Hudson Hill Center For Rehabilitation & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Yonkers, New York.
- Location
- 65 Ashburton Avenue, Yonkers, New York 10701
- CMS Provider Number
- 335080
- Inspections on file
- 24
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Hudson Hill Center For Rehabilitation & Nursing during CMS and state inspections, most recent first.
Two residents with cognitive impairment and known elopement risks were able to exit the facility unsupervised due to lapses in required one-to-one supervision and failures in the wander guard alarm system. In both cases, staff left the residents unattended without arranging coverage, and the facility's alarm system did not alert staff to the exits. There was also a lack of documentation showing that ordered safety interventions were implemented.
A resident assessed as an elopement risk with dementia and other conditions had a wander guard applied, but the care plan and CNA monitoring instructions were not updated until two days later. Staff relied on informal knowledge rather than documented procedures, and required documentation was missing until the delay was identified by leadership.
A resident with severe cognitive impairment and a history of wandering eloped from the facility on two occasions. After the first incident, the facility's investigation called for increased monitoring and one-to-one supervision at night, but these interventions were not added to the care plan or implemented. As a result, the resident eloped again and was found by police, requiring emergency evaluation.
A resident with multiple complex medical conditions experienced a delay in receiving antiviral treatment for Influenza A due to nursing staff not promptly notifying the physician after positive lab results. The lack of timely communication led to a delay in starting Tamiflu and implementing droplet precautions, contrary to facility protocol and CDC guidelines.
A resident with multiple complex medical conditions and severe cognitive impairment tested positive for Influenza A, but staff failed to promptly implement droplet precautions and notify the physician as required by facility protocol. Documentation was lacking for both the clinical rationale for testing and the communication of results, resulting in a delay in infection control measures.
A resident with severe cognitive and mobility impairments, who required two-person assistance for bed mobility and was known to be combative, fell from bed and sustained a laceration when a CNA provided care alone and turned away to retrieve equipment, leaving the resident unattended. The resident's care plan specified the need for two staff during such activities, but this was not followed, resulting in an accident despite other fall precautions being in place.
A resident with diabetes and neuropathy accessed an unsupervised hot liquid cart, filled a basin, and soaked their feet, resulting in second- and third-degree burns that required hospitalization and a skin graft. The facility lacked a specific policy and consistent staff monitoring for hot liquid carts, allowing the resident to obtain scalding water without detection.
The facility did not include patient care assistants in its facility-wide assessment, omitting their roles, training, and competencies, despite these assistants being scheduled daily to help with grooming and housekeeping. The assessment also failed to document the training provided to these assistants, and interviews revealed that both the assistants and their training program were not recognized as required elements in the assessment.
A resident with diabetes and peripheral vascular disease sustained severe burns after soaking their feet in hot liquid obtained from a cart, undetected by staff. The facility's investigation was incomplete, as statements from a CNA and another resident who witnessed the event were not obtained, and the investigative summary lacked a documented conclusion date, contrary to facility policy.
A resident sustained second- and third-degree burns from hot water obtained from a hot liquid cart. The administrator did not initiate or document any policy changes, protocol updates, or action plans to prevent recurrence, nor was there evidence of performance improvement plans for deficiencies identified in QAPI meetings. Attendance at QAPI meetings was documented, but no follow-up actions were recorded.
A resident sustained second- and third-degree burns from hot water obtained from a hot liquid cart, and there was no documented evidence that the QAPI committee developed or implemented an action plan to address the deficiency. Review of QAPI meeting minutes and staff interviews confirmed the lack of targeted follow-up or corrective action related to the incident.
The facility failed to ensure residents' mail privacy, as 15 residents reported their mail was opened by staff before delivery. The facility's policy allowed unopened mail unless advised otherwise, but the Admission Agreement permitted opening financial mail for assistance. The Administrator was unaware of this stipulation, leading to a deficiency in maintaining residents' privacy.
The facility failed to implement proper admission policies, requiring residents or their representatives to assume financial liability and waive rights. Two cognitively impaired residents signed agreements without understanding, and another resident denied signing. The facility's electronic signature process lacked transparency and security measures.
The facility failed to ensure accurate MDS 3.0 assessments for residents, leading to documentation errors. One resident's pressure ulcer and deep tissue injury were incorrectly noted as present on admission, another resident's smoking status was omitted, and a third resident's discharge location was inaccurately recorded. These errors were acknowledged by the MDS Director and were unintentional discrepancies from medical records.
Two residents at risk for pressure ulcers did not receive necessary preventive care, leading to the development of avoidable wounds. One resident did not have documented evidence of turning, repositioning, or use of heel booties, resulting in pressure ulcers. Another resident's air mattress was not set according to their weight, with no documentation of air pressure checks. Staff interviews confirmed the lack of adherence to care plans and facility policies.
