Grand Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bronx, New York.
- Location
- 700 White Plains Road, Bronx, New York 10473
- CMS Provider Number
- 335744
- Inspections on file
- 42
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 29 (2 serious)
Citation history
Health deficiencies cited at Grand Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective system to reconcile and verify methadone doses supplied by external opioid treatment programs, resulting in multiple residents with opioid use disorder receiving methadone under conditions where physician orders did not match the dosages on clinic-labeled bottles. Despite existing policies for controlled substances and medication administration, there was no specific policy, procedure, or formal agreement governing methadone from outside clinics, and staff did not receive or use clinic documentation to confirm current dosages. Nurses reported relying mainly on resident names on bottles and did not routinely compare bottle dosages to physician orders, while physicians and the consultant pharmacist described processes in which methadone orders were entered or signed based on bottle labels without independent verification. These systemic gaps led to repeated discrepancies between ordered and labeled methadone doses for numerous residents.
The facility failed to ensure methadone was administered according to physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Policy required nurses to use the eMAR as the source for medication administration and to verify the five rights, but methadone bottles for several residents carried doses that did not match the physician orders entered in the electronic record, despite daily administration being documented. Nursing staff reported either not cross-checking bottle dosages against orders or relying solely on the bottle label or resident familiarity, and they often did not notice discrepancies. The attending physician, DON, and medical director described a process in which the methadone clinic determined doses, nurses transcribed bottle labels or clinic information into the electronic record, and physicians signed orders without independent verification or direct clinic documentation, contributing to inconsistent and inaccurate methadone dosing information.
The medical director failed to provide adequate oversight of methadone medication management, including the development and implementation of procedures to safely reconcile and verify methadone received from external opioid treatment programs. Facility policy assigned the medical director responsibility for oversight of medical care practices and clinical standards, yet the medical director did not know how methadone was delivered, relied on methadone clinic reports entered by nursing staff into the EMR, and electronically signed orders without reviewing the source documentation. An attending physician reported having residents on methadone maintenance but was unsure of each resident’s correct dosage and stated that nurses administered the dose on the methadone bottle even when it did not match the physician’s order, demonstrating a lack of coordinated, standardized processes for methadone prescribing and administration.
A resident with severe cognitive impairment was found unable to stand and was later diagnosed with a hip fracture of unknown origin. The facility did not report this injury of unknown source to the State Department of Health within the required timeframe, resulting in a delay of ten days before notification.
A resident with severe cognitive impairment and a history of falls was repeatedly observed without required fall prevention interventions, including floor mats and a bed in the lowest position, despite these being specified in the care plan. Staff interviews confirmed that these interventions were not consistently implemented.
The facility did not report allegations of staff borrowing money from residents and failing to repay within required timeframes, and failed to submit follow-up investigation reports within five business days. In each case, the initial or follow-up reporting was delayed, and investigations could not substantiate the allegations due to inconsistent statements or lack of evidence. Leadership interviews revealed a lack of awareness of reporting requirements.
A resident with significant medical needs reported being threatened by two CNAs, but the allegation was not immediately communicated to supervisory staff as required by facility policy. The Director of Recreation documented the report but failed to notify the DON or Administrator directly, resulting in a delayed investigation and lack of immediate protective measures.
The facility did not transfer the personal funds of two deceased residents to the probate jurisdiction within the required 30-day period, as confirmed by record review and staff interviews. The Payable Coordinator and Administrator acknowledged the delay but could not explain why the transfers were not completed on time.
A resident with multiple complex diagnoses exhibited restlessness, a stuffy nose, and a low-grade fever. Despite these changes, staff did not document notifying the physician or performing a follow-up assessment after administering acetaminophen. The resident later expired from cardiac arrest, and the physician was only notified post-mortem. This failure to follow assessment and notification protocols resulted in actual harm.
A resident with severe cognitive impairment and multiple medical conditions became restless and developed a low-grade fever. Staff documented the symptoms, notified the RN Supervisor, and administered Tylenol, but did not inform the resident's representative or physician of the change in condition, as required by policy. Interviews confirmed the family was not notified, and there was no evidence of reassessment after treatment.
The facility did not maintain required temperature levels, with all sampled resident rooms and common areas found below regulatory standards, some as low as 40 to 53°F. Multiple residents filed complaints and grievances about cold conditions, and maintenance logs documented ongoing heating issues. The Administrator and Medical Director were unaware of the extent of the problem, and the facility lacked proper maintenance contracts and failed to address vendor recommendations for boiler repairs, resulting in Immediate Jeopardy and Substandard Quality of Care.
The facility did not ensure safe and comfortable temperatures in resident rooms and common areas due to lack of heat, with all sampled areas below regulatory requirements. The Administrator was unaware of the issue, and there was no evidence of routine maintenance for boiler and PTAC units. The Director of Maintenance was unable to secure vendor services due to unpaid balances, and the Administrator denied receiving vendor communications about necessary repairs. These failures resulted in Immediate Jeopardy.
The facility failed to maintain its boiler system, resulting in malfunctioning heating equipment and temperatures in resident rooms and common areas falling below regulatory requirements. Despite multiple vendor proposals and reports of insufficient heat, the facility did not act to address the boiler deficiencies, and only a portion of the boilers were operational. Staff interviews revealed that maintenance requests were hindered by unpaid bills and lack of administrative approval, and the Administrator was unaware of the extent of the heating problem.
Two residents were involved in an altercation due to inadequate supervision, resulting in one resident sustaining head lacerations. Despite known behavioral issues, the facility failed to update care plans or ensure proper monitoring, leading to the incident.
A facility failed to review and revise comprehensive care plans for three residents after significant events. A resident's care plan for an indwelling catheter was not updated after an ER visit for urinary retention. Another resident's care plan for behavior and victimization was not revised after a physical abuse incident, lacking evidence of required monitoring. A third resident's care plan was not reviewed following a physical altercation. The DON acknowledged the oversight in care plan updates.
The facility failed to provide sufficient nursing staff, particularly CNAs, leading to delays in resident care, especially during evenings and weekends. Residents reported long wait times for assistance with personal care, and staffing schedules consistently showed fewer CNAs than required. Staff interviews confirmed the challenges in maintaining adequate care due to staffing shortages, with agency staff often not showing up for work.
The facility failed to conduct annual performance reviews for CNAs, as required by their policy. A review of personnel files showed no evidence of such reviews for five CNAs. Interviews revealed that the responsibility for these evaluations fell through the cracks due to personnel changes, leading to the deficiency noted by surveyors.
The facility failed to administer resources effectively, leading to repeated deficiencies in staffing, infection control, and care quality. The administration and Director of Nursing were aware of staffing issues but did not adequately address them, resulting in unmet resident needs and unmonitored previous citations. The Director of Nursing was unaware of specific care issues, including infection control and care plan updates.
The facility lacked an active governing body to implement management policies, leading to deficiencies in resident care. Inconsistent communication between the Administrator and Governing Body hindered effective management. Residents reported delayed call light responses and insufficient staffing, especially on weekends, with no prompt action or follow-up on their concerns.
The facility's QAPI program failed to identify and prioritize issues, resulting in widespread deficiencies in Nursing Services, Administration, and Infection Control. Repeated deficiencies from past surveys were noted, and the facility lacked documented evidence of corrective actions. Interviews revealed a lack of awareness and oversight by the Director of Nursing, Administrator, and Operator/Owner, contributing to the ongoing issues.
