The facility has a presence on social media and online advertising Person responsible: Administrator/Designee D) QA – Monitor of the deficient practice: A 10% audit will be completed monthly x 6 months reviewing the staffing sheets to determine any shifts of excessively low staffing, specifically Certified Nursing Assistants. Any negative findings will be presented to QAPI to determine further discuss specific reasons and corrective measures relative to nursing staffing needs, especially with Certified Nursing Assistants. The Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Failure to Maintain Fire Resistance Barrier in Ceiling Assemblies
Penalty
Summary
During a recertification survey, it was observed that the facility failed to maintain the ceiling assembly to provide at least a two-hour fire resistance barrier on all four resident floors. The survey, conducted over three days, revealed unsealed openings around electrical wires and conduits in the ceiling assemblies within the electrical closets on all nursing units. This deficiency was noted despite the facility having documentation from a ceiling tile manufacturer indicating that the ceiling was equipped with a UL listed two-hour fire resistive ceiling tile assembly. The Life Safety Director of the facility acknowledged the issue during an interview, stating that the ceiling openings around the wires and conduits would be sealed with the appropriate fire stopping material. The deficiency was identified during Life Safety inspections, which took place between 9:00 am and 2:30 pm on the specified dates. The failure to maintain the fire resistance barrier as required by the 2012 NFPA 101 and 2012 NFPA 220 standards was a significant finding during the survey.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 K 161 – Building Construction Type and Height The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: No residents were affected by the deficient practice. The Medical Director is in agreement that there was no additional risk to residents. The facility corrected the deficiency by sealing the openings with fire stopping material around the electrical wires and conduits of the ceiling assemblies within the electrical closets on all nursing units. 01/09/2025 B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. A full house audit will be completed to ensure that all ceiling assemblies are free of unsealed openings. Person responsible: Director of Maintenance/ Designee C) Systemic Changes to ensure the deficient practice will not recur: The Nurse Educator will inservice all facility maintenance staff regarding the following: - all fire rated ceiling tiles and assemblies are to be free of unsealed openings; and - unsealed openings are to be sealed with appropriate fire stopping material. Education will be verified by posttests or return demonstration to ensure education retention. D) QA – Monitor of the deficient practice: Audit tool created to inspect ceiling tiles and assemblies for unsealed openings. An audit will be completed monthly to inspect 10% of ceiling tiles and assemblies to ensure areas are free of unsealed openings. Any negative findings will be immediately corrected and presented at QAPI quarterly. Audits will be completed monthly x 6 months. The Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Deficiencies in Shower Room and Generator Enclosure Maintenance
Penalty
Summary
During a recertification survey, it was observed that a common shower room and the generator enclosure in the facility were not maintained in good repair. On multiple days, surveyors noted that one of the two common shower rooms on the 2West Nursing Unit was locked and inaccessible to residents due to a leaking issue from a compromised floor seal, which required the entire floor to be replaced. The Director of Maintenance confirmed the issue and stated that the shower room had been closed since an unspecified month in 2023. Additionally, the emergency generator enclosure was found to have signs of corrosion, with holes around rusted areas. The Life Safety Director acknowledged the generator's condition and indicated it would be addressed.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 I 310 – Physical Environment The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: Shower room – the quality of life of the residents on 2 west were not affected by the non-functioning shower room. The facility will correct this deficiency by repairing the compromised floor seal in the 2 west shower room. Repair to be completed on or before 02/18/2025. The functionality of the generator was not affected by rusted areas and corrosion of the generator enclosure. No residents were affected by the deficient practice. The generator enclosure will be repaired/replaced to ensure same is free of corrosion, holes and rusted areas on or before 02/18/2025. Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. All other shower rooms were inspected for functionality. There were no negative findings. There was no further generator enclosure to be inspected. Person responsible: Director of Maintenance Systemic Changes to ensure the deficient practice will not recur: Nursing Staff specifically Certified Nursing Assistants will be educated to notify the maintenance department if a shower room is in need of repair. The maintenance staff will be educated to inspect generator structure to ensure enclosure is free of corrosion, dust and holes. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA – Monitor of the deficient practice: Audit tool will be created to inspect all shower rooms monthly x 3 months to ensure functionality. Any negative findings will be corrected. The Director of Maintenance/Designee will complete this audit and report results to QAPI quarterly. Audit tool will be created to inspect generator structures to ensure enclosure is free of rust, corrosion and holes. Any negative findings will be corrected. The Director of Maintenance/Designee will complete this audit and report results to QAPI quarterly. The Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Resident Excluded from Care Plan Meeting Despite Intact Cognition