The facility failed to provide necessary respiratory care for three residents. A resident was observed self-suctioning a tracheostomy without a physician's order, another received incorrect oxygen flow rates, and a third had no documented evidence of oxygen tubing changes. These deficiencies highlight lapses in adherence to physician orders and facility protocols.
The facility failed to maintain an effective pest control program, resulting in a roach infestation on multiple floors. Residents reported significant roach activity in their rooms, with one resident resorting to using a glove to kill roaches near their bed. Despite exterminator visits, the infestation persisted, and there was no documented evidence of a valid Pest Management Contract or an action plan to address the issue. Staff confirmed the presence of roaches, and the deficiency was exacerbated by residents keeping food in their rooms and ongoing construction.
The facility did not ensure residents and their representatives were informed of their right not to sign a binding arbitration agreement as a condition of admission. Two residents' admission agreements included language implying consent to arbitration without documented evidence of an option to decline. The administrator was unaware of the agreement's contents and stated it was a template used by other facilities.
The facility failed to provide required annual in-service training, including dementia management and abuse prevention, to CNAs. Documentation was lacking for five CNAs regarding dementia training, and one CNA did not complete the required 12 hours of training. Interviews revealed scheduling issues, particularly for overnight staff, contributing to these deficiencies.
A resident's dignity was compromised when their soiled fitted mattress sheet was not changed for six days, despite being cognitively intact and dependent on staff for daily activities. The resident reported infrequent sheet changes, and staff mentioned a linen shortage. However, a CNA stated that sufficient supplies were available, and the Director of Housekeeping confirmed linens were delivered twice daily. The failure to address the stained sheet in a timely manner led to the deficiency.
A resident-to-resident altercation in an LTC facility was not reported to the State Survey Agency within the required two-hour timeframe. The incident involved a physical confrontation resulting in a cut lip and pain for one resident, while the other was sent for psychiatric evaluation. The Director of Nursing was aware of the reporting requirement but reported the incident late.
A facility failed to notify a resident's representative in writing about a facility-initiated discharge. The resident, with complex medical conditions, received a discharge notice, but there was no evidence it was sent to their representative. The Ombudsman noted issues with the notification process, and the Social Worker confirmed the lack of documentation for mailing the notice to the representative.
A resident with a primary language of Spanish was not provided with necessary interpretive services, as documented in their care plan. The facility's staff were unaware of how to access translation devices, and the need for interpretive services was not documented in the Certified Nurse Aide instructions. Interviews revealed a lack of Spanish-speaking aides and insufficient training on language translation devices.
A resident with a history of dysphagia and pneumonitis was not provided with a plan to address their dietary needs and minimize choking hazards, despite hospital recommendations. The facility failed to monitor the resident's oral intake and difficulty swallowing, and communication breakdowns among staff led to a lack of follow-up on the resident's dietary needs. The resident was found unresponsive after being served a lunch meal tray, and the facility did not thoroughly investigate the incident to rule out choking.
A physician failed to review a resident's total care plan, including dietary needs, leading to the resident not receiving necessary dietary modifications for dysphagia. The physician did not incorporate hospital and dietician recommendations into the care plan, relying instead on nursing staff for information.
A resident's tax refund checks were mishandled by the facility, as they were opened and deposited into the facility's account without the resident's consent. The resident, who was cognitively intact, was not informed of the receipt or deposit of these checks. The facility failed to provide documented evidence of the resident's authorization for financial management or detailed transaction history, violating the resident's right to manage their financial affairs.
A resident's tax refund checks were misappropriated by the facility's Business Office, which deposited them into a facility account without the resident's consent. The resident, who managed their own finances, was not informed of the checks' arrival or the transactions. Facility policies on resident funds were not followed, and the Administrator was unaware of the issue.
A resident with a history of acute stress reaction and substance abuse did not receive a psychology consult as ordered, despite expressing a need for therapy to address past traumas. The facility failed to ensure the consult was conducted, leading to a deficiency in providing necessary behavioral health services.
The facility failed to properly label and store drugs and biologicals, as an expired insulin pen was found in the medication storage room refrigerator, and a controlled medication was improperly stored in a medication cart. Staff interviews revealed non-compliance with medication storage policies, and issues with accessing the controlled medication box were noted.
A resident reported that a dialysis transportation worker withdrew $5,900 from their cash app account under false pretenses. The facility failed to ensure the worker did not have access to non-dialysis residents and did not conduct a thorough investigation, including interviews with other residents or obtaining a statement from the accused worker. The resident had intact cognition and was not protected by an abuse care plan.
A resident alleged that a dialysis transportation worker withdrew $5,900 from their cash app account under the pretense of assisting with finding an apartment. The facility reported the incident to law enforcement but failed to interview other residents transported by the worker or obtain a written statement from the accused. No abuse care plan was initiated to protect the resident, and the facility did not substantiate the allegation due to a lack of evidence.
