Granville Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Granville, New York.
- Location
- 17 Madison Street, Granville, New York 12832
- CMS Provider Number
- 335331
- Inspections on file
- 21
- Latest survey
- December 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Granville Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to maintain food service safety standards, with soiled dishwashing areas and improperly dried containers in the main kitchen, and soiled refrigerator gaskets and floors in the nourishment rooms. The Food Service Director acknowledged the oversight in cleaning schedules and noted issues with the dishwasher's sanitizing temperature.
The facility failed to provide sufficient nursing staff, resulting in delayed care and unmet staffing needs on multiple occasions. Residents reported long wait times for assistance, particularly on weekends. The Director of Nursing acknowledged the staffing challenges, citing a small pool of additional staff due to the facility's remote location.
A resident with severe cognitive impairment and moderately impaired vision did not receive necessary follow-up optometry care or replacement glasses after their glasses were broken. Despite a scheduled follow-up, there was no evidence of further consultations, and the DON was unaware of the issue.
The facility failed to comply with NFPA 101, 2012 Edition, regarding exit discharges. The B-Wing west exit discharge was grass, not an all-weather surface, and several exits were not marked to indicate egress direction. The facility did not provide evidence of corrective actions or an approved waiver for delays due to winter weather.
The facility failed to maintain its emergency generator fuel reserve as required by NFPA 110 standards. The fuel reserve was not tested in 2023, and a 2024 analysis showed excessive particle count and water contamination. There was no evidence of treatment or retesting, and the facility did not implement its Electronic Plan of Correction by the specified date.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. From early to mid-December, the facility consistently fell below required staffing levels, leading to significant delays in assistance for residents. Interviews with staff and residents highlighted the impact of understaffing, with reports of long wait times for care and missed therapy sessions. The facility's administrator acknowledged the staffing challenges, citing recent staff departures and the remote location as contributing factors.
The facility's Emergency Preparedness Plan was not updated annually as required, containing outdated information such as instructions for elevator use during a fire, despite the facility having no elevators. Additionally, a training posttest from 2018 was not replaced with a current version. The administrator acknowledged these issues during the survey.
The facility's emergency preparedness plan was found deficient as it lacked documentation on identifying the resident population and their unique needs, strategies to address these needs, services available during an emergency, and continuity of care plans. This deficiency could impact all residents.
The facility did not provide emergency lighting in accordance with NFPA 101 Life Safety Code on two of three units and the core area. Observations revealed that light switches did not provide emergency lighting when off in specific areas, and emergency lighting was absent along certain egress paths. A broken light fixture cover was also noted, exposing a bulb. These issues were confirmed through staff interviews.
The facility failed to provide adequate care and documentation for residents, including not administering tuberculosis tests, failing to notify providers of critical blood sugar levels, and exceeding prescribed medication limits. Additionally, vital signs were not properly monitored or documented, affecting residents with various medical conditions.
Several residents in the facility reported that their meals were often cold, unattractive, and not palatable, with discrepancies between meal tickets and the food served. One resident experienced significant weight loss due to the unappealing food, while another noted a lack of snacks at night. Temperature testing confirmed that meals were not served at appropriate temperatures, indicating a failure to adhere to the facility's policy on providing nourishing and well-balanced meals.
The facility failed to maintain fire-rated doors in accordance with NFPA standards, as observed with a kitchen door and a soiled utility room door that did not self-close and latch. A note on the kitchen door indicated awareness of the issue, and interviews confirmed plans to address the deficiency, but these were not implemented at the time of the survey.
A survey found that exit passageways in a facility were improperly used for storage, violating NFPA 101 Life Safety Code. The kitchen storeroom exit was cluttered with bins for shredding, containers for soiled items, and milk crates, while the employee entrance exit was used to store equipment. An administrator acknowledged the issue.
The facility failed to maintain the automatic sprinkler system in accordance with NFPA standards. Observations showed boxes stored too close to sprinkler deflectors in the kitchen and dust-coated sprinkler heads in the laundry area, indicating non-compliance with fire safety regulations.
A resident with impaired vision did not receive timely optometry services as required by facility policy. Despite the resident's need for regular eye care, no follow-up consultations were documented after an initial visit in March 2023. Interviews revealed a gap in communication and scheduling, resulting in a deficiency in maintaining the resident's vision care.
A resident with a history of lumbar fracture and cancer experienced unmanaged pain due to the facility's failure to adhere to pain management protocols. Despite a care plan, the resident received excessive acetaminophen and inappropriate oxycodone dosages, leading to severe pain and a family member calling 911 for hospital transport. The facility did not reassess pain within the required timeframe, and documentation was incomplete.
A resident with broken front teeth did not receive timely emergency dental services, despite experiencing slight pain. The facility's policy required both routine and emergency dental services, but the resident had not been scheduled for a dental appointment. Interviews revealed that the resident's dental needs were not promptly addressed, with the Finance Director planning to add the resident to the list for the next dental visit.