The facility failed to maintain infection control practices during medication administration. An LPN did not sanitize the blood pressure machine and cuff after using them on multiple residents. Similarly, an RN did not sanitize the glucometer after finger stick blood sugar tests and failed to perform hand hygiene. Another LPN also neglected to sanitize the blood pressure equipment after use. Despite receiving education on these practices, staff did not adhere to the facility's policy requiring equipment cleaning between uses.
Two residents in an LTC facility did not receive regular showers as per their care plans, leading to a deficiency. One resident, with Cerebral Palsy and Depression, preferred showers at a later time, but this was not accommodated, resulting in missed showers. Another resident, with Non-Alzheimer's Dementia and Bipolar Disorder, also did not receive showers according to the schedule. Staff interviews revealed communication gaps and lack of awareness about the residents' preferences and care needs.
A resident with a history of healed pressure ulcers and a care plan for a pressure ulcer relieving device was found with a deflated air mattress on multiple occasions. Despite the resident's complaints of pain, the facility staff failed to address the issue, and there was no documentation of the use of pressure relieving devices. Interviews revealed a lack of awareness and communication among staff regarding the mattress issue.
A resident with behavioral issues, including stealing and involvement in altercations, did not receive necessary behavioral health care and services. The facility failed to evaluate intervention effectiveness, update care plans, and ensure consistent monitoring. Staff interviews revealed a lack of coordination and awareness in managing the resident's behavior.
The facility failed to store insulin pens properly, as observed during a survey. Insulin pens for four residents were stored together in a medication cart, contrary to the facility's policy requiring separate storage to ensure sanitation. A nurse admitted the oversight, while the DON stated there was no requirement for individual storage, indicating a lack of consistent policy implementation.
A resident with cerebral palsy and depression did not have their bathing preferences honored, as the facility failed to provide scheduled showers and instead gave bed baths without documented refusal. The resident preferred evening showers, but this was not communicated or reflected in their care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's preferences, contributing to the deficiency.
The facility failed to ensure accurate documentation in the MDS assessments for three residents, leading to discrepancies in their recorded statuses. A resident's discharge status was inaccurately documented, another's Schizophrenia diagnosis was omitted, and a third resident's behavioral symptoms were not recorded despite a physical altercation. The MDS Coordinator acknowledged these oversights, reflecting a failure to adhere to the facility's policy for comprehensive assessments.
The facility did not submit the required direct care staffing information for Quarter 3 of 2024 on time, as required by CMS. The Director of Human Resources and the Administrator were responsible for ensuring the submission, but an oversight led to the failure to meet the deadline.
The facility failed to maintain adequate staffing levels, leading to compromised resident care. Staffing schedules showed consistent shortages of LPNs and CNAs, particularly on weekends. Staff and residents reported delayed care, with Registered Nurse Supervisors covering LPN duties and residents experiencing delayed medication and inadequate incontinence care. The Assistant Administrator acknowledged the issue but was unclear on staffing adjustments, and the Director of Nursing did not provide further clarification.
The facility failed to properly dispose of garbage, with surveyors observing uncovered and overflowing dumpsters, scattered trash, and flies. Interviews revealed unclear responsibility for maintaining the garbage area, with the Director of Housekeeping and Administrator unaware of the issues.
The facility failed to provide consistent hot water for bathing and hygiene across all units, with water temperatures significantly below the required level and some areas lacking water flow. Residents reported being washed with cold water for months, and maintenance logs confirmed ongoing issues. Despite temporary measures like providing wipes, the deficiency persisted, indicating inadequate response.
The facility did not comply with food safety standards as kitchen staff were observed not wearing hairnets, contrary to the facility's policy. The policy requires all food service personnel to wear hairnets to maintain cleanliness. The issue was confirmed by the Cook and Food Service Director, and the Administrator acknowledged it as a new problem.
A resident with a diabetic foot ulcer did not receive the recommended wound treatment due to a lack of communication and documentation by the nursing staff. Despite recommendations from an Infectious Disease consultant and a podiatrist, there were no treatment orders documented, and the resident's care plan did not address the wound. Interviews revealed that the RN supervisor failed to notify the attending physician, and the LPN was unaware of the wound due to the absence of written orders.
A resident with a diabetic foot ulcer did not receive proper evaluation and treatment due to the facility's failure to ensure the attending physician reviewed and authenticated specialist recommendations. Despite consultations with an Infectious Disease specialist and a podiatrist, there was no documentation of the attending physician or nurse practitioner evaluating the wound or entering treatment orders. A communication lapse between the nurse practitioner and registered nurse contributed to this deficiency.
The facility did not post nurse staffing information daily from January to May 2024, particularly on weekends. The policy assigned the staffing coordinator to post schedules but did not specify nurse staffing data. Interviews revealed confusion over weekend posting responsibilities, with the Staffing Coordinator and RN Supervisor providing conflicting accounts. The DON confirmed daily posting requirements, and the Administrator considered it an isolated incident.
Two residents in the facility did not receive prescribed medications as per their care plans. One resident missed a dose of Lantus Insulin due to being asleep, and the physician was not notified. Another resident did not receive an antibiotic infusion for bacteremia as ordered upon hospital discharge. Despite multiple medication reviews, the antibiotic was not administered. These incidents indicate a failure in the facility's medication administration and communication processes.
The facility failed to provide quarterly financial statements to two residents, despite their cognitive ability and significant balances in their Personal Needs Accounts. Interviews revealed gaps in the process, with no proof of receipt or mailing of the statements.
The facility failed to ensure professional standards of quality for a resident with a PICC line. There was no documentation of the PICC in the resident's chart, nor evidence of dressing changes or site monitoring. Staff interviews revealed a lack of awareness and documentation regarding the PICC line.
A facility failed to document blood sugar levels for a diabetic resident as required by physician's orders. The issue was due to an error in the electronic medical record system, which did not allow nurses to enter the blood sugar results. The nursing staff performed the tests but could not document them, and the administration was unaware of the problem until the survey.
Failure to Reconcile and Verify Methadone Doses from External Opioid Treatment Programs
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain a system to accurately reconcile, verify, and oversee methadone medications received from external opioid treatment programs. Facility policies on controlled substance handling, medication administration, and consultant pharmacist services required accurate receipt, logging, and administration of controlled drugs, as well as verification of the five rights of medication administration using the electronic MAR and prescription labels. However, the facility had no policy or procedure specific to methadone received from opioid treatment programs and could not provide any documented agreement outlining coordination with those programs. Surveyors identified 10 residents, all diagnosed with opioid use disorder and various comorbidities such as endocarditis, heart failure, anemia, asthma, coronary artery disease, diabetes, hypertension, cerebral infarction, schizophrenia, benign prostatic hypertrophy, and viral hepatitis, whose methadone administration records showed discrepancies between physician orders and the dosages labeled on methadone bottles. In several cases, the physician’s order reflected a lower dose than the bottle label (for example, 60 mg ordered vs. 70 mg labeled, 115 mg ordered vs. 125 mg labeled, 80 mg ordered vs. 90 mg labeled, 120 mg ordered vs. 130 mg labeled, and 280 mg ordered vs. 295 mg labeled), while in other cases the physician’s order reflected a higher dose than the bottle label (for example, 40 mg ordered vs. 30 mg labeled, 95 mg ordered vs. 85 mg labeled, 30 mg ordered vs. 24 mg labeled, 20 mg ordered vs. 30 mg labeled, and 90 mg ordered vs. 80 mg labeled). Despite these discrepancies, the MARs documented administration of the physician-ordered doses, and controlled drug accountability records, when present, reflected the physician-ordered doses rather than the doses indicated on the clinic-supplied bottles. Interviews with nursing staff and medical providers revealed that methadone from the external clinics was handled without systematic reconciliation against physician orders or clinic documentation. Nurses reported that residents were escorted to methadone clinics, and the escort returned with labeled methadone bottles that were handed to the unit nurse, who logged only the number of bottles in the controlled drug record and stored them in a locked box. Nurses stated they did not receive paperwork from the clinics to verify dosage or changes, did not cross-check the dosage on the bottle against the physician’s order, and often relied only on the resident’s name on the bottle or familiarity with the resident. The attending physician stated that orders were entered by nurses based on the bottle labels and then signed, that they did not receive physical or electronic orders from the clinics, and that they were unsure of the correct methadone dosages but believed residents must receive the dosage indicated on the bottle and that the physician’s order and bottle label did not necessarily need to match. The consultant pharmacist reported that regimen reviews were limited to medications dispensed from the linked pharmacy and that there was no way to verify the correctness of methadone orders from the clinics. The Medical Director acknowledged not knowing the delivery process, stated that clinic reports were signed without review, and later characterized the situation as a system failure. The Administrator stated that nurses were responsible for reconciling physician orders with methadone regimens on the bottles and that attending physicians should have performed monthly record reviews to identify discrepancies. This combination of missing policies, lack of formal agreements, and staff practices resulted in methadone dosages that were inconsistent between physician orders and clinic-labeled bottles for multiple residents. The situation was determined to have caused no actual harm but posed a likelihood for serious harm that constituted Immediate Jeopardy to residents receiving methadone maintenance therapy.