Two residents in an LTC facility experienced deficiencies in care. One resident with a history of vaginal bleeding did not receive a timely gynecological appointment due to transfer issues, leading to a hospital transfer. Another resident's intravenous antibiotic treatment was delayed by three days due to a failure in medication reconciliation. Staff interviews revealed lapses in communication and procedural adherence.
Failure to Prevent Elopement and Inadequate Supervision of At-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at risk for elopement received adequate supervision and that the environment was free from accident hazards, as evidenced by two separate incidents involving residents with documented elopement risks. In the first case, a resident with diagnoses including anxiety disorder, cerebral infarction, and schizoaffective disorder, and with a history of wandering and elopement attempts, was placed on one-to-one supervision. Despite this, the assigned Patient Care Assistant left the resident unattended to take a dinner break without arranging for coverage, and the resident was able to exit the facility undetected. The facility's wander guard system did not alarm, and the resident was later found at a nearby bus station. Staff interviews confirmed that the resident was known to be at high risk for elopement and that one-to-one supervision required the staff member to remain within arm's reach at all times, which was not followed in this instance. In the second case, another resident with diagnoses including dementia with mood disturbance, agitation, and Parkinson's disease, and with severely impaired cognition and wandering behaviors, also eloped from the facility on two separate occasions. The resident was assessed as an elopement risk and had a wander guard in place. After the first elopement, interventions such as 30-minute visual checks and one-to-one supervision at night were ordered, but there was no documented evidence that these interventions were implemented. The resident subsequently eloped again, exiting through the front entrance without staff detection, and was found by police walking on a nearby street. Staff interviews revealed that the wander guard system did not alarm or secure the elevators or exit doors at the time, and there was a lack of internal cameras to monitor resident movement. Throughout both incidents, facility staff, including the DON and Administrator, acknowledged that the required supervision protocols were not followed and that the wander guard system was not fully integrated with all exits and elevators. Staff responsible for one-to-one supervision left residents unattended without arranging for relief, and there was a lack of documentation to show that required safety interventions were consistently implemented. The facility's policies on elopement prevention and one-to-one supervision were not adhered to, directly contributing to the residents' ability to leave the premises unsupervised.
Failure to Timely Develop and Document Elopement Risk Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to timely develop and implement a comprehensive care plan addressing elopement risk for a resident with dementia, cerebral infarction, and cervical spondylosis. The resident was assessed as an elopement risk and had a wander guard device applied, but the elopement care plan was not initiated until two days later. Additionally, the Certified Nurse Aide Assignment/Accountability Record and related monitoring instructions were not updated at the time the wander guard was placed, contrary to facility policy. Interviews revealed that staff relied on informal knowledge rather than documented instructions to monitor the resident's wander guard, and the required documentation in the care plan and CNA records was missing until after the delay was identified. The Director of Nursing confirmed that the care plan should have been updated immediately upon assessment and intervention, and that the omission was not in line with facility expectations or policy.
Failure to Revise Care Plan After Elopement Incident
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to include measurable interventions addressing an identified elopement risk. After an initial elopement incident, the facility's investigation summary specified that the resident should be monitored every 30 minutes for three days and placed on one-to-one supervision at night. However, these interventions were not incorporated into the resident's care plan, nor were they implemented. The care plan remained unchanged despite the resident's ongoing risk factors, including severely impaired cognition, wandering behaviors, and diagnoses such as adjustment disorder, dementia with mood disturbance and agitation, and Parkinson's disease. As a result of the care plan not being updated, the staff did not receive directives to implement the required interventions. Subsequently, the resident eloped again and was found by local police wandering on a nearby street, after which the resident was brought to the emergency room for evaluation. Interviews with nursing staff and the Director of Nursing confirmed that the care plan should have been revised to reflect the new interventions following the initial elopement, and that the failure to do so led to the deficiency.
Delay in Notification and Treatment for Positive Influenza A Result
Penalty
Summary
A deficiency occurred when the facility failed to provide timely medical evaluation and treatment for a resident who tested positive for Influenza A. The laboratory report indicated a positive result for Influenza A, but there was no documented evidence that nursing staff reviewed or addressed these results on the day they were received or the following day. Additionally, there was no documentation that the physician was notified of the positive test result during this period. As a result, antiviral treatment with Tamiflu was not initiated until two days after the positive result was available. The resident involved had significant medical conditions, including malignant neoplasm of the cerebellum, diabetes mellitus, multiple sclerosis, thrombocytopenia, and severely impaired cognition. Interviews with facility staff confirmed that the delay in treatment was due to a lack of timely communication from nursing staff to the physician. Staff also acknowledged that droplet precautions could have been implemented sooner, as a physician's order is not required to begin such precautions when Influenza is suspected or confirmed. The delay in starting Tamiflu and implementing appropriate precautions represented a failure to provide necessary care and services according to the facility's own Influenza protocol and CDC guidelines.