Penalty
Summary
The facility failed to ensure that a resident had the right to participate in the development and implementation of their person-centered plan of care. This deficiency was identified for a cognitively intact resident who had no known family or designated representative. Despite having a Brief Interview for Mental Status (BIMS) score indicating intact cognition, the resident was not invited to their Comprehensive Care Plan meeting. The facility's policy requires that residents, along with their families or legal representatives, be encouraged to participate in care plan development and revisions. However, the resident was excluded from the meeting due to perceived periods of confusion, without an assessment of their mental status on the day of the meeting. The resident, who has diagnoses including Schizophrenia, Anxiety Disorder, and Depression, expressed a desire to be involved in their care plan meetings. Interviews with facility staff, including the Social Worker and the Director of Social Services, acknowledged that the resident should have been invited to participate in the meeting. The Administrator also confirmed that it is a resident's right to be invited to their care plan meeting, especially if they are cognitively intact. This oversight was documented during the Recertification Survey, highlighting a failure to adhere to the facility's own policies and procedures regarding resident participation in care planning.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 F 553 – Right to participate In Plan of Care The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) An invitation was issued and Resident #93 participated in his person-centered plan of care on 12/18/2024. b) The Social Worker who failed to invite Resident #93 to participate in his care plan meeting received educational disciplinary action on 01/13/2025. B) Identification of other Residents having the potential to be affected by the deficient practice: All cognitively intact residents without family or legal representative are at risk for this deficiency. A list was compiled of all current Residents who had a care plan meeting scheduled from the timeframe of (MONTH) 15, 2024 to (MONTH) 31, 2024. Utilizing this list, an audit was created and completed to ensure the Residents and/or their legal representative were invited to participate in their plan of care. Any negative findings were immediately corrected by issuing invitations and convening a care plan meeting. Person responsible: Assigned Unit Social Worker C) Systemic Changes to ensure the deficient practice will not recur: The “Care Planning – Interdisciplinary Team” policy and procedure with a review date of 01/2025 was reviewed and found to be in compliance. All Social Workers responsible for the enforcement of issuing invitations and facilitating the care planning meetings will be re-educated on the facility’s policy and procedure regarding same. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Director of Social Work will conduct audits of all residents scheduled for care planning to ensure that Residents and/or their representatives are invited to participate in the care planning process. Any negative findings will be immediately corrected and results of findings will be reported to the QAPI committee quarterly. This audit will be conducted weekly x 3 months then monthly x one year. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Failure in Discharge Planning for Resident Requesting Transfer
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a cognitively intact resident who requested a transfer to another nursing facility. The resident, diagnosed with Paranoid schizophrenia and Depression, expressed a desire to move to a facility in Suffolk County. Despite a Physician's Order and recommendations from Psychiatry Consultations for Social Services to discuss nursing home options with the resident, there was no documented evidence that these discussions took place. The resident's discharge goals were not addressed, and the section of the Minimum Data Set (MDS) assessment related to the resident's overall goal for discharge was left blank. Interviews with facility staff revealed a lack of communication and responsibility regarding the discharge planning process. The resident's assigned Social Worker did not meet with the resident to discuss discharge options, citing the resident's occasional confusion as a reason. The Discharge Planner was unaware of the Physician's Order and did not recall any discussions with the Social Worker about the resident's request. The Director of Social Services acknowledged that the Social Worker should have engaged with the resident to understand their reasons for wanting a transfer and to improve their experience at the facility. The Administrator confirmed that the resident's right to participate in care plan meetings was not upheld, and the Physician's Order was not followed.