Removal Plan
- The Director of Nursing reviewed all residents receiving methadone from an external opioid treatment program, confirmed residents with dosage discrepancies, and clinically assessed those residents with no signs/symptoms of toxicity or adverse reactions.
- The Director of Nursing contacted each methadone clinic to confirm the current prescribed methadone dose and frequency.
- The Director of Nursing contacted the Medical Director and obtained telephone orders to ensure the physician orders correspond with the doses on the methadone bottles.
- The Pharmacy Consultant completed a regimen review of residents prescribed methadone and confirmed discrepancies were corrected and no other discrepancies were identified.
- The facility created and implemented a new policy and procedure for methadone administration, order verification, reconciliation, and chain of custody, including use of a Reconciliation and Chain of Custody Receipt Form completed by the methadone clinic, reconciliation by the receiving licensed nurse against the facility physician order, escalation/verification steps for discrepancies, documentation in nursing progress notes, and retention of forms in a binder in the nursing office.
- All licensed nurses, attending physicians, the pharmacy consultant, and facility escorts received in-service training on the new policy.
Methadone Dosing Discrepancies and Failure to Verify Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure methadone was administered in accordance with physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Facility policy required that medication administration and documentation be timely and accurate, that the eMAR serve as the source for pouring and administering medications, and that licensed nurses verify the five rights by comparing the medication name, strength, route, and dosage schedule on the MAR against the prescription label. Despite this, a review of methadone administration records for 23 residents on methadone identified 10 residents whose methadone bottles were labeled with doses that did not match the physician’s orders entered in the electronic medical record. For these 10 residents, the physician’s orders and bottle labels showed consistent discrepancies in methadone dosages, although the eMARs documented administration of the ordered doses. Examples included residents with diagnoses such as endocarditis, heart failure, anemia, asthma, coronary artery disease, schizophrenia, viral hepatitis, and opioid use disorder. One resident had a physician’s order for 60 mg daily while the bottle was labeled 70 mg; another had an order for 115 mg while the bottle was labeled 125 mg; another had an order for 80 mg with a bottle labeled 90 mg. Additional residents had orders for 40 mg with a bottle labeled 30 mg, 95 mg with a bottle labeled 85 mg, 30 mg with a bottle labeled 24 mg, 20 mg with a bottle labeled 30 mg, 120 mg with a bottle labeled 130 mg, 280 mg with a bottle labeled 295 mg, and 90 mg with a bottle labeled 80 mg. All of these residents had methadone orders documented in the eMAR and received daily methadone doses as charted, but the labeled bottle doses did not match the physician orders. Interviews with nursing staff and medical leadership revealed systemic process failures and inconsistent practices in verifying methadone doses. An LPN stated that when administering methadone, they checked the physician’s order in the electronic record and then administered methadone labeled with the resident’s name, but did not cross-check the dosage on the bottle against the physician’s order and had not noticed discrepancies. An RN reported only checking the resident’s name on the bottle and not the physician’s order or dosage, explaining that they were familiar with the residents, despite acknowledging they were supposed to ensure the bottle dosage matched the order. Other RNs stated they followed the dosage on the bottle without comparing it to the physician’s order and had not noticed differences. Interviews with the attending physician, DON, and medical director further described a lack of clear communication and documentation processes between the facility and the methadone clinic. The attending physician stated that the methadone clinic prescribed the dosage and frequency, that they did not receive physical or electronic orders from the clinic, and that nurses entered orders into the electronic record from the bottle labels, which the physician then signed without knowing the intended methadone dose for each resident. The attending physician also stated that the physician’s order and the bottle dosage did not necessarily need to match for nurses to administer the medication. The DON reported that residents went to the methadone clinic to pick up medication, returned it to the unit nurse, and that the nurse called the attending physician with the dosage and entered the order, with no receipt or paperwork from the clinic. The medical director stated that the clinic sent a report with dosages and frequencies, that nurses entered this into the electronic record, and that they signed orders without reviewing the report, later characterizing the situation as a system failure due to lack of established processes and communication.
Failure of Medical Director Oversight for Methadone Medication Management
Penalty
Summary
The deficiency involves the failure of the medical director to collaborate with the facility to develop and implement procedures for the safe and accurate provision of methadone medications received from external opioid treatment programs. The facility’s policy on Physician Visits and Physician Delegation stated that the medical director’s role is to provide oversight of medical care practices, regulatory compliance programs, and clinical standards. Despite this, the medical director did not ensure that current standards of practice were followed for reconciling, verifying, and overseeing methadone medications from methadone clinics. Surveyor interviews revealed that an attending physician acknowledged having residents on methadone maintenance programs but stated they were unsure of the methadone dosage each resident was supposed to receive and that nurses were to administer the dosage indicated on the methadone bottle, even if it did not match the physician’s order. The medical director stated they did not know the process by which methadone was delivered to the facility and that the methadone dosage was determined by the methadone clinic, which sent a report to the facility. The medical director reported that nurses entered this information into the EMR as physician orders, which the medical director electronically signed without reviewing the clinic report, and that their only responsibility was to assess residents and renew orders. In a follow-up interview, the medical director characterized the lack of established processes and communication between the facility and the methadone clinic as a system failure.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving injury of unknown source were reported immediately, as required by policy and regulation. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia and diabetes, was found unable to stand on their left leg and was transferred to the hospital, where a closed left hip fracture was diagnosed. The resident was unable to explain how the injury occurred, and there was no documentation of a fall or traumatic event. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the New York State Department of Health until ten days after the change in the resident's condition was observed. Record review and interviews revealed that the delay in reporting was due to a lack of immediate notification to the Director of Nursing by the nursing supervisor. The Director of Nursing only became aware of the fracture after the resident was readmitted from the hospital and subsequently reported the injury. The facility's investigation did not find evidence of abuse, mistreatment, or neglect, and there was no documentation that the fracture was pathological. However, the failure to report the injury of unknown source within the required timeframe constituted a deficiency.