Delay in Initiating Droplet Precautions for Influenza A Positive Resident
Penalty
Summary
The facility failed to implement timely infection prevention and control measures for a resident who tested positive for Influenza A. After a respiratory panel plus COVID test was completed, the positive result for Influenza A was obtained, but droplet precautions were not initiated until two days later. There was no documented evidence that droplet precautions were started immediately after the positive result, as required by the facility's Influenza Protocol. The medical record also lacked documentation of the clinical rationale for ordering the test, and there was no record of timely physician notification regarding the positive result. Interviews with facility staff revealed that nurses are responsible for notifying physicians of abnormal test results and can initiate droplet precautions without a physician's order. However, in this case, there was a delay in both notifying the physician and implementing necessary precautions. The Director of Nursing and the Medical Director both confirmed that the delay represented a lapse in communication and infection control practices. The resident involved had significant medical conditions, including severe cognitive impairment, and was at increased risk due to the delay in implementing appropriate infection control measures.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Parkinson's disease, impaired mobility, and a history of being combative with care, fell from their bed and sustained a laceration to the left eyebrow. The resident was completely dependent on staff for all activities of daily living, including bed mobility and transfers, and required the assistance of two staff members for these tasks. On the day of the incident, a certified nurse aide was providing care alone and turned away from the resident to retrieve a mechanical lift pad, during which time the resident fell from the bed to the floor. The resident's care plan and assessment documentation indicated a need for two-person assistance for bed mobility and transfers due to the resident's inability to move independently and their tendency to be combative, including kicking, hitting, and reaching for objects. Despite these documented needs, the aide performed care and repositioning without a second staff member present. The resident was positioned in bed with their body against the wall, and the bed was in a low position, but the aide left the resident unattended while turning to get equipment, resulting in the fall. Interviews with staff confirmed that the resident was known to be completely dependent and often combative, requiring two-person assistance for safe care. The environment at the time of the incident was otherwise free of hazards, with appropriate fall precautions in place, but the lack of adequate supervision and failure to follow the resident's care requirements directly led to the accident and injury.
Failure to Prevent Resident Access to Hot Liquid Cart Resulting in Severe Burns
Penalty
Summary
A deficiency occurred when a resident with diabetes, peripheral vascular disease, and polyneuropathy, who was cognitively intact but required supervision for activities of daily living, was able to access hot water from an unattended hot liquid cart. The resident filled a basin with hot water and soaked their feet in another resident's room without staff knowledge or detection. The resident, who had neuropathy and could not feel pain in their feet, sustained second- and third-degree burns, resulting in blisters and subsequent hospitalization for burn evaluation and treatment, including a skin graft. The facility's hot liquids safety policy required that hot liquids be served at safe temperatures and that precautions be taken to regulate the temperature of liquids accessible to residents. However, there was no specific policy addressing the monitoring of hot water carts on resident units, and staff monitoring of the carts was inconsistent and informal, relying on word of mouth. The hot liquid cart was left accessible to residents, and staff were unaware that the resident had obtained hot water until after the injury occurred. Interviews revealed that the hot liquid cart was typically left outside the dining room and was accessible for extended periods, especially when logistical issues such as elevator availability delayed its removal. Documentation and interviews confirmed that staff did not observe the resident obtaining the hot water or soaking their feet, and the incident was only discovered after the resident reported blisters. The lack of consistent monitoring and absence of a clear policy for supervising hot liquid carts directly contributed to the resident's ability to access scalding water, resulting in actual harm. The event was classified as Immediate Jeopardy due to the actual harm and the risk posed to other residents.
Omission of Patient Care Assistants from Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all personnel, specifically omitting patient care assistants from the documentation. Although patient care assistants were scheduled daily on each unit to assist residents with grooming and housekeeping tasks, their roles, education, training, and competencies were not documented in the facility assessment. The assessment also did not reflect the training provided to these assistants, despite the facility operating a patient care assistant school on the premises and utilizing these individuals in resident care support roles. Interviews with the Staffing Coordinator confirmed that patient care assistants, who are students trained by the facility, were not included in staffing numbers but appeared on daily schedules. The Administrator acknowledged being unaware that both the patient care assistants and the training program needed to be included in the facility assessment. The deficiency was identified during a partial extended survey, with documentation and interviews supporting that the facility assessment did not meet regulatory requirements for comprehensively listing all direct care staff and their competencies.