A resident experienced significant weight loss due to the facility's failure to conduct weekly weight checks as ordered by the dietician. Despite a care plan addressing nutritional issues, the resident's weight dropped significantly, exacerbated by dissatisfaction with the facility's food. Communication lapses and lack of adherence to the weight management policy contributed to the deficiency.
Deficiencies in Food Service Safety Standards
Penalty
Summary
The facility failed to maintain food service safety standards in the main kitchen and two resident unit nourishment rooms. In the main kitchen, the dishwashing machine's temperature display panel and the floors beneath it were found to be soiled with food particles or dirt. Additionally, the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried, resulting in moisture accumulation. In the A-Unit nourishment room, the refrigerator door gaskets were soiled with food particles, while in the B-Unit nourishment room, both the refrigerator and the floor were soiled with food particles or dirt. During interviews, the Food Service Director acknowledged that maintaining cleanliness is a joint effort between the nursing staff and kitchen staff. They admitted that the cleaning schedule and checklist for the unit's nourishment areas did not include the gasket area, which contributed to the oversight. Furthermore, the director noted that the dishwasher was not reaching the proper temperature for sanitizing, necessitating repairs. Although the maintenance director had repaired the dishwasher, the area was not cleaned afterward, leading to the observed deficiencies.
Deficiency in Staffing Levels Leads to Delayed Resident Care
Penalty
Summary
The facility was found to be deficient in providing sufficient nursing staff to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the recertification survey, it was observed that the facility did not meet its assessed minimum staffing needs on multiple occasions between February 15, 2025, and April 13, 2025. Specifically, the facility's staffing schedule showed that on ten occasions, the number of Certified Nurse Aide (CNA) hours provided was significantly below the required hours based on the facility's census. For example, on March 11, 2025, with a census of 88 residents, the facility required 215.6 hours of direct CNA care but only provided 136 hours. Residents reported during interviews that the facility was short-staffed at times, leading to long wait times for care and call bells not being answered promptly. A group resident meeting revealed that staffing was particularly low on weekends, with only one or two aides per unit. The Director of Nursing acknowledged awareness of the federal regulation regarding required CNA hours per census and stated that staffing adjustments were attempted when there were call-ins. However, the facility faced challenges in filling staffing gaps due to a small pool of additional staff, attributed to their remote location.
Failure to Provide Vision Care and Assistive Devices
Penalty
Summary
The facility failed to ensure that a resident received the necessary treatment and assistive devices to maintain vision. The resident, who was admitted with diagnoses including severe cognitive impairment, had moderately impaired vision and used corrective lenses. A consult form indicated that the resident was seen by an optometrist with a follow-up scheduled for later in the year. However, a handwritten note revealed that the resident's glasses were broken, and there was no documented evidence of further optometry consultations. An email from the optometry service confirmed that the resident had not been seen since the initial visit. During an interview, the Director of Nursing was unaware of the issue and acknowledged that the resident should have had a follow-up appointment and received new glasses.
Non-Compliance with NFPA 101 Exit Discharge Requirements
Penalty
Summary
The facility was found to be non-compliant with the National Fire Protection Association (NFPA) 101, 2012 Edition, Sections 19.2.7 and 7.7, during a recertification survey. Specifically, the exit discharges from three resident units were not maintained as required. The B-Wing west exit discharge was observed to be grass instead of an all-weather surface, which is necessary for safe egress. Additionally, the exit discharges from the A-Wing west exit, B-Wing west exit, C-Wing north exit, and C-Wing south exit were not marked to clearly indicate the direction of egress travel to a public way. During a Life Safety Code Post-Survey Review, it was noted that the facility did not provide evidence of installing an all-weather surface on the B-Wing west exit discharge or implementing the Electronic Plan of Correction. The facility had requested a waiver due to winter weather conditions preventing the completion of the required work. However, the facility did not provide an approved time-limited waiver from the Centers for Medicare & Medicaid Services, and the Electronic Plan of Correction was not fully implemented by the documented Credible Allegation Date.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The facility has requested a time limited waiver for the installation of a permanent all-weather surface as winter weather conditions will prevent completion at this time. The all-weather surface will be installed on the exit discharge from the B-Wing west exit. The facility began the process of vendor quotes on (MONTH) 13, 2025 and have one thus far. Several other vendors have been contacted to review the scope of work. The facility will continue to obtain quotes through the month of (MONTH) as more providers become available with a vendor decision by (MONTH) 1, 2025. Work will be scheduled for a (MONTH) 9, 2025 start and should be completed within one week from start to finish. Completion date set for no later than (MONTH) 18, 2025. During this period the Administrator will check-in with the Sanitarian the first of each month to update progress on the project. During construction, periodic inspections of all exit discharges to ensure that they are clear at all times as well as staff education on same will be completed by the Maintenance Director and/or Administrator. Until the permanent all-weather surface can be installed, a temporary walkway will be put in place from the B-Wing west exit to the public way. All staff to be in-serviced on fire safety. A copy of the resident safety plan, facility life safety floor plan will be submitted to [email protected] by (MONTH) 29, 2025. Appropriate evacuation route/discharge signage was ordered and scheduled to be fully installed to mark the direction of egress travel from the four noted areas of exit discharge by (MONTH) 29, 2025. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed an audit of all exit discharges to ensure all exit discharges were clearly marked to a public way and all-weather discharge passageway surfaces were intact. No additional areas of concern were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Education will be provided to all maintenance staff on maintaining exit discharges with all-weather surfaces and marking exit discharges to make clear the direction of egress travel to the public way. Appropriate direction of egress signage will be installed for the four noted exits to clearly indicate the direction of egress pathways to the public way by (MONTH) 29, 2025. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The maintenance director or maintenance assistant will audit exit passageways for appropriate signage and all-weather surface integrity weekly for two months and monthly thereafter for four months. The results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly and additional recommendations for interventions and duration of audits will be given as needed. This task has also been added to the weekly environmental rounding schedule. Responsible Party: Director of Maintenance