Failure to Provide Required Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident identified as being at risk for falls received adequate supervision and assistive devices as outlined in their care plan. Specifically, the resident, who had diagnoses including schizoaffective disorder, dementia, and anxiety disorder, was assessed as having severely impaired cognition and significant functional limitations. The resident's care plan required the bed to be maintained in the lowest position and the use of bilateral floor mats to prevent falls. Despite these interventions being documented, multiple observations showed the resident's bed was in the highest position and no floor mats were present. These observations occurred on more than one occasion, and staff confirmed that floor mats were not in use in the resident's room. The resident had a documented history of multiple falls, with incidents occurring both on and off the floor mats, and was known to be non-compliant and to get up independently. The facility's policies required individualized fall prevention interventions and regular monitoring by nursing supervisors to ensure compliance with care plans. However, interviews with staff, including a CNA and the DON, revealed that the required interventions were not consistently implemented, resulting in the resident being left without the necessary fall prevention measures as specified in their care plan.
Failure to Timely Report and Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting and follow-up of alleged misappropriation of resident property to the State Survey Agency as required by regulations. In three cases involving residents with intact cognition and various medical diagnoses, allegations were made that staff members borrowed money from residents and did not repay it. The facility did not report one of these allegations to the New York State Department of Health within the required 24-hour timeframe, and in all cases, failed to submit the required Follow-Up Investigation Reports within five business days of the incidents. For one resident with depression and opioid abuse, an allegation was made that a patient care assistant borrowed money several months prior and did not repay it. The initial report to the state was delayed, and the follow-up investigation report was also submitted late. The facility's investigation could not substantiate the allegation due to inconsistent statements and lack of corroborating evidence. Another resident with cerebral palsy, anxiety disorder, and hypertension reported a similar incident involving a certified nursing assistant. While the initial report was timely, the follow-up investigation report was again submitted late, with the investigation unable to confirm the allegation due to lack of witnesses and denial by the staff member involved. Interviews with facility leadership revealed a lack of awareness regarding the specific reporting timelines for both initial and follow-up reports. The Director of Nursing and the Administrator both indicated they were either unaware of the requirements or the late submissions, and delays were attributed to the need for additional information and difficulty contacting involved staff. Facility policy and state guidance both require immediate reporting and timely completion of investigations, which were not followed in these cases.
Failure to Immediately Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple medical conditions, including Multiple Sclerosis, Hemiplegia, and Adjustment Disorder. The resident, who had intact cognition and required assistance with activities of daily living, reported to the Director of Recreation and a nursing supervisor that two Certified Nursing Assistants had threatened to slap them if they pressed the call bell again. The Director of Recreation documented the allegation but did not immediately report it to the appropriate supervisory staff, citing a lack of specific details such as the staff member's name or the date of the incident. Instead, the written statement was placed in the mailboxes of the Social Worker and, purportedly, the Director of Nursing, but was not directly communicated to them. As a result, the Social Worker and Director of Nursing were not made aware of the allegation until several days later, delaying the initiation of an internal investigation. The facility's policy required immediate reporting and prompt initiation of investigations into abuse allegations, but this process was not followed. There was no documented evidence that an investigation was started until days after the initial report, and no immediate measures were put in place to protect the resident from further potential abuse.
Failure to Timely Transfer Deceased Residents' Personal Funds
Penalty
Summary
The facility failed to transfer the personal funds of two deceased residents to the probate jurisdiction administering their estates within the required 30-day period. According to the facility's admission agreement, refunds for the balance in a resident's personal account, after deducting any amounts owed to the facility, are to be made to the resident after discharge or, in the case of death, to the probate jurisdiction or by a New York small estate affidavit, unless otherwise claimed by the Department of Social Services. Record review showed that for two residents who had expired, there was no disbursement of their remaining funds or final accounting sent to the Public Administrator within the required timeframe. Interviews with facility staff revealed that the Payable Coordinator is responsible for reviewing monthly reports to identify residents who have been discharged or have expired and who have a balance left in their accounts. The Payable Coordinator acknowledged that the funds for the two deceased residents were not transferred within 30 days but could not provide an explanation for the delay. The Administrator confirmed the process for transferring funds after a resident's death but also indicated that the required transfer did not occur within the specified period for these cases.
Failure to Assess and Notify Physician After Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a comprehensive clinical assessment was performed to identify changes in a resident's condition and did not provide treatment and care in accordance with professional standards. The resident, who had a history of severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, traumatic brain injury with epilepsy, and incontinence, was observed with symptoms including a stuffy nose, low-grade fever of 100.5°F, and restlessness. Despite these changes, there was no documented evidence that the medical doctor was notified of the resident's elevated temperature and restlessness. Additionally, after acetaminophen was administered for the fever, there was no documentation of a follow-up assessment to evaluate the resident's response to the medication. Multiple staff interviews confirmed that the resident appeared weaker and was experiencing changes in condition, but the required notifications and assessments were not consistently documented or performed. The medical doctor was only informed after the resident had expired due to cardiac arrest secondary to coronary artery disease. The facility's policy required timely identification, documentation, and response to significant changes in a resident's condition, but these procedures were not followed, resulting in actual harm to the resident.
Failure to Notify Representative and Physician of Resident Condition Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's designated representative and physician of significant changes in the resident's condition. The resident, who was severely cognitively impaired and had multiple diagnoses including epilepsy, non-Alzheimer's dementia, depression with schizophrenia, traumatic brain injury, and incontinence, exhibited restlessness and developed a low-grade fever of 100.5°F. Certified Nursing Assistant observed the resident appearing weaker and reported this to the LPN, who documented the symptoms and administered Tylenol. The Registered Nurse Supervisor was notified and attempted to contact the medical doctor without success. However, there was no documentation that the resident's representative or family was informed of these changes, as required by facility policy and state regulation. Interviews with staff confirmed that the family was not notified because the resident was not perceived to be in distress, and there was no evidence of reassessment after Tylenol administration. The Director of Nursing acknowledged that both the physician and family should have been notified when the resident exhibited fever and restlessness. The lack of notification and documentation constituted a failure to comply with the facility's policy and regulatory requirements for informing representatives of significant changes in a resident's condition.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels throughout the building, as required by federal and state regulations. Observations during the survey revealed that all sampled resident rooms, corridors, and stairwells on five resident floors had temperatures below the required range, with some areas as low as 40 to 53 degrees Fahrenheit. Multiple complaints and grievances were filed by residents regarding the loss of heat over a period of time, and maintenance logbooks documented ongoing heating issues in 23 resident rooms. Despite these reports, there was no documented evidence that the facility had identified or addressed unsafe room temperatures. The Administrator was unaware of the loss of heat or that room temperatures had dropped below regulatory standards, and stated that the PTAC units were not necessary because the boiler was supposed to provide heat. However, maintenance records and vendor invoices indicated that the boiler system was not functioning properly, with only 5 of 13 boilers operational at one point, and that the facility had not maintained an active service contract for preventive maintenance. Vendor communications documented repeated recommendations and proposals for repairs and maintenance that were not addressed by the facility. Staff interviews confirmed that the heating issues were discussed in meetings and that activities staff were called in to distribute hot drinks due to the cold conditions. The Medical Director was not aware of the heat-related issues, and temperature logs maintained by the facility were incomplete, lacking specific room or corridor information. The facility's failure to maintain adequate heating resulted in Immediate Jeopardy and Substandard Quality of Care, affecting all residents in the building.
Removal Plan
- Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs revealed temperatures within acceptable ranges.
- Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas.
- The Administrator provided a vendor contract to provide annual maintenance to boilers, and for the maintenance of Packaged Terminal Air Conditioner units.
- The facility completed staff training on identifying and addressing temperature related issues, procedures for reporting issues, deploying emergency measures, and ensuring resident comfort. All staff received the in-service.
- Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the temperature.
- The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues.
Failure to Maintain Safe Temperatures and Boiler Maintenance
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in residents' rooms and common areas, as required by State and Federal regulations. Six resident grievances were filed over several days regarding lack of heat, and observations confirmed that temperatures in all sampled rooms, corridors, and stairwells were below required ranges. The Administrator was not aware of the loss of heat in the building during this period. Additionally, there was no documented evidence that the boiler room equipment and Packaged Terminal Air Conditioner (PTAC) units were routinely maintained. The PTAC units were found to be incorrectly connected and not providing heat, and the boilers were not functioning adequately due to lack of maintenance. The Director of Maintenance reported that attempts to have the boilers serviced were unsuccessful because the vendor refused to come due to overdue unpaid balances, and all requests for materials or services required prior approval from the Administrator. The vendor confirmed that the boilers had significant issues from lack of maintenance and were operating at only 40% capacity, with proposals for repairs sent to both the Administrator and Director of Maintenance. Despite this, the Administrator denied receiving any such communications. These failures resulted in Immediate Jeopardy due to the likelihood of more than minimal harm to all residents.
Removal Plan
- The Administrator is conducting meetings with department heads to review any issues.
- Staff have been in-serviced, a policy was created on how agency staff will also be in-serviced.
- Morning meetings attended by all department heads are being conducted.
- Resident council meeting was rescheduled.
- The Administrator provided documentation of regular rounds.
- A binder of Vendor Documents was created and placed at the Security Desk by the elevators.
- Emergency Preparedness plan for loss of heating was revised and discussed at the QAPI meeting, the Administrator is the Acting Director of Maintenance.
Failure to Maintain Boiler System Results in Inadequate Heating
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically neglecting routine maintenance of the boiler system. The annual service contract for the boilers had expired, and the facility did not have a current contract in place. Multiple proposals and quotes from vendors to address identified boiler deficiencies and to provide ongoing maintenance were not acted upon by the facility. Invoices and service records showed repeated reports of insufficient heat and hot water, with only a fraction of the boilers functioning at any given time. The lack of maintenance led to the heating system malfunctioning, resulting in inadequate heating throughout the building. Observations during the survey revealed that temperatures in resident rooms, corridors, and stairwells were below the required state and federal ranges, with some areas measured as low as 40 degrees Fahrenheit. Resident rooms closest to the stairwells had the lowest temperatures. There was no documented evidence that the facility staff were inspecting or maintaining the heating system equipment, including the boilers and Packaged Terminal Air Conditioner (PTAC) units. The Director of Maintenance confirmed that the PTAC units were not blowing hot air due to incorrect connections and that the Administrator had been made aware of the issue. Interviews with the Director of Maintenance, the Administrator, and the boiler vendor revealed that the vendor had stopped servicing the facility due to unpaid bills, and that the Director of Maintenance was not permitted to order services or materials without prior approval from the Administrator. The Administrator was unaware of the extent of the heating issues and the low temperatures in resident rooms. The vendor reported that the boilers were operating at only about 40% capacity due to lack of maintenance, which contributed to the insufficient heat and hot water throughout the building.
Removal Plan
- Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs revealed temperatures within acceptable ranges.
- Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas.
- The Administrator provided a vendor contract for annual boiler maintenance and the maintenance of Packaged Terminal Air Conditioner units.
- The facility completed staff training on identifying and addressing temperature-related issues, procedures for reporting problems, deploying emergency measures, and ensuring resident comfort. 100% of staff received the in-service.
- A Quality Assurance meeting was held to discuss the findings of the Immediate Jeopardy. Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the thermometers.
- The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by an incident involving two residents. Resident #118, who had a history of stealing and involvement in physical altercations, was not adequately supervised or monitored despite staff awareness of their behavior. On August 2, 2024, Resident #118 snatched a $20 bill from Resident #151's hand in an elevator, leading to Resident #151 hitting Resident #118 on the head with a cane. This altercation resulted in Resident #118 sustaining head lacerations that required emergency medical intervention, including 14 staples. The facility's policy on Abuse Prohibition and Prevention, which was reviewed in May 2023, mandates a zero-tolerance approach to abuse and requires the provision of a safe environment for all residents. However, the facility's investigation into the incident revealed that there was cause to believe resident abuse had occurred. Despite the policy's requirements, there was no documented evidence that the care plans for either resident were reviewed or updated following the incident. Resident #151 had a care plan for victimization, but it lacked evidence of evaluation or revision after the altercation. Similarly, Resident #118's care plan, which included interventions for behavior monitoring and safety, was not updated, and there was no evidence of the required close observation or 1:1 monitoring. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, highlighted a lack of consistent monitoring and supervision of Resident #118, particularly when they left their assigned unit. Staff members were aware of Resident #118's behavior issues, such as stealing and wandering to other units, but there was no clear protocol for monitoring the resident's movements or ensuring their safety. The Director of Social Services acknowledged the altercation but indicated that the responsibility for monitoring and intervention lay with the nursing department. The Director of Nursing confirmed awareness of Resident #118's behavioral issues but did not provide a clear response on how the resident was monitored when leaving their unit.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised periodically and after each assessment, including both comprehensive and quarterly review assessments. This deficiency was evident in the cases of three residents. Resident #84's care plan for an indwelling catheter was not reviewed and revised after returning from an emergency room visit due to urinary retention and pain at the catheter insertion site. Additionally, the care plan was not updated after quarterly assessments and the annual assessment. Resident #118's care plan interventions for behavior and victimization were not reviewed and evaluated after a resident-to-resident physical abuse incident. The care plan lacked updates following the incident where Resident #118 was hit in the head by another resident. Furthermore, there was no documented evidence of close observation or 1:1 monitoring as stated in the care plan interventions. Resident #151's care plan interventions were not reviewed and evaluated following a resident-to-resident physical altercation. The care plan for victimization was not updated after the incident, and there was no evidence of the interventions being reviewed. The Director of Nursing acknowledged that the nurse supervisor is responsible for updating the care plans, but the oversight was not addressed.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents, as evidenced by observations, record reviews, and interviews conducted during the Recertification and Abbreviated Survey. Several residents reported a shortage of Certified Nursing Assistants (CNAs), particularly during evenings and weekends, leading to delays in assistance with toileting, bathing, and personal care. The facility's staffing schedules from July to November 2024 consistently showed fewer CNAs than required, with some shifts having only one CNA for units with up to 45 residents. Interviews with residents revealed significant delays in response times to call bells, with some residents waiting up to four hours for assistance. Residents expressed frustration over the lack of timely help, which sometimes resulted in missed showers and inadequate personal care. Staff interviews corroborated these findings, with CNAs and nurses acknowledging the staffing shortages and the resulting challenges in providing adequate care. The facility's staffing plan indicated a need for 4 CNAs per unit during day and evening shifts and 3 during night shifts. However, actual staffing often fell short of these numbers, with agency staff frequently not showing up for work. The Director of Nursing and the Administrator acknowledged the staffing issues, citing challenges in hiring and retaining staff, particularly due to better pay offered by staffing agencies. Despite efforts to improve staffing, the facility continued to struggle with maintaining adequate levels of care.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews for Certified Nursing Assistants (CNAs) were conducted at least once every 12 months, as required by their policy. This deficiency was identified during a Recertification Survey conducted from November 13 to November 21, 2024. The facility's policy, dated June 2024, mandates annual performance reviews for nurse aides, but a review of personnel files for five CNAs showed no documented evidence of such reviews. Interviews with the Director of Human Resources and the Director of Nursing revealed that the CNAs were hired years ago, and no performance reviews could be located in their files. The Director of Nursing could not explain the absence of these reviews. The Administrator acknowledged that the Nursing Department is responsible for conducting these evaluations and attributed the oversight to personnel changes within the facility, which led to the responsibility of performance reviews being neglected. The facility's assessment tool, dated October 2024, indicated that performance reviews should provide structured feedback and identify areas for improvement, but it did not specify the frequency of these reviews. This lack of adherence to policy and oversight resulted in the deficiency noted by the surveyors.