Failure to Thoroughly Investigate Resident Burn Incident
Penalty
Summary
A deficiency was identified when the facility failed to thoroughly investigate an alleged violation involving a resident who sustained second and third-degree burns to both feet after immersing them in hot liquid obtained from a hot liquid cart. The incident occurred when the resident, who had diagnoses including diabetes mellitus, peripheral vascular disease, and polyneuropathy, accessed hot liquid from a cart on the unit and carried it to another resident's room without staff detection. The resident, who was cognitively intact and required some assistance with activities of daily living, soaked their feet in the hot liquid for 25 to 30 minutes, resulting in significant burns. The facility's accident/incident report was found to be inconsistent with the accounts provided by the resident and witnesses. Specifically, there was no documented evidence that statements were obtained from the certified nurse aide and another resident who witnessed the incident, as required by the facility's policy. Interviews confirmed that the certified nurse aide observed the resident with their feet in the basin and reported the incident to nursing staff, but was not asked to provide a written statement. Similarly, the other resident present during the incident was not interviewed for a statement at the time of the investigation. Further, the investigation summary lacked a documented date of conclusion, and the process for collecting and reviewing witness statements was not consistently followed. Nursing management acknowledged that statements from all relevant witnesses were not obtained and that investigative summaries were not dated, which was contrary to facility policy. These lapses resulted in an incomplete investigation of the incident involving the resident's injury.
Failure to Implement and Document Quality Improvement Actions After Resident Burn Incident
Penalty
Summary
The facility administrator failed to ensure effective and efficient use of resources to maintain the highest practicable well-being of each resident. Specifically, a resident sustained second- and third-degree burns after obtaining hot water from a hot liquid cart. Following this incident, there was no evidence that the administrator initiated any policy changes or protocol updates to prevent recurrence, nor was there documentation of a review of the incident details. Additionally, the administrator did not provide documented evidence of action plans or performance improvement plans for deficiencies identified during Quality Assurance and Performance Improvement (QAPI) meetings. The facility's QAPI policy requires the establishment of an interdisciplinary Quality Assessment and Assurance committee, including the administrator, to meet regularly and address quality deficiencies. However, while attendance sheets for several QAPI meetings were provided, there was no documentation of implemented action plans or performance improvement plans for identified deficiencies. Interviews with the administrator and DON revealed uncertainty regarding policy updates and a lack of immediate changes following the incident, as well as inconsistent participation in QAPI meetings by the administrator.
Failure to Develop and Implement QAPI Action Plan After Resident Burn Incident
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address identified quality deficiencies. Specifically, after a resident sustained second- and third-degree burns from hot water obtained from a hot liquid cart, there was no documented evidence that the QAPI committee took steps to identify or correct the deficiencies related to this incident. Review of QAPI meeting minutes following the incident did not reveal any action plans or performance improvement plans addressing the event. Interviews with the Administrator and Director of Nursing confirmed that while QAPI meetings are held and issues are discussed, there was no documentation or evidence of targeted actions taken in response to the burn incident. The facility's policy requires the QAPI committee to develop plans of action for identified deficiencies, but this process was not followed in this case, as shown by the lack of documentation and follow-up specific to the incident.
Violation of Residents' Mail Privacy
Penalty
Summary
The facility failed to ensure residents' right to privacy when sending and receiving mail, as evidenced by the experiences of 15 residents who reported that their mail was opened by facility staff before being delivered to them. The facility's policy on mail, dated May 2024, stated that residents were allowed to send and receive personal mail unopened unless otherwise advised by the attending physician and documented in the residents' medical records. However, during a Resident Council meeting, all attendees reported receiving mail that had been opened by facility staff prior to delivery. Interviews with the Activities Director and Security Director revealed that the Security Director received and sorted the mail, and the Business Office Coordinator and Manager were involved in handling residents' financial mail, which was opened and managed by the Business Office. The facility's Admission Agreement included provisions that allowed the facility to open residents' financial mail for assistance and payment purposes, which was not aligned with the facility's policy on mail privacy. The Administrator, during an interview, stated that they were unaware of the Admission Agreement's stipulation allowing the facility to open mail addressed to residents. This discrepancy between the facility's policy and practice, as well as the lack of awareness by the Administrator, contributed to the deficiency in maintaining residents' right to privacy in their correspondence.