Failure to Maintain Emergency Generator Fuel Reserve
Penalty
Summary
The facility failed to maintain its emergency generator fuel reserve according to the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition section 8.3. Specifically, there was no documented evidence that the emergency generator fuel reserve was tested in 2023. A Fuel Analysis Report dated June 24, 2024, indicated that the fuel reserve failed analysis due to excessive particle count and water contamination. The report suggested using portable filtration or a more aggressive approach to filtration and investigating the source of water contamination. However, there was no documented evidence that these suggestions were followed or that the fuel reserve was treated to reduce contamination levels. During a Life Safety Code Post-Survey Review survey, it was found that the facility did not provide evidence of retesting the emergency generator fuel reserve until it passed the fuel quality test. The facility's Electronic Plan of Correction stated that corrective actions would be taken if the fuel reserve failed retesting, but the facility did not ensure the plan was fully implemented by the Credible Allegation Date. An interview with the administrator revealed that the results of the retesting were not yet available, indicating a lack of timely follow-up on the deficiency.
Plan Of Correction
Plan of Correction: Approved February 14, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) Per the vendor suggestions, the facility will use portable filtration or a more aggressive approach to filtration to address the high particle count in the fuel reserve and will investigate and resolve the source of the water contamination in the fuel reserve. Should the fuel reserve fail retesting, corrective actions will be taken with additional retesting until the fuel reserve passes the fuel quality test as required by the National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 2010 edition 8.3. The facility maintenance director scheduled the vendor to test the generator fuel reserve and treat for contamination as needed. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The facility audit for other emergency generator fuel reserves found that there was another emergency generator fuel reserve tank on the grounds. This tank will be drained as the generator is not connected to the building in any way and is not needed. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Facility Maintenance Director was educated by the administrator on having the generator fuel reserve tested annually and to complete recommendations given by the vendor. The generator fuel reserve testing has been added to the preventative maintenance schedule to be completed annually. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) Findings of the annual fuel reserve testing will be reviewed by the Quality Assurance Performance Improvement Committee annually and additional recommendations for interventions will be given as needed. Responsible Party: Director of Maintenance
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of understaffing from December 1, 2024, to December 18, 2024. The staffing schedule analysis revealed that the facility consistently fell below the required minimum staffing levels, with Certified Nurse Aides (CNAs) providing fewer hours of direct care than necessary for the resident census. This deficiency was corroborated by interviews with nursing staff and residents, who reported inadequate staffing levels leading to delays in care. Residents reported significant delays in receiving assistance, with some waiting over an hour for help. One resident mentioned waiting two hours to be taken to the bathroom, which sometimes resulted in missing therapy sessions. Observations on December 17, 2024, showed multiple call lights activated with no staff present, further indicating insufficient staffing. Interviews with CNAs and a Licensed Practical Nurse (LPN) highlighted the stress and overwork due to the lack of staff, with CNAs frequently working double shifts to cover the shortfall. The facility's administrator acknowledged the staffing issues, attributing them to the remote location and recent staff departures. Despite efforts to employ agency and contract workers, the facility struggled to maintain adequate staffing levels. The administrator expressed optimism about improving staffing levels, but the deficiency persisted during the survey period, impacting the residents' care and well-being.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action: The facility currently has ads posted online and is offering a sign-on bonus to attract new certified nursing assistants to Granville Center. Due to a lack of certified nursing assistants in the local area, the facility recruits out-of-state certified nursing assistants and houses them nearby. 2. All residents and staff have the ability to be affected by this deficient practice. Plan to prevent reoccurrence: The facility currently has ads posted online and is offering a sign-on bonus to attract new certified nursing assistants to Granville Center. Due to a lack of certified nursing assistants in the local area, the facility recruits out-of-state certified nursing assistants and houses them nearby. 3. The facility systemic changes: Increased their certified nursing assistant pay rates on 12/22/24 in an effort to attract more staff. The facility has recruited additional certified nursing assistants from out-of-state who will begin between (MONTH) and February. Should the certified nursing assistant staffing levels fall below the minimum established levels, the Administrator or Director of Nursing will implement the emergency staffing plan. The Administrator, Director of Nursing, and Scheduler will meet 3 times per week to review upcoming certified nursing assistant schedules. The Administrator will organize a recruitment and retention committee to come up with new ideas to recruit and retain certified nursing assistants. 4. The facility emergency staffing plan and ideas from the recruitment and retention committee will be submitted to the Quality Assurance Performance Improvement Committee monthly for review and recommendations. Responsible Parties: Administrator
Outdated Emergency Preparedness Plan
Penalty
Summary