Inadequate Administration and Staffing Deficiencies
Penalty
Summary
The facility was found to be inadequately administered, failing to use its resources effectively and efficiently to ensure the highest practicable well-being of its residents. The administration did not maintain sufficient staffing levels to meet residents' needs, and there was a lack of monitoring and enhancement of care quality, as evidenced by repeated deficiencies from previous surveys. These deficiencies included issues with activities of daily living, medication storage, infection control, and performance evaluations for nursing assistants. The administration was aware of the staffing issues but did not provide evidence of efforts to retain staff or monitor previous citations to prevent recurrence. The Director of Nursing was also aware of the staffing issues but did not understand the extent of their impact on resident care and services. During interviews, the Director of Nursing admitted to being unaware of several issues, including infection control problems, deflated mattresses, and outdated care plans. The Director of Nursing also could not explain how residents with behavioral issues were supervised when off the unit. The Administrator acknowledged the repeated staffing deficiency and mentioned contracting staffing agencies to fill positions, but was unaware of the newly identified issues, considering them isolated incidents.
Lack of Active Governing Body and Inadequate Resident Care
Penalty
Summary
The facility was found to lack an active governing body responsible for establishing and implementing management policies, as evidenced by multiple deficiencies identified during the Recertification and Complaint Survey. There was inconsistent communication between the facility Administrator and the Governing Body, which hindered effective management and regulatory compliance. The facility's policy on Quality Assurance and Performance Improvement (QAPI) indicated that the Governing Body is accountable for the program, including identifying and prioritizing problems and ensuring corrective actions are effective. However, the Operator/Owner of the facility admitted to attending QAPI meetings only once a year, relying on the Administrator to submit monthly reports, which suggests a lack of active oversight. During a Special Resident's Council Meeting, residents reported that call lights were not answered promptly, especially on weekends, and they were often left in bed due to insufficient staffing. These concerns were previously raised in an August 2024 Resident Council meeting, where issues such as staff using cell phones, poor customer service, and room cleanliness were also noted. The residents expressed that the facility did not act promptly on their concerns, and there was no follow-up from the staff, indicating a failure in addressing and resolving resident issues effectively.
Inadequate QAPI Program and Oversight Lead to Widespread Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems and opportunities for improvement. This was evident during the Recertification and Complaint Survey, where widespread deficiencies were noted in Nursing Services, Administration, and Infection Control. The facility also had repeated deficiencies from previous surveys, indicating a lack of effective corrective action. The QAPI plan, last revised in May 2023, was intended to guide the facility in improving the quality of care and resident life, but the facility could not provide documented evidence of systems and reports for identifying, reporting, investigating, analyzing, and correcting these deficiencies. Interviews with facility staff revealed a lack of awareness and oversight regarding the deficiencies. The Director of Nursing was unaware of the infection control issue, attributing it to an isolated incident and new staff. The Administrator acknowledged awareness of staffing issues but claimed other issues were isolated and not previously known. The Operator/Owner attended QAPI meetings only once a year and relied on the Administrator for compliance, indicating insufficient oversight by the governing body. This lack of effective governance and oversight contributed to the facility's failure to address and rectify ongoing deficiencies.
Infection Control Deficiency in Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed during the recertification survey. Specifically, Licensed Practical Nurse #4 did not sanitize the blood pressure machine and cuff after using them on Residents #69, #47, and #92. This oversight occurred despite the facility's policy requiring equipment shared between residents to be cleaned and disinfected after each use to prevent cross-contamination. Licensed Practical Nurse #4 acknowledged forgetting to sanitize the equipment after each use. Similarly, Registered Nurse #5 did not sanitize the glucometer after using it for finger stick blood sugar tests on Residents #412 and #87. The nurse also failed to perform hand hygiene after removing gloves and before leaving the residents' rooms. Although Registered Nurse #5 was aware of the requirement to clean the glucometer after each use, they did not adhere to this practice during the observed instances. Additionally, Licensed Practical Nurse #1 did not sanitize the blood pressure machine and cuff after using them on Residents #7 and #74. Despite having received education on the necessity of cleaning the equipment after each use, Licensed Practical Nurse #1 admitted to missing this step. The Director of Nursing and Infection Prevention Nurse confirmed that licensed nurses had received in-service education on cleaning equipment between resident usage.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services and assistance to maintain grooming and personal hygiene. This deficiency was identified during a Recertification and Complaint Survey, where it was found that two residents, Resident #48 and Resident #169, were not provided regular showers according to their care plans. The facility's policy required that residents be offered showers as specified in their care plans, but this was not adhered to for these residents. Resident #48, diagnosed with Cerebral Palsy and Depression, required substantial assistance for showering and had a care plan specifying showers twice a week. However, records showed that Resident #48 received only bed baths on certain dates and not the scheduled showers. Interviews revealed that Resident #48 preferred showers at a later time, but this preference was not accommodated, and there was a lack of communication among staff regarding the resident's preferences and care needs. Resident #169, with diagnoses including Non-Alzheimer's Dementia and Bipolar Disorder, was also dependent on staff for bathing. The care plan specified showers twice a week, but records indicated that showers were not consistently provided according to the schedule. Staff interviews highlighted a lack of awareness and communication regarding the resident's shower schedule, contributing to the failure to provide the necessary care. The Director of Nursing acknowledged the issue but could not explain why the residents did not receive showers as per their care plans.
Failure to Maintain Pressure Relief Mattress for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure ulcers received care consistent with professional standards to prevent pressure ulcers. This deficiency was identified for a resident with a history of healed pressure ulcers who had a care plan for using a pressure ulcer relieving device when in bed. The resident was observed with a deflated air mattress on three occasions, which was not addressed by the facility staff despite the resident's complaints of pain and discomfort. The facility's policy required regular inspection and maintenance of mattresses, including specialized pressure relief mattresses. However, there was no documentation of the use of pressure relieving devices for the resident, and the maintenance log did not record any entries regarding the deflated mattress. Interviews with staff revealed a lack of awareness and communication regarding the mattress issue, with the primary Certified Nursing Assistant unaware of the deflation, and the Maintenance Director stating that the maintenance department does not oversee mattresses. The Wound Care Nurse was only notified of the issue after the surveyor's observation, and a leak was found in the mattress.