Deficient Admission Policies and Consent Procedures
Penalty
Summary
The facility failed to establish and implement an admission policy that did not require residents or their representatives to incur personal financial liability or waive their rights. This was evident for all 11 residents reviewed for admission. The admission agreements required resident representatives to assume responsibility for the resident, hold the facility harmless for injury, death, and loss of property, and be personally liable for payment of charges. Additionally, the agreements allowed the facility to open residents' financial mail and manage their income without proper consent. Two residents, who were moderately cognitively impaired, signed admission agreements without documented evidence of their understanding due to their cognitive status. One resident, diagnosed with dementia, signed electronically without evidence of comprehension, while another resident with complex medical conditions and communication difficulties also signed without understanding. These agreements were signed despite the residents' cognitive impairments, raising concerns about their ability to consent. Another resident, who was cognitively intact, denied signing an admission agreement and was unaware of how their electronic signature appeared on the document. This resident had been managing their own finances and did not consent to the facility managing their Supplemental Security Income. The facility's process for obtaining electronic signatures and the lack of individual signatures for supplemental attachments further complicated the situation, as the administrator was unaware of the details and security measures involved in the electronic signature process.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status, leading to deficiencies in the documentation of residents' conditions. Specifically, for one resident with a history of dysarthria, dementia, and stroke, the MDS inaccurately documented the presence of a pressure ulcer and deep tissue injury as being present upon admission, despite these conditions not being present at that time. Another resident, who was a known smoker with diagnoses of diabetes mellitus and chronic obstructive pulmonary disease, was not identified as an active smoker in the MDS assessment, despite documentation in the care plan and nursing notes indicating their smoking status. Additionally, a third resident with diagnoses including diabetes mellitus and cervical disc disorder was inaccurately documented in the MDS as being discharged to a hospital, when in fact, they were discharged to the community with transportation provided to an airport. The inaccuracies in the MDS assessments were acknowledged by the MDS Director, who stated that the errors were unintentional and resulted from discrepancies in the information obtained from the residents' medical records. The facility's administrator was unaware of these inaccuracies prior to the survey findings.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services to promote wound healing and prevent new ulcers from developing. Specifically, for Resident #276, who was at risk for skin breakdown, there was no documented evidence that preventative measures, such as turning and repositioning or the use of heel booties as per the physician's order, were implemented prior to the development of a left heel pressure ulcer and a left dorsal foot deep tissue injury. The resident's care plan included interventions for potential impaired skin integrity, but these were not documented in the Certified Nurse Aide tasks or the Treatment Administration Record. Interviews with facility staff, including the Registered Nurse Supervisor and the Wound Nurse, confirmed the lack of documented interventions and the avoidable nature of the wounds. Resident #115, who had a diagnosis of chronic obstructive pulmonary disease, unspecified dementia, and Alzheimer's disease, was also at risk for skin breakdown. The resident had a Stage 3 pressure ulcer on the left heel and was prescribed an air mattress to aid in pressure relief. However, observations revealed that the air mattress was not inflated according to the resident's weight, as it was set at 350 pounds while the resident weighed 181 pounds. There was no documented evidence that the air pressure inflation monitoring was checked and documented by nurses each shift, as required by the facility's policy. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, indicated a lack of awareness and responsibility for checking the air mattress settings. The deficiencies in care for both residents highlight a failure in the facility's implementation of pressure ulcer prevention measures. The lack of documentation and adherence to care plans and physician orders contributed to the development and progression of pressure ulcers in these residents. The facility's policies on pressure injury prevention and air mattress support surface were not effectively followed, leading to avoidable harm to the residents.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for three residents. Resident #168, who was cognitively intact and had a tracheostomy, was observed performing self-suctioning without a physician's order. Despite the resident's claim that a respiratory therapist had approved their self-suctioning, there was no documented evidence of such an evaluation. Additionally, a registered nurse had previously observed the resident self-suctioning and reported it to respiratory therapy, but no documentation was found to support this claim. Resident #194, who had severe cognitive impairment and a tracheostomy, was observed receiving oxygen at incorrect flow rates of 7 and 8 liters per minute, despite physician orders for 3 and 5 liters. The Medical Administration Record inaccurately documented the administration of oxygen at the prescribed rate. The registered nurse unit manager acknowledged the incorrect oxygen flow but could not explain the discrepancy. Resident #69, with severe cognitive impairment and on continuous oxygen therapy, had no documented evidence of oxygen tubing changes as per physician orders. Observations revealed that the nasal cannula tubing was not dated, and a registered nurse confirmed the lack of documentation regarding the last tubing change. The facility's protocol required checking the order every shift and changing the cannula every three days, but this was not adhered to.
Pest Control Deficiency Due to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a roach infestation on multiple floors. Observations and interviews revealed that residents on the 2nd, 4th, and 6th floors experienced significant roach activity in their rooms. One resident on the 2nd floor reported seeing roaches in their room and bathroom, while another resident on the 6th floor described a pervasive infestation, with roaches visible at all times and worsening at night. The resident had to resort to using a glove to kill roaches near their bed. Despite previous exterminator visits, the roach activity did not decrease. The facility's pest control policy, dated June 2024, required a written agreement with a qualified pest service, but there was no documented evidence of a valid Pest Management Contract. The Facility Survey Report and Facility Assessment did not identify a third-party contractual agreement with a pest control company, nor did they document pest control as a necessary service. Interviews with staff, including certified nurse aides and housekeepers, confirmed the presence of roaches and indicated that exterminators had visited the facility, but the infestation persisted. The Pest Logbook documented roach sightings on the 4th floor but not on the 2nd or 6th floors. The Director of Housekeeping stated that the facility worked with a Pest Management Company, and exterminators visited weekly. However, there was no documented evidence of exterminator meetings, recommendations, or actions taken to address the infestation. The Administrator confirmed that pest control services were provided, but there was no documentation of recommendations or an action plan to address the roach infestation. The deficiency was further compounded by residents keeping food in their rooms and ongoing construction in the facility, which made controlling the infestation challenging.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents and their representatives were explicitly informed of their right not to sign a binding arbitration agreement as a condition of admission. This deficiency was identified during a recertification survey, where it was found that the admission agreements for two residents included language that implied their signatures were applicable to a binding arbitration agreement. The facility's admission packet contained an admission agreement and a list of attachments, including a binding arbitration agreement, but there was no documented evidence that residents were given the option to sign the admission agreement without consenting to the arbitration agreement. During interviews, the facility's administrator stated that they were not aware of the contents of the admission agreement and did not know that binding arbitration agreements were offered to residents. The administrator also mentioned that the admission agreement was a template likely used by other facilities under the same corporate entity. Despite the administrator's claim that the facility did not require residents to sign the arbitration agreement, there was no explanation provided on how residents could differentiate their admission agreement signature from consent to the arbitration agreement.