The facility failed to maintain an updated Emergency Preparedness Plan as required by regulations. During the recertification survey, it was found that the plan was not reviewed and updated at least annually, and updated copies were not maintained in the designated locations. Specifically, the emergency plan included outdated information, such as instructions for a fire emergency that mentioned not using elevators, despite the facility being a single-floor building without elevators. Additionally, the plan contained a training posttest dated July 2018, which was outdated and not replaced with a current version. During an interview, the administrator acknowledged the outdated posttest and fire plan, indicating they would be purged and replaced with current documents.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The reference to elevator use was removed from the Emergency Plan tab 21 on 12/17/2024. The updated posttest was added to the Emergency Plan tab 22 on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The Emergency Plan will undergo a comprehensive review and update all sections that are not current. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The administrator has been educated by the regional administrator on completing a comprehensive annual review of the emergency plan. The emergency plan will be reviewed annually and as needed if changes occur. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The Emergency Plan will be updated where necessary during the annual review. Emergency plan changes/updates will be reviewed for recommendations by the Quality Assurance Performance Improvement Committee annually and as needed when changes occur. Responsible Party: Administrator
Emergency Preparedness Plan Lacks Key Elements
Penalty
Summary
The facility was found to be non-compliant with emergency preparedness requirements during a recertification survey. The deficiency was identified due to the absence of documented evidence in the emergency preparedness plan regarding the identification of the resident population served and their unique needs. Additionally, the plan lacked strategies to address these needs, a description of the types of services the facility could provide during an emergency, and how the facility would maintain continuity of care to protect residents' health and safety if normal operations were disrupted. This deficiency could potentially affect all residents at the facility.
Plan Of Correction
Plan of Correction: Approved January 23, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The Emergency Preparedness Plan was updated to reflect the types of services the facility could provide to their unique population of residents in the event of an emergency on 12/17/2024 and how the facility will maintain continuity of care to adequately protect the health and safety of our residents in the event of any limitations or cessation of normal operations during an emergency. The number of days of emergency supply of food, water, medical supplies, pharmaceutical supplies, generator fuel, disposable paper supplies, linen needs, etc. will be detailed in the updated plan. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The Emergency Plan will undergo a comprehensive review and update all sections that are deemed not current. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The facility will complete a comprehensive review of the emergency plan annually and update where necessary to ensure it includes identification of the resident population and their needs, strategies used to address the needs of their residents, and a description of the types of services the facility can provide during an emergency. The administrator was educated by the regional administrator on completing a comprehensive annual review of the emergency plan. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The annual review of the emergency plan and all other emergency plan updates will be reviewed by the Quality Assurance Performance Improvement Committee annually and as needed when updates occur. Responsible Party: Administrator
Failure to Provide Emergency Illumination
Penalty
Summary
The facility failed to provide emergency illumination in accordance with the National Fire Protection Association (NFPA) 101 Life Safety Code, 2012 Edition Sections 19.2.8 and 7.8, on two of three units and the core area. Specifically, during observations, it was noted that the light switches controlling normal and emergency lighting for the means of egress and exit access did not provide lighting when the switch was in the off position in the A-Wing TV Lounge, the core area main dining room, and the C-Wing Physical Therapy room. Additionally, emergency lighting was absent along the path of egress to the public way from the C-Wing RN station exit and along the south driveway. Furthermore, the light fixture cover at the C-Wing north exit discharge was broken, exposing the light bulb. These deficiencies were confirmed through interviews with the Maintenance and Life Safety Consultant and the Administrator.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The facility will install emergency lighting along the egress path from C-wing nursing station exit and along the south driveway leading to the public way. The light fixture cover at the C-Wing north exit discharge was replaced on 12/18/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator and maintenance director completed external rounds of the facility to ensure emergency lighting was present along all means of egress to the public way. No additional areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Monthly monitoring of lighting and fixtures at exit discharges and paths leading to the public way has been added to the preventative maintenance schedule. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The monthly preventative maintenance monitoring of lighting will be presented to the Quality Assurance Performance Improvement Committee monthly for four months for review and additional recommendations for interventions and duration of audits will be given as needed. Responsible Party: Director of Maintenance
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for all ten residents reviewed for quality of care. Specifically, the facility did not administer and read the purified protein derivative test for tuberculosis for two residents, and failed to notify a provider when a resident's blood sugar was critically low. Additionally, the facility did not monitor the vital signs of a newly admitted resident as required. One resident was administered an excessive amount of Acetaminophen, exceeding the prescribed limit, and was left in distress without adequate pain management, leading to a call to 911 for hospital transport. The facility also documented vital signs for this resident after they had already been discharged. Furthermore, the facility failed to obtain and document monthly vital signs according to provider orders for several residents, with instances of duplicate vital signs being recorded, indicating a lack of proper monitoring and documentation. The deficiencies highlight a pattern of inadequate care and documentation practices across multiple units within the facility, affecting residents with various medical conditions, including diabetes, hypertension, and mental health disorders. These failures demonstrate a significant lapse in adhering to established care protocols and ensuring the well-being of the residents.