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 F 660 – Discharge Planning Process The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) A discharge planning meeting was held on 12/18/2024 with Resident #93 to address his request to be transferred to another facility. Resident is scheduled for discharge on 01/15/2025. b) Resident #93 was seen by the Social Worker with no psychological harm noted from this deficient practice. c) The Social Worker who failed to initiate the discharge planning process for Resident #93 received educational disciplinary action on 01/13/2025. B) Identification of other Residents having the potential to be affected by the deficient practice: All cognitively intact residents without family or legal representative are at risk for this deficiency. The Director of Social Work will compile a list of all Residents with a BIMS score of 13 – 15. Utilizing this list, the Social Worker will create an audit tool and interview Residents to determine if they had expressed a desire to be discharged to another facility. Any residents found to have this request will have a discharge planning meeting to determine the feasibility of facilitating the discharge. The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. C) Systemic Changes to ensure the deficient practice will not recur: The “Discharge Summary and Plan” policy and procedure with a review date of 01/2025 was reviewed and found to be in compliance. a) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultant’s recommendation and implementing the physician’s order; or b. Documenting their disagreement and documenting the reason for disagreement. All Social Workers responsible for the enforcement of the “Discharge and Summary Plan” policy and procedure will receive re-education regarding this policy. Education will also emphasize the inclusion of residents in all care plan meeting discussions and documentation of discharge meetings held. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Director of Social Work/Designee will have the responsibility of interviewing 10% of the population of Residents with a BIMS score of 13-15, to ensure their request for discharge (if applicable) was addressed by the assigned Social Worker. Any negative findings will be immediately corrected and results of findings will be reported to the QAPI committee quarterly. This audit will be conducted weekly x 3 months, then monthly x one year. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Failure to Provide Hearing Aids to Resident
Penalty
Summary
The facility failed to ensure that a resident with highly impaired hearing received proper assistive devices to maintain their hearing abilities. The resident, who had a Physician's order to use hearing aids for both ears, was not provided with their hearing aids daily, and the hearing aids were not recharged as required. The facility's policy recommended charging the hearing aids every night, but this was not consistently done. The resident, who had moderately impaired cognition, was observed without hearing aids, and their family member reported this issue to the staff. The resident expressed difficulty in communicating without the hearing aids. The deficiency was attributed to a failure in transcribing the Physician's order for the hearing aids onto the Medication and Treatment Administration Records, which led to the nursing staff not being aware of the need to recharge and apply the hearing aids. The overnight nurse assigned to the resident was unaware of the hearing aids until informed by the Registered Nurse Unit Manager. The Director of Nursing Services acknowledged the oversight and stated that the order for the hearing aids was not transcribed due to unexplained technical issues, resulting in the resident not receiving the necessary assistance to maintain their hearing abilities.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 F 685 – Device to Maintain Hearing The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) For Resident #59 – the hearing aids were immediately charged and inserted for use on 12/15/2024. b) The Treatment Administration Record (TAR) was updated to include the application and removal of the hearing aids as well as placing them to charge at hour of sleep. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents with hearing aides have the potential to be affected by this deficient practice. An immediate audit was conducted of all residents utilizing hearing aids to ensure they were charged or in place. There were no negative findings. An audit tool was developed to identify all Residents with a hearing device and type. Utilizing this list, the Unit Manager will ensure the following: a) A physician’s order is in place that includes the application, removal and charging of device, if applicable. b) The Treatment Administration Record (TAR) is updated to reflect the physician’s order. c) The care plan and CNA task is updated to reflect same. C) Systemic Changes to ensure the deficient practice will not recur: The facility’s policy and procedure titled “Hearing Aid: Rechargeable Type” was reviewed and found to be in compliance. All licensed nursing staff will be educated regarding the policy “Hearing Aid: Rechargeable Type”, in addition to how to transcribe the order in the Treatment Administration Record. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Nurse Managers/Designee will have the responsibility of auditing all residents with a rechargeable hearing aid on a daily basis x 1 week; then weekly x 3 months; to ascertain compliance with this policy. Any negative findings will be reported to the Assistant Director of Nursing for follow up and report to the QAPI committee. The Assistant Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Failure to Implement Psychiatric Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure that the medical care of a resident was properly supervised by a physician, particularly in monitoring changes in the resident's medical status. This deficiency was identified for a resident with diagnoses of Schizophrenia, Anxiety Disorder, and Depression, who had intact cognition as indicated by a BIMS score of 13. The resident expressed feelings of unhappiness, loneliness, and lack of primary support, and the psychiatrist recommended exploring options for transferring the resident to another facility of their choice and receiving behavior therapy and counseling. However, the Nurse Practitioner who reviewed these recommendations did not document agreement or disagreement with them, nor did they implement the recommendations. The facility's policy required that physicians approve or document reasons for disagreeing with consultant recommendations. Despite this, the Nurse Practitioner, who was a remote medical provider, did not enter a physician's order for the recommended behavioral counseling services. The resident's primary physician was unaware of the psychiatrist's recommendations, and the medical director stated that the Nurse Practitioner should have referred the resident to social services and entered the necessary orders. The resident expressed a desire to be placed in a group home in Suffolk County, where they previously received psychological services, but this was not facilitated due to the lack of appropriate physician orders.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F 710 – Physician Services** The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: 1. Resident #93’s choice to be transferred to another facility was initiated immediately upon notification and resident transferred to a Suffolk County placement. 2. Evaluation by the Social Worker and the Psychologist revealed no psychological harm sustained by resident as a result of this deficient practice. 3. The Attending Physician re-addressed the Psychiatrist’s recommendations dated 10/22/2024 by placing an order for [REDACTED]. 4. The Nurse Practitioner who failed to address the Psychiatrist consult dated 10/21/2024, was re-educated on 12/18/2024 that documented evidence is required in the medical record if there is agreement or disagreement with the consultant’s recommendation and if in agreement, same must be implemented. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents with a Psychiatry consult have the potential to be affected by the deficient practice. The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. C) Systemic Changes to ensure the deficient practice will not recur: b) The policy and procedure titled “Consultation” was reviewed and found to be in compliance. c) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultant’s recommendation and implementing the physician’s order; or b. Documenting their disagreement and documenting the reason for disagreement. d) Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Medical Director D) QA – Monitor of the deficient practice: The Medical Director will have the responsibility of auditing 10% of Psychiatry consultations monthly to ensure there is documented evidence of the attending physician addressing any recommendations made. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed monthly x 6 months. The Medical Director is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #93, during a recertification survey. Resident #93, who has diagnoses including Schizophrenia, Anxiety Disorder, and Depression, expressed feelings of being down, depressed, and hopeless to the social worker. Despite a psychiatrist's recommendation for behavior therapy or counseling, these services were not offered. The resident's comprehensive assessment and plan of care required such interventions, but there was no documented evidence of a referral for these services. The facility's Consultation Policy and Procedure required that a physician approve or document disagreement with any consultant's recommendations. However, the Nurse Practitioner reviewing the psychiatrist's recommendations did not document agreement or disagreement, nor were any physician's orders for behavior therapy or counseling entered into the resident's medical record. The social worker reported the resident's mood to the nursing staff but did not document this communication or ensure follow-up for obtaining a physician's order for counseling services. Interviews with facility staff revealed a lack of communication and follow-through regarding the psychiatrist's recommendations. The social worker did not document their communication with the nursing staff, and the Director of Social Services acknowledged the need for documentation and follow-up. The Nurse Practitioner, who was a remote provider, stated they were instructed not to write physician orders, leaving the responsibility to in-house medical providers. The resident's primary physician was unaware of the psychiatrist's recommendations, and the medical director emphasized the need for documentation of agreement or disagreement with consultant recommendations. The resident expressed a desire for psychological services, which they had received in a previous group home setting.