Deficiency in CNA Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service training, including specific training in dementia management and resident abuse prevention. During a recertification survey, it was found that five CNAs did not have documented evidence of receiving dementia management training. Additionally, one CNA did not complete the required 12 hours of in-service training or the abuse prevention training. The facility's policy mandates regular in-service training for all personnel, and the facility assessment specifies that training must include dementia management and abuse prevention. Interviews with the Nurse Educator and the Director of Nursing revealed gaps in the training schedule, particularly for overnight staff. The Nurse Educator, who was responsible for staff training, had stopped working night shifts in October 2024, which contributed to the missed training sessions. The Director of Nursing was aware of the general lack of training for overnight staff but was not specifically aware of the missed training for the CNA in question. This lack of training documentation and scheduling oversight led to the identified deficiencies.
Resident Dignity Compromised Due to Unchanged Soiled Linens
Penalty
Summary
The facility failed to ensure a dignified experience for a resident, identified as Resident #90, during a recertification and abbreviated survey. The deficiency was observed when the fitted mattress sheet on Resident #90's bed was stained and not changed for six days. Resident #90, who was cognitively intact and dependent on staff for daily activities, reported that their sheets were changed infrequently, and staff mentioned a linen shortage. However, Certified Nurse Aide #29, who was familiar with the resident, stated that they had sufficient supplies and had changed the sheets on 12/14/24. Despite this, the stained sheet was observed on multiple occasions, indicating a lapse in maintaining the resident's dignity. Interviews with staff, including a Registered Nurse and the Director of Housekeeping, revealed that while there could be occasional shortages of linens, procedures were in place to address these shortages by contacting the laundry department. The Director of Housekeeping confirmed that linens were delivered twice daily and additional supplies could be provided if needed. Despite these procedures, the stained sheet on Resident #90's bed was not addressed in a timely manner, leading to the deficiency in maintaining the resident's right to a dignified existence.
Delayed Reporting of Resident Altercation
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe, as mandated by the Elder Justice Act. On September 12, 2024, a resident-to-resident altercation occurred between Resident #42 and Resident #273 at 2:50 PM in the facility's elevator. The altercation escalated from a verbal exchange to a physical confrontation, resulting in Resident #273 sustaining a cut lip and pain in the right scapula. Despite the incident being reported to the Director of Nursing at the time it occurred, the facility did not notify the State Survey Agency until 6:17 PM, exceeding the two-hour reporting requirement for incidents involving bodily injury. Resident #42, who was involved in the altercation, was later transferred to the hospital for evaluation and has a medical history including schizophrenia, depression, and dementia. Resident #273, who was injured, has diagnoses including end-stage renal disease requiring hemodialysis, chronic obstructive pulmonary disease, and an anxiety disorder. The Director of Nursing acknowledged the delay in reporting the incident and was aware of the requirement to report within two hours.
Failure to Notify Resident's Representative of Discharge
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing of a facility-initiated discharge for Resident #255. The resident, who had medically complex conditions and depression, was cognitively intact and had a discharge plan in place to return to the community. On December 16, 2024, Resident #255 received a Notice of Discharge, but there was no documented evidence that a copy of this notice was sent to the resident's representative. The facility's policy required written notification to the resident and/or representative, but this was not adhered to in this case. The Ombudsman reported concerns about the facility's discharge notification process, noting that their office did not receive a copy of the discharge notice simultaneously with the resident. The Social Worker issued a revised Notice of Discharge to the resident on December 16, 2024, and emailed a copy to the Ombudsman. However, there was no documented evidence that the notice was mailed to the resident's representative, and the Social Worker was unable to contact the representative to discuss the discharge plans. The Administrator confirmed the lack of documented evidence of mailing the notices to resident representatives.
Failure to Provide Language Interpretation Services
Penalty
Summary
The facility failed to ensure that a resident who primarily spoke Spanish was provided with the necessary interpretive services to communicate effectively with staff. This deficiency was identified during a recertification and abbreviated survey. The resident, who had a history of cerebral infarct, diabetes mellitus, and muscle weakness, was documented in their care plan as needing an interpreter for communication with healthcare staff. Despite this, the facility did not provide a Spanish translator, and staff were unaware of how to access translation devices or services. Interviews with the Director of Nursing and Certified Nurse Aides revealed that the resident's need for interpretive services was not documented in the Certified Nurse Aide instructions. Additionally, there were not enough Spanish-speaking aides to meet the needs of all Spanish-speaking residents, and staff had not been trained on using language translation devices. The facility's policy on communication and language access was not effectively implemented, leading to a failure in providing the necessary care and services for the resident's communication needs.