Plan Of Correction
Plan of Correction: Approved February 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action: Resident #365 no longer resides in facility. Resident #368 has reached compliance upon return from hospital with two-step Purified protein derivative plant and read per facility policy and completed on 1/9/2025. Provider notified on 1/9/2025 of incident with no new orders recommended. The Medical provider was notified on 1/9/2025 of residents #638, 29, 89, 73 that facility failed to monitor vital signs per provider order with no new order recommended. Licensed staff responsible for failure to notify medical provider of resident blood sugar outside parameters was counseled and reeducation completed on 1/10/2025 by the Assistant Director of Nursing. 2. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence: Nurse management conducted a 90-day look back from 10/9/24 through 1/9/25 for residents with active orders for blood sugar monitoring. As a result of the audit, no issues noted. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence, the previous 30 days of admissions were reviewed for compliance with purified protein derivative placement and results documented per policy. Audit completed on 1/10/2025. A total of 30 residents were reviewed. Out of the 30, 8 residents were discharged, 2 were compliant, and 20 were identified to be out of compliance. A [MEDICATION NAME] screen was completed for those residents per policy. The results of the [MEDICATION NAME] screen were reported to the medical provider for further review. No further directives given. Nursing management conducted a full house review on 1/17/2025 on residents with active orders containing Tylenol to determine the potential for the resident to exceed the recommended limit. Results of the review concluded one resident was identified at risk to potentially exceed the daily recommended limit. Those residents identified were submitted to the medical provider for review with one resident with new orders. A full house review was conducted on 1/16/2025 on residents’ vital signs per the provider order. The results of those residents with orders for monthly vital signs concluded all residents to be out of compliance. Results submitted to the medical provider with new order for one resident. Results of resident review for new admission vital sign orders concluded 23 residents reviewed. Review of audit concluded 14/23 residents were identified to be out of compliance. Any residents identified as having vital sign omissions received updated vitals and results reviewed with the medical provider. 3. The systemic changes: The facility reviewed the policies titled Vital Signs, Diabetes Mellitus Guidelines, and [MEDICAL CONDITION]. They were reviewed by medical with no revisions necessary. The facility educator re-educated licensed staff on vital signs, diabetes mellitus guidelines, and [MEDICAL CONDITION] policies with emphasis on notifying the provider with results of blood sugar outside parameters, administration and timely result documentation per MD order of Purified protein derivative, daily recommended Tylenol consumption not to exceed recommended limit, and obtaining and monitoring of resident-specific vital sign order for frequency. This education was accompanied by a post-test to ensure retention. All results of blood sugar, results of the [MEDICATION NAME] skin test, and results of vital signs will be documented in the medication administration record. The facility supervisor will complete a 24-hour look back of all new Tylenol orders to ensure there is no potential to exceed the recommended daily limit. The facility supervisor will complete a 24-hour look back on residents' blood sugars to ensure residents identified with blood sugars outside parameters were reviewed and submitted to the medical provider. The facility supervisor will complete a 48-hour look back on residents who received a [MEDICATION NAME] skin test to follow up and document [MEDICATION NAME] skin test read. The facility supervisor will complete a 24-hour look back of those residents with active vital sign orders to determine vital signs obtained per provider order. Any result out of compliance, the supervisor will notify the medical provider for further directives and will document the outcome in the medical record. 4. Quality assurance: The Unit managers will audit all new admissions' Purified protein derivative status to ensure compliance is met. This will be audited weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Assistant Director of Nursing will submit weekly immunization documentation tracker form weekly. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit residents' blood sugars. This audit will look for any documented value outside parameters to ensure the medical provider was notified. This will be conducted weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit compliance with vital signs completion weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. Unit managers will audit all active Tylenol orders to ensure residents do not exceed the daily limit. This audit will be done weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Director of Nursing will oversee all audits. Responsible Party: Director of Nursing.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for several residents. Specifically, four residents complained about the quality of the food, noting that it was often cold, unattractive, and not palatable. Additionally, discrepancies were found between the meal tickets and the actual food served to the residents, with some items missing from the trays. This issue was observed during a recertification and abbreviated survey, where residents expressed dissatisfaction with the temperature and presentation of their meals. Resident #107, who had intact cognitive ability, reported that their meals were consistently cold and unappealing. During an observation, it was noted that the resident's lunch tray did not match the meal ticket, missing several items. Temperature testing of the meal revealed that the food was not served at the appropriate temperature, with pasta noodles and beef stroganoff being below the expected temperature. Despite these issues, the resident stated that the replacement meal was satisfactory. Resident #97, who had a history of dementia and protein-calorie malnutrition, also reported that the food was cold and visually unappealing. This resident experienced significant weight loss, which was attributed to their lack of appetite due to the unappealing food. Resident #75 expressed similar concerns, noting that the food was cold and lacked flavor, and they were not provided with snacks at night. Resident #8 reported receiving food they did not like and that meals were often served cold. These deficiencies highlight the facility's failure to adhere to its policy of providing nourishing, palatable, and well-balanced meals that meet residents' preferences and dietary needs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 1. The Registered Dietician and Food Service Director met with residents #97, 75, 8, and 107 to review meal preferences and dislikes. Revisions were updated in the menu software program. Resident #75 was provided a new lunch tray and a night snack has been scheduled per resident preference. The facility hired a new Food Service Director on 1/2/2025. 