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F 740 – Behavioral Health Services** The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) Resident #93 was seen by the Psychologist on 12/18/2024 to address his feelings of hopelessness and Depression. b) The Attending Physician re-addressed the Psychiatrist’s recommendations dated 10/22/2024 by placing an order for [REDACTED]. c) Resident #93 – The assigned Social Worker addressed the Resident’s feelings of hopelessness and reports of feeling depressed by providing emotional support on 01/13/2025. d) The Social Worker who failed to provide emotional support to Resident #93 and failed to ensure the Resident received Psychology services as recommended by the Psychiatrist received educational disciplinary action on 01/13/2025. B) Identification of other Residents having the potential to be affected by the deficient practice: The Medical Director will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the past 6 months, to ensure that all recommendations made are reviewed and implemented if applicable; or that there is documented evidence if the physician disagreed with the recommendation. Any negative findings will be immediately corrected. The Director of Social Work/Designee will be responsible for conducting an audit of all recommendations made by the Psychiatrist for the months of (MONTH) through (MONTH) 2024, to ensure that all recommendations made are reviewed and implemented if applicable by the assigned Social Worker. Any negative findings will be immediately corrected. Persons responsible: Medical Director & Director of Social Work C) Systemic Changes to ensure the deficient practice will not recur: e) The policy and procedure titled “Consultation” was reviewed and found to be in compliance. f) All onsite and offsite attending medical providers will be re-educated on the procedure of: a. Documenting their agreement with a consultant’s recommendation and implementing the physician’s order; or b. Documenting their disagreement and documenting the reason for disagreement. Person responsible: Medical Director g) All Social Workers will be re-educated on the following: a. Residents identified with signs and symptoms of Depression will receive documented emotional support and will be referred to the Psychiatrist and Psychologist for follow up. h) Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Medical Director will have the responsibility of auditing 10% of Psychiatry consultations monthly to ensure there is documented evidence of the attending physician addressing any recommendations made. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed monthly x 6 months. The Medical Director is responsible for the correction of this deficiency. The Director of Social Work will have the responsibility of auditing 10% of Residents scheduled weekly for care plan meeting, to ensure that any resident identified as having signs and symptoms of Depression on the MDS 3.0 is having same addressed by the unit assigned Social Worker. Any negative findings will be immediately corrected and reported to the QAPI committee. This audit will be completed weekly x 3 months, then monthly x 3 months. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Controlled Substance Documentation Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation and reconciliation of controlled substances, specifically Oxycodone, for a resident. The pharmacy delivered 56 tablets of Oxycodone 10 mg for a resident, but the Individual Resident's Controlled Substance Record inaccurately documented that only 46 tablets were received. Furthermore, the record showed 41 tablets available, while the actual count in the blister packs was 50 tablets. This discrepancy was not identified by the nursing staff during the required shift change reconciliation process. The resident involved was admitted with conditions including pain, osteomyelitis, and a stage 4 pressure ulcer, and was on a scheduled pain medication regimen. Despite the facility's policy requiring narcotics to be counted and reconciled at each shift change, the discrepancy in the Oxycodone count was overlooked by the nurses responsible for medication administration and reconciliation. Interviews with the nursing staff revealed a lack of awareness and oversight in accurately documenting and reconciling the controlled substance records, which was acknowledged by the Assistant Director of Nursing Services and the Director of Nursing Services.