Failure to Address Resident's Dietary Needs and Aspiration Risk
Penalty
Summary
The facility failed to provide person-centered care and services necessary to maintain the highest practicable well-being for a resident with a history of pneumonitis due to inhalation of food/vomit and dysphagia. The resident was not provided with a plan to address their individual needs and minimize choking hazards, despite hospital recommendations for a soft, bite-sized diet texture, mildly thick liquids with no straw, and intermittent supervision. The facility did not adjust the resident's diet according to their verbalized request for chopped texture proteins due to difficulty with chewing chicken and beef. The facility's policies on accidents and incidents, as well as aspiration precautions, were not adequately followed. Nursing staff were responsible for monitoring residents for signs of aspiration risk and implementing precautions, but there was no documented evidence that the resident's oral intake and difficulty swallowing were monitored. The Speech Language Pathologist did not evaluate the resident after a certain date, and the dietary technician did not follow up to ensure a change in diet consistency was ordered. The resident was found unresponsive in their room after being served a lunch meal tray, and the facility did not thoroughly investigate the incident to rule out choking. Interviews with facility staff revealed communication breakdowns and a lack of follow-up on the resident's dietary needs. The dietary technician communicated the resident's request for a downgraded diet to the registered nurse and director of rehabilitation but did not ensure a speech therapy evaluation was ordered. The speech therapist missed the hospital's diet order for soft foods and thickened liquids and did not receive any referrals for the resident after discontinuing services. The director of nursing was unaware of the resident's dysphagia diagnosis and the hospital's dietary recommendations, and the investigative report did not include information on whether the resident aspirated during the lunch meal.
Physician's Failure to Review Resident's Total Care Plan
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and documented the resident's total program of care, including medications and treatments, at each required visit. This deficiency was identified for a resident with a history of cerebral infarction, dysphagia, and other complex medical conditions. The resident had been discharged from the hospital with specific dietary recommendations due to a swallowing disorder, which were not incorporated into the care plan by the attending physician. The physician did not review the hospital's speech pathology evaluation or the dietician's notes, which documented the resident's difficulty with a regular texture diet and the need for a modified diet. The attending physician admitted to only reviewing hospital discharge paperwork related to medication orders and not paying attention to nutrition or diet orders. The physician relied on nursing staff to provide necessary information for treatment plans, which led to the oversight of the resident's dietary needs. The medical director confirmed that the physician should have reviewed the resident's medical record, including nutrition and dietician notes, when assessing the resident and determining the plan of care. This lack of comprehensive review and documentation resulted in the resident not receiving the appropriate dietary modifications necessary for their condition.
Failure to Manage Resident's Financial Affairs and Inform of Tax Refund Checks
Penalty
Summary
The facility failed to ensure the resident's right to manage their financial affairs, as evidenced by the mishandling of a resident's tax refund checks. The resident, who was cognitively intact and had been living at the facility for approximately four years, reported during a Resident Council Meeting that the facility did not inform them upon receipt of their tax refund checks. The checks were opened and deposited into the facility's operating account without the resident's written authorization. The facility's policies on privacy, confidentiality, and resident rights were not adhered to, as there was no documented evidence of the resident's consent to manage their finances or open their mail. The Business Office Manager confirmed that the tax refund checks were deposited into the resident's account without informing the resident. The facility was unable to provide documented evidence of the resident's written authorization for the facility to manage their finances or a detailed accounting of the transactions related to the tax refund checks. Additionally, the facility failed to provide the resident with quarterly statements or detailed transaction history, which are required to ensure transparency and accountability in managing resident funds. Interviews with the Business Office Manager and the Administrator revealed a lack of communication and oversight regarding the handling of resident mail and financial management. The Administrator, who was not involved in the Business Office operations, was unaware of the practices related to opening resident mail and depositing checks. The facility's failure to inform the resident and obtain proper authorization for managing their finances resulted in a deficiency in maintaining a system that assures a full and complete accounting of the resident's personal funds.
Misappropriation of Resident's Tax Refund Checks
Penalty
Summary
The facility failed to protect a resident's right to manage their own finances, resulting in the misappropriation of the resident's tax return checks. Resident #162, who was cognitively intact and had been managing their own finances since admission in 2020, reported that their tax return checks were taken by the facility's Business Office without their knowledge or consent. The checks, issued in 2023 and 2024, were deposited into a facility account, and the resident was not informed of their arrival or the transactions. The facility's policies on misappropriation and personal needs accounts were not followed, as the resident did not consent to the facility managing