2. All residents have the potential to be affected by the deficient practice. The facility did an audit of 10 consecutive meals on the units to ensure residents' food was warm, palatable, and presentable. This audit also included checking that meal tickets were accurate and the preferences were served. 3. The Policy titled "Food Service" has been reviewed with no revisions necessary. The Registered Dietician or the staff educator will provide re-education to dietary staff on the policy titled "Food Service." The emphasis is on meal production to include tray accuracy as well as residents’ personal food preferences and meal temperatures. The Food Service Director or Supervisor will facilitate a meal production meeting daily with dietary staff and report to the registered dietician should any deviations to the menu be needed. Facility nursing staff will be re-educated on the Food Service policy with emphasis on tray accuracy, residents’ personal food preferences, and food temperatures. 4. The Registered Dietitian or Food Service Director will conduct reviews on 15 trays for accuracy, temperatures, and resident preferences weekly x 4 weeks and monthly x 3 months. The Food Service Director or Registered Dietitian will conduct a review on 15 trays per week on tray accuracy, appearance, and palatability weekly x 4 weeks, then monthly x 3 months. The Food Service Director or Registered Dietitian will review food temperature logs daily for 30 days, then weekly thereafter to ensure safe food temperatures are maintained. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. 5. Responsible party: Food Service Director
Failure to Maintain Fire-Rated Doors
Penalty
Summary
The deficiency involves the failure to maintain the means of egress in accordance with adopted regulations, specifically concerning fire-rated doors. During observations on multiple occasions, it was noted that a 1½-hour rated kitchen door and an A-Wing 1½-hour rated soiled utility room door did not self-close and latch as required by the National Fire Protection Association (NFPA) 80 Standard for Fire Doors and Other Opening Protectives, 2010 Edition Chapter 5. A note was posted on the kitchen door instructing individuals to ensure the door was closed tightly, indicating a known issue. The facility's Fire/Smoke Door Inspection document, dated 12/29/2023, confirmed that fire-rated doors should self-close and latch, yet this was not occurring. Interviews conducted with a Maintenance and Life Safety Consultant and the Administrator revealed acknowledgment of the issue, with plans to adjust the doors to self-close and seat properly to the frame and to include them in a preventative maintenance program. However, these actions were not in place at the time of the survey, leading to the citation.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The kitchen door was adjusted for proper closure and latching on 12/13/2024. The signage was removed which was temporarily placed there until maintenance could make the adjustments. The A-Wing soiled utility door was adjusted on 12/17/2024 for proper closure and latching. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. An audit of all self-closing fire-rated doors will be conducted to ensure they all self-close and latch appropriately. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) All facility wide self-closing doors have been placed on the preventive maintenance program for monitoring and adjustments as/if needed. Education to be provided to maintenance staff on the location of and the requirements to ensure fire-rated doors self-close and latch. In addition, education will be provided to dietary, nursing and housekeeping staff on which doors are to be self-closing and to report to the maintenance staff (via work orders) when these doors do not self-close. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) As part of the facility wide preventive maintenance program, all self-closing fire-rated doors will be checked with findings documented on the paper checklist. The entire facility preventive maintenance (which includes the aforementioned doors) program which details, daily, weekly, monthly, quarterly, semi-annual and annual activities will be submitted to the QAPI Committee beginning in January, 2025 to ensure all preventive maintenance activities have been completed and any needed corrective action has been completed. Responsible Party: Director of Maintenance
Improper Storage in Exit Passageways
Penalty
Summary
During a recertification survey, it was observed that the exit passageways in a facility were not maintained according to the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition section 7.1.3.2.3. Specifically, the exit passageway from the kitchen storeroom was used as storage space for plastic bins designated for confidential shredding, two 33-gallon containers for soiled mop heads and cloth rags, and empty milk crates. Additionally, the employee entrance exit passageway was used to store equipment. These observations were made on December 17, 2024, at 2:10 PM. During an interview conducted at 2:59 PM on the same day, an administrator acknowledged the issue and stated that they would prioritize keeping the exit passageways clear.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) All items were removed from both exit passageways on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The administrator completed rounds of the facility to ensure all exit passageways were maintained free of obstructions. No other areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) The maintenance director and food service director were educated by the administrator on maintaining exit passageways via a physical tour of the areas. Education was given on maintaining exit passageways clear and to use the newly designated alternate storage areas. The maintenance director or administrator will complete a weekly audit of the kitchen storeroom exit and employee entrance exit to ensure the passageways are free of any stored items or equipment blocking the passageway. Any noncompliance will be corrected upon identification. The audit will be completed weekly for 8 weeks and monthly for 2 months thereafter. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) The facility will ensure that the exit passageways are kept clear at all times via the weekly environmental rounding schedule with any violations immediately addressed. Findings of the weekly and monthly audits will be reviewed by the Quality Assurance Performance Improvement Committee monthly, and additional recommendations for interventions and duration of audits will be given as needed. Responsible Party: Director of Maintenance