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 755 – Pharmacy Services The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: a) There was no psychological harm or complaint of pain for Resident #162 as a result of this deficient practice. b) For Resident #162, the narcotic [MEDICATION NAME] 10mg was reconciled to reflect the accurate number of tablets received as 56 tablets on 12/18/2024. c) The Licensed Practical Nurse who inaccurately documented the number of [MEDICATION NAME] received from the pharmacy for Resident #162 received an educational counseling dated 12/18/2024. d) The Licensed Practical Nurses responsible for reconciling the narcotic count of [MEDICATION NAME] for Resident #162 at beginning and ending of shifts and failed to observe the inaccurate count, received an educational counseling on 12/18/2024. e) The Licensed Practical Nurse who failed to immediately reconcile the narcotic count of [MEDICATION NAME] for Resident #162 after medication administration received an educational counseling on 12/18/2024. B) Identification of other Residents having the potential to be affected by the deficient practice: All residents on controlled medication have the potential to be affected by the deficient practice. Upon identification of the inaccurate narcotic count for the medication [MEDICATION NAME] for Resident #162 on 12/18/2024, the Nurse Managers conducted an immediate audit of all narcotics on all units to ensure there were no further discrepancies in the number of tablets received and documented. There were no negative findings. The Nurse Managers also conducted an audit on 12/18/2024, reviewing the narcotic book to ensure that licensed nurses were immediately documenting and reconciling the narcotic count after medication administration. There were no negative findings. C) Systemic Changes to ensure the deficient practice will not recur: The facility policy and procedure titled “Controlled Substance/ Narcotic Management” was reviewed and found to be in compliance. All Licensed Nurses will be re-educated on the importance of ensuring an accurate narcotic count as well as reconciling the narcotic count immediately after the medication is administered. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA – Monitor of the deficient practice: The Managers and RN Supervisors will be responsible for auditing the narcotic books on a daily basis x 3 weeks then weekly x 3 months to ensure accuracy of narcotic count and timely reconciliation after medication administration. Any negative findings will be immediately corrected and reported to the Assistant Director of Nursing for follow up and report to the QAPI committee. The Assistant Director of Nursing is responsible for the correction of this deficiency. Date of correction: 02/18/2025
Deficiency in Egress Lighting Control
Penalty
Summary
The facility was found to have a deficiency related to the illumination of means of egress in general resident congregation spaces. During a recertification survey, it was observed that the lighting within resident lounges on all nursing units and in the chapel was controlled by manual light switches. These switches had the capability to completely turn off all the lights, which is not compliant with the requirement for continuous illumination of egress paths. This issue was identified during Life Safety inspections conducted over two days, where it was noted that the lighting setup did not prevent manual switches from controlling the lighting in these areas. The facility's Life Safety Director acknowledged the issue during an interview, indicating that the current configuration allowed for the complete shutdown of lighting in critical areas.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 K 281 – Illumination of Means of Egress The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. Immediate Corrective Action for Resident found to be affected by the deficient practice: No residents were affected by the deficient practice. The Medical Director is in agreement that there was no additional risk to residents. The facility corrected the deficiency by reconfiguring the light switches to prevent all lighting being completely turned off within resident lounges on all nursing units and the chapel. 01/17/2025 B) Identification of other Residents having the potential to be affected by the deficient practice: All residents have the potential to be affected by the deficient practice. Review of incident reports revealed no issues as a direct effect of the above-mentioned deficiency. A full house audit will be completed to ensure that other resident congregation spaces have light switches preventing all lighting being turned completely off. Person responsible: Director of Maintenance C) Systemic Changes to ensure the deficient practice will not recur: The Nurse Educator will inservice all facility maintenance staff that all resident congregant spaces must have lighting that are not controlled by manual switches. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Nurse Educator QA – Monitor of the deficient practice: Audit tool created to inspect all resident congregant spaces to ensure configuration of light switches to allow illumination of means of egress at all times. This audit will be completed monthly x 3 months and presented to QAPI quarterly. Director of Maintenance is responsible for the correction of this deficiency. Date of correction: 02/18/2025
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Meadow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hempstead Park Nursing Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Townhouse Center For Rehabilitation & Nursing | 1.7 mi | ★★★★★ | 1 | 0 |
| A Holly Patterson Extended Care Facility | 1.8 mi | ★★★★★ | 18 | 0 |
| Mayfair Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Nassau Rehabilitation & Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
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