Failure to Provide Adequate Behavioral Health Care and Monitoring
Penalty
Summary
The facility failed to ensure that Resident #118 received necessary behavioral health care and services, as evidenced by multiple incidents of behavioral symptoms such as stealing from other residents and involvement in resident-to-resident altercations. The facility did not evaluate the effectiveness of interventions to address the resident's behavior, lacked an individualized approach in the care plan, and failed to monitor and supervise the resident adequately. The care plan for victimization/aggressive behavior was not updated following an altercation on 08/02/2024, and there was no documented evidence of close observation or 1:1 monitoring as required by the care plan. Resident #118 was admitted with diagnoses including violent behavior, unspecified mood disorder, and Parkinson's disease, which contributed to moderate cognitive impairment and required supervision with most activities of daily living. Despite these needs, the facility's care plans were not effectively implemented or updated to address the resident's ongoing behavioral issues. The care plans included interventions such as identifying triggers, room changes, and psychiatric evaluations, but these were not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and coordination in monitoring Resident #118's behavior. Certified Nursing Assistants and Licensed Practical Nurses acknowledged the resident's behavior issues but did not consistently monitor or redirect the resident when they left their unit. The Director of Social Services and the Director of Nursing were aware of the resident's behavior but did not ensure that appropriate interventions were in place or that care plans were updated. This lack of coordination and documentation contributed to the facility's failure to provide necessary behavioral health care and services to Resident #118.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that all medications and biologicals were stored safely, specifically concerning the storage of insulin pens. During a recertification survey, it was observed that insulin pens belonging to four different residents were stored together in a compartment in the top drawer of a medication cart on the 5th floor. This storage method did not comply with the facility's policy, which requires medications to be stored in accordance with manufacturer's specifications and professional standards to ensure proper sanitation. A registered nurse administering medications acknowledged the oversight, stating that the insulin pens should have been stored separately in individual plastic bags but were not due to being busy. However, the Director of Nursing contradicted this by stating there was no requirement to store insulin pens in individual plastic bags. This discrepancy highlights a lack of consistent understanding and implementation of the facility's medication storage policy.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination by not supporting their bathing preferences. Resident #48, who has cerebral palsy and depression, was assessed as cognitively intact and required substantial assistance for bathing. The resident expressed a preference for showering, which was documented as somewhat important in their assessment. However, the facility did not document the resident's bathing preferences in their care plan, and the resident's scheduled showers were not consistently provided. Instead, the resident received bed baths on several occasions without evidence of refusal or preference for this alternative. Interviews with staff revealed a lack of awareness and communication regarding the resident's preferences. Certified Nursing Assistants reported that the resident sometimes refused showers due to the early schedule, preferring evening showers instead. However, this preference was not communicated to or acknowledged by the nursing staff, and the resident's care plan was not updated to reflect this change. The Director of Nursing confirmed that the shower schedule could be adjusted based on resident preferences, but this was not done for Resident #48, leading to the deficiency.
Inaccurate Documentation in MDS Assessments
Penalty
Summary
The facility failed to ensure accurate documentation in the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their recorded statuses. Resident #462's discharge status was inaccurately documented as being discharged to a short-term general hospital, while the nursing progress notes indicated the resident was discharged to the community. The MDS Coordinator acknowledged this oversight during an interview. Resident #311's diagnosis of Schizophrenia was omitted from the quarterly MDS assessment, despite being documented in the Hospital and Community Patient Review Instrument and a psychiatric evaluation. The MDS Coordinator expressed caution in coding Schizophrenia due to a memorandum from the Centers for Medicare and Medicaid Services, although the new psychiatrist did not diagnose Schizophrenia. Resident #118's behavioral symptoms were not documented in the MDS assessment, despite an incident where the resident was involved in a physical altercation after grabbing money from another resident. The Director of Nursing confirmed that the MDS Coordinator was responsible for the accuracy of the assessment. These inaccuracies in the MDS assessments reflect a failure to adhere to the facility's policy, which mandates a standardized and comprehensive assessment process to ensure proper care delivery and resident-centered care planning.
Failure to Submit Direct Care Staffing Data Timely
Penalty
Summary
The facility failed to submit the required direct care staffing information for Quarter 3 of 2024 in a timely manner, as mandated by the Centers for Medicare and Medicaid Services (CMS). According to the CMS Electronic Staffing Data Submission Payroll-Based Journal, facilities are required to submit direct care staffing information, including agency and contract staff, based on payroll and other auditable data. This data must be submitted quarterly and received by the end of the 45th calendar day after the last day of each fiscal quarter to be considered timely. However, the facility did not submit the necessary data for the period from April 1 to June 30, 2024, by the specified deadline. During interviews conducted as part of the Recertification Survey, the Director of Human Resources stated that they are responsible for ensuring all time management records of staff are completed and sent to the Administrator for submission. The Administrator, who is responsible for submitting the Payroll Based Journal, acknowledged awareness of the deadline but could not explain the failure to submit the data, attributing it to an oversight. This oversight resulted in non-compliance with the CMS requirements for timely submission of staffing data.
Staffing Shortages Compromise Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, compromising their safety and well-being. The facility's staffing levels were consistently below the minimum levels assessed as necessary to provide adequate care. The staffing policy outlined the required number of licensed nurses and nurse aides, but the actual staffing schedules for April, May, and June 2024 showed repeated shortages, particularly on weekends. Interviews with staff and residents confirmed these deficiencies, with reports of inadequate staffing leading to delayed care and unmet needs. On specific dates, the facility experienced significant shortages of both Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs). For instance, on June 9, 2024, there were only 15 CNAs on the day shift against a required 20, and similar shortages were noted on other days. Staff interviews revealed that Registered Nurse Supervisors often had to perform the duties of LPNs due to these shortages. Additionally, the facility's Assistant Administrator, who also served as the Assistant Director of Nursing, acknowledged the staffing issues but was unclear on how adjustments were made according to the staffing policy. Residents reported negative impacts due to the staffing shortages, such as delayed medication administration and inadequate incontinence care. One resident mentioned waiting longer for medication on weekends and staying in bed due to insufficient staff to assist with transfers. Another resident expressed concerns about the lack of nurse aides, leading to delays in receiving care. The facility's Director of Nursing did not provide further clarification on the staffing procedure, indicating a lack of effective communication and management in addressing the staffing deficiencies.
Improper Garbage Disposal and Lack of Responsibility
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a Recertification Survey. The surveyors noted that the dumpster outside the facility was not covered, and various types of garbage were scattered on the ground around it. Items such as broken food service carts, an air conditioning unit, and wooden pallets were found lying next to the dumpster. Additionally, an overflowing garbage bin contained furniture, laundry containers, and computers, while an uncovered recycling bin had clear plastic bags with exposed cans and cardboard boxes. Flies were observed around the dumpster, indicating a lack of proper containment. Interviews with facility staff revealed a lack of clarity regarding responsibility for maintaining the garbage disposal area. The Director of Housekeeping stated that garbage pickup was scheduled for specific days and believed there was no need to cover bins containing non-perishable items. They also mentioned that the kitchen staff shared responsibility for maintaining the garbage bins. The Administrator was unaware of the garbage disposal issues and stated that the dumpster should not contain perishables, and lids should always be closed. It was unclear who was responsible for maintaining the garbage disposal area, contributing to the deficiency.
Inadequate Hot Water Supply in Facility
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the lack of consistent hot water supply across all six units observed during the recertification survey. The issue persisted from April through June, with maintenance logs indicating multiple entries of hot water supply problems. Observations revealed water temperatures significantly below the required 110 degrees Fahrenheit, with some shower rooms having no water flow or pressure. Residents reported being without hot water for months, and some were washed with cold water, highlighting the facility's failure to address the ongoing issue effectively. Interviews with staff and residents further confirmed the deficiency. The Maintenance Director acknowledged ongoing boiler repairs, while the Director of Nursing mentioned providing wipes to residents as a temporary measure. Despite these efforts, the Administrator claimed no resident complaints were received, contradicting resident statements during the Resident Council Meeting. The facility's inability to provide a policy on loss of hot water and the recurrence of the issue indicate a lack of adequate response to the deficiency.