Sprinkler System Maintenance Deficiency
Penalty
Summary
The automatic sprinkler system in the main kitchen of the facility was not maintained according to the National Fire Protection Association (NFPA) 13 Standard for the Installation of Sprinkler Systems 2010 Edition. Specifically, observations revealed that boxes were stored within 18 inches of the bottom of sprinkler deflectors in the kitchen walk-in refrigerator and walk-in freezer. Additionally, three sprinkler heads in the laundry dryer area were found to be coated with dust or lint. These deficiencies were identified during observations conducted on two separate occasions, indicating a failure to adhere to fire safety regulations as required by the NFPA standards.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? 1) The items on the top storage of the main kitchen were removed on 12/17/24. The three sprinkler heads in the laundry dryer area were cleaned on 12/17/24. Education was provided to all dietary staff relative to appropriate storage areas by Regional Dietician on 12/17/2024. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? 2) All residents and staff have the ability to be affected by this deficient practice. The maintenance director or designees audited storage areas to ensure nothing is stored within 18 inches of the bottom of the sprinkler. No additional areas were identified. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not recur? 3) Weekly audits of storage in the kitchen to be conducted by Food Service Director or maintenance director weekly times 4 weeks and monthly times 2 months. The laundry room sprinkler heads have been placed on the monthly preventive maintenance schedule for routine cleaning. The food service director and maintenance director were educated on storing items at below 18 inches from sprinkler deflector. The maintenance director was educated on keeping all sprinklers free from dust and lint. How will the corrective action be monitored to ensure the deficient practice does not recur and the title of the person responsible for correction? 4) Findings of the weekly audits and monthly preventative maintenance of sprinkler heads will be reviewed by the Quality Assurance Performance Improvement Committee monthly for 3 months and additional recommendations for interventions and duration of audits will be given as needed. Responsible Parties: Administrator, Dietician, Food Service Director and Director of Maintenance.
Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain the vision ability of a resident, identified as Resident #70, who was reviewed for communication. Resident #70, who was admitted with chronic obstructive pulmonary disease, hypertension, and seizures, was documented as having impaired vision and using corrective lenses. The facility's policy required timely medical care, yet the resident's medical record showed no optometry consults or a comprehensive care plan for vision after a scheduled follow-up in March 2023. Interviews revealed that the resident expressed a desire to see an eye doctor, and a registered nurse acknowledged the need for optometry visits every 6-12 months. However, there was a lack of documented follow-up or scheduling for optometry services. The medical records staff indicated they rely on nurse managers to email them for scheduling appointments, but no such communication was documented for Resident #70, leading to a deficiency in providing necessary vision care.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action: Resident #70 was seen by optometry on 3/25/2024 with recommendations to follow up in 1 year. Medical records clerk was re-educated on scanning consults into resident’s chart timely on 1/13/2025. 2. Plan to prevent reoccurrence: Medical records completed a full house review of facility resident’s optometry consults from the previous 12 months to identify any additional missed scanned consults. This audit was completed on 1/17/2025. Results of the audit will be provided to medical provider for review. 3. The facility systemic changes: Education was given to medical records on 1/13/2025 by the Director of Nursing to ensure they are following the consultation policy. Medical records will document and monitor vision consults utilizing a consultation tracker form to ensure completed consults are scanned into resident chart. 4. Medical records coordinator will conduct a review of residents’ vision consults weekly x 4 weeks then monthly x 3 months. Results will be submitted to the Director of Nursing for final review. The results of the reviews will be brought to QAPI for review and determination of frequency reviews and any additional recommendations. Responsible Party: Director of Nursing
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident, resulting in a significant deficiency. The resident, who was admitted with a history of lumbar vertebra fracture, uterine cancer, and bone cancer, was not administered pain medication in a manner that effectively managed their pain. Despite having a comprehensive care plan that included administering medications as ordered and notifying the physician if interventions were unsuccessful, the facility did not adhere to these guidelines. The resident expressed severe pain, rated at 10 out of 10, and the family member had to call 911 to have the resident transported back to the hospital. The facility's policies on medication administration and pain management were not followed. The Medication Administration Record showed that the resident received excessive acetaminophen, exceeding the prescribed limit of 3000 milligrams in 24 hours, within just over 13 hours. Additionally, the facility failed to administer the appropriate dosage of oxycodone for the resident's reported pain level. The resident's pain was not reassessed within the 30-60 minute window as required by the facility's policy, and there was a lack of documentation for some medication administrations. Interviews with family members and staff revealed that the resident was in distress due to unmanaged pain and other unmet needs, such as soiled clothing and lack of food. The Director of Nursing acknowledged that Tylenol was administered for severe pain, but did not confirm if this was appropriate. The facility's failure to manage the resident's pain effectively and adhere to their own policies resulted in the resident being sent back to the hospital for proper care.