Non-Compliance with Food Safety Standards
Penalty
Summary
The facility failed to ensure that food was prepared in accordance with professional standards for food service safety, as observed during the Recertification Survey. Specifically, kitchen staff were seen not wearing hairnets in the kitchen, which is a violation of the facility's policy. The policy, last reviewed in February 2024, mandates that all food service personnel maintain high standards of personal cleanliness and wear hairnets or coverings that cover all hair while working. On two separate occasions, dietary workers were observed without hair coverings in the kitchen areas. Interviews with the Cook and the Food Service Director confirmed that it is mandatory for kitchen staff to wear hairnets and beard protectors. The Administrator acknowledged that the Food Service Director is responsible for ensuring compliance with this policy and stated that this was a new issue for the facility.
Failure to Provide Recommended Foot Care for Diabetic Ulcer
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for a resident with a diabetic foot ulcer, as per professional standards of practice. The resident, who had diagnoses of Diabetes Mellitus with Foot Ulcer and Peripheral Vascular Disease, did not receive the recommended wound treatment from both an Infectious Disease consultant and a podiatrist. The resident was observed with a yellow-stained and soiled gauze dressing on their left foot, indicating a lack of proper wound care. The deficiency was further highlighted by the absence of a comprehensive care plan and appropriate interventions to address the resident's foot wound. Despite recommendations for a topical antibiotic ointment and hydrogel dressing, there were no documented treatment orders in the resident's records. The nursing staff failed to document and communicate the necessary treatment orders to the attending physician, resulting in the resident not receiving the prescribed care. Interviews with the nursing staff and medical personnel revealed a breakdown in communication and responsibility. The Registered Nurse supervisor did not notify the attending physician of the consultation recommendations, and the Licensed Practical Nurse was unaware of the resident's wound due to the lack of written orders. The Director of Nursing and Medical Director both indicated that the responsibility for following up on consultation recommendations was not adequately fulfilled, leading to the deficiency in care.
Failure to Review and Authenticate Treatment Recommendations for Diabetic Ulcer
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and authenticated treatment recommendations for a resident with a diabetic foot ulcer. The resident, who had diagnoses of Diabetes Mellitus with Foot Ulcer and Peripheral Vascular Disease, was seen by an Infectious Disease consultant and a podiatrist. However, there was no documented evidence that the attending physician or nurse practitioner evaluated the resident's wound or reviewed the treatment recommendations provided by these specialists. This lack of documentation spanned from early April to early June, during which time no treatment orders were entered for the resident's wound. The facility's policies required the attending physician to authenticate orders from consulting physicians, but this was not adhered to in the case of the resident's diabetic ulcer. Interviews with the nurse practitioner and attending physician revealed a communication breakdown, as the nurse practitioner was not informed of the consultation recommendations by the registered nurse, preventing the entry of necessary treatment orders. Consequently, the resident's wound care was not properly managed according to the recommendations provided by the specialists.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily, as required, during the period from January 2024 through May 2024. The facility's policy, effective August 2023, assigned the responsibility of posting the daily schedule to the staffing coordinator but did not explicitly include the posting of nurse staffing data. A review revealed that there were no postings available for Saturdays and Sundays during the specified period. Interviews conducted during the survey indicated a lack of clarity regarding responsibility for weekend postings. The Staffing Coordinator stated that the Registered Nurse Supervisor was responsible for posting on weekends, while Registered Nurse #4, the weekend supervisor, stated they were not given this responsibility. The Director of Nursing confirmed that nurse staffing information must be posted daily and that Registered Nurse Supervisors were responsible for weekend postings. The Administrator mentioned that the posting board had been moved to a noticeable location and considered the issue an isolated incident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a complaint survey for two residents. The first resident, diagnosed with Diabetes Mellitus, did not receive their prescribed Lantus Insulin at the scheduled time because they were asleep. There was no documentation indicating that the physician was notified of the missed dose, which is a requirement when a medication is missed or refused. Interviews with the resident and staff revealed that the nurse responsible for the oversight no longer worked at the facility, and the Director of Nursing was unaware of the incident. The second resident, who was admitted with hospital discharge orders for an antibiotic intravenous infusion for bacteremia, did not receive the prescribed antibiotic. The hospital discharge summary included a prescription for a 4-week course of antibiotics, but the facility's records showed no evidence that the antibiotic was ordered or administered. Despite multiple reviews and reconciliations of medications by the nurse practitioner and physician, the antibiotic was not included in the orders or administered. Interviews with the nursing staff and the Director of Nursing indicated that the discharge medication orders were typically reviewed and reconciled, but in this case, the antibiotic was overlooked. These deficiencies highlight a failure in the facility's medication administration process, where critical medications were not administered as prescribed, and there was a lack of communication and documentation regarding missed doses. The facility did not adhere to the required protocols for notifying physicians of missed medications, which is essential for maintaining the residents' health and safety.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to ensure that individual financial records were made available to residents and/or their representatives through quarterly statements and upon request. This deficiency was identified during a recertification survey conducted from 12/18/23 to 12/22/23. Specifically, there was no documented evidence that quarterly statements were provided to two residents, Resident #72 and Resident #131, out of 35 residents reviewed for Personal Funds. Both residents were cognitively intact and had significant balances in their Personal Needs Accounts (PNA) over the reviewed periods, but neither received the required quarterly financial statements. Interviews with the residents and staff revealed gaps in the process of distributing these statements. Resident #131 confirmed they had not received any financial statements and expressed a desire to receive them. The Human Resources/Payroll Manager indicated that the Account Receivables Department was responsible for preparing the statements, which were then given to the Director of Social Work to distribute. However, the Director of Social Work admitted that while statements were supposed to be provided quarterly, there was no system in place to obtain proof of receipt or mailing. The Administrator also confirmed that statements were given based on the residents' cognitive status but did not provide evidence of compliance with the policy.
Failure to Document and Monitor PICC Line for Resident
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of quality for Resident #205, who was observed with a Peripherally Inserted Central Catheter (PICC) in their right arm on two occasions. There was no documentation in the resident's chart about the presence of the PICC, nor was there any evidence that the PICC dressing was changed or that the site was monitored for infection. The facility's policy required weekly flushing and dressing changes for PICC lines, but these were not documented for Resident #205. Additionally, the Comprehensive Care Plan (CCP) for antibiotic therapy did not indicate the name and route of administration for the antibiotic, and the physician's orders did not document the type of intravenous access or include orders for PICC dressing changes, flushing, or monitoring for infection. Interviews with staff revealed a lack of awareness and documentation regarding Resident #205's PICC line. The Assistant Director of Nursing, who completed the resident's admission assessment, could not recall if the resident had a PICC. The charge nurse on the unit acknowledged the presence of the PICC but admitted to not documenting it. The Nurse Practitioner stated that the Medical Doctor would document any intravenous access, and Registered Nurses were responsible for putting in orders for PICC care. The Director of Nursing confirmed that the facility had a protocol for PICC lines, which included orders for flushing, dressing changes, and monitoring the site, but could not explain why these orders were not in place for Resident #205.
Failure to Document Blood Sugar Levels for Diabetic Resident
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically for a resident with Diabetes Mellitus. The resident had a physician's order to perform fingerstick blood tests twice daily and notify the physician if the blood sugar levels were outside the specified range. However, the blood sugar results were not documented in the electronic Medication Administration Record (eMAR) from the time the order was given until the survey date. The last recorded blood sugar result was on 10/16/23, despite the order being dated 11/06/23. Interviews with the nursing staff and administration revealed that the nurses were performing the fingerstick tests but were unable to document the results due to an error in the electronic medical record system. The error occurred because the order was entered without enabling the documentation feature for blood sugar levels. The Director of Nursing and the Assistant Director of Nursing were unaware of this issue until it was brought to their attention during the survey.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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