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Resident #112 no longer resides in facility. Registered Nurse #4 no longer employed at facility. 2. All residents have the potential to be affected by the deficient practice. Nursing managers conducted a 90-day look back audit from 10/13/2024 - 1/13/2025 of all residents’ pain scales to determine other residents who have triggered for pain and received appropriate pain relief. 3. The Facility systemic changes: The policy titled Pain Management was reviewed by administration with no revisions necessary. The Facility educator will re-educate licensed staff on the policy titled “Pain Management.” Re-education will focus on provider notification with any resident reports of increased pain that is not being relieved with current interventions for further directive. 4. The Nurse Managers will conduct reviews of those residents who have triggered for pain to ensure appropriate intervention and provider notification. Pain medication reviews will be completed weekly x 4 weeks then monthly x 3 months. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible Party: Director of Nursing
Failure to Provide Emergency Dental Services
Penalty
Summary
The facility failed to provide or obtain emergency dental services for a resident who had broken a front tooth. The resident, who had diagnoses including hypertension, chronic obstructive pulmonary disease, and depression, was observed with broken top front teeth and reported having broken them two weeks prior without having seen a dentist. The facility's policy, last revised in 2019, stated that both routine and emergency dental services were available to meet the oral needs of each resident, yet this was not adhered to in the case of the resident. Interviews conducted during the survey revealed that the resident had not been scheduled for a dental appointment despite experiencing slight pain. A Licensed Practical Nurse indicated that the information would be passed to the Finance Director, who was responsible for arranging dental appointments. The Finance Director acknowledged that the resident had last seen a dentist several months prior and would be added to the list for the next dental visit, indicating a delay in addressing the resident's immediate dental needs.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action taken: Resident #75 was immediately referred to dentist on 12/18/2024 and evaluated on 12/19/2024. 2. Plan to prevent reoccurrence: All residents have the potential to be affected by the deficient practice. Nursing conducted a full house audit on 1/16/2025 to ensure no other residents had any broken teeth or emergency dental care needs. None were noted. 3. The facility systemic changes: The policy titled Dental Services was reviewed by administration with no revisions. The Facility educator will re-educate licensed staff on policy titled “Dental Services.” The education will focus on actions needed when someone needs emergency dental care. 4. The Unit Managers will conduct a review of oral inspection for broken teeth and any emergent dental care not previously noted. This audit will be conducted weekly x 4 weeks then monthly x 3 months. Results will be submitted at QAPI for review and determination recommendation of frequency reviews required. Responsible party: Director of Nursing
Failure to Monitor Nutritional Status Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, identified as Resident #97, who was under review for nutrition. The resident, who had a diagnosis of malnutrition and dementia, experienced significant weight loss without the required weekly weight monitoring as ordered by the dietician. The facility's policy mandated weekly weight checks for four weeks following admission and more frequently if clinically indicated, but this was not adhered to for the weeks of 11/25/2024 and 12/09/2024. Resident #97 was admitted with a history of malnutrition and had a care plan focused on addressing nutritional problems, including unintentional weight loss. Despite the care plan's goal to maintain stable weight, the resident's weight dropped from 119 pounds in August to 107 pounds by December, indicating a significant weight loss of over 10 percent. The resident expressed dissatisfaction with the facility's food, describing it as cold and unappealing, which contributed to their reduced intake and subsequent weight loss. Interviews and record reviews revealed that the dietician had ordered weekly weights due to the resident's significant weight loss, but these orders were not consistently followed. The registered nurse responsible for monitoring weights did not receive the necessary communication from the dietician, resulting in missed weight checks. This oversight was compounded by the absence of active orders for weekly weights in the resident's records, highlighting a breakdown in communication and adherence to the facility's weight management policy.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action taken: the weekly weight order was obtained and entered for resident #97. The resident’s weight was obtained and the facility provider notified. The Registered Dietitian met with resident #97 regarding food preferences and dietary supplements. 2. All residents have the potential to be affected by the deficient practice. Plan to prevent reoccurrence: Registered Dietitian completed a full house of those residents who were recommended to have weekly weights. Those residents found to have weight omissions will have weights obtained and evaluated by the Registered Dietitian and nursing. 3. The facility systemic changes: The policy titled Weight Management was reviewed with no revisions necessary. The Director of Nursing re-educated the Registered Dietitian on 1/13/2025 on facility policy titled Weight Management with the focus on ensuring the recommended weight order is in place. 4. The Registered Dietitian will conduct an audit on all residents with weekly weights to ensure physician order [REDACTED]. Results of the reviews will be reviewed by the DON and Registered Dietitian weekly. Results of reviews will be submitted at QAPI for review and determination of frequency reviews required. Responsible party: Registered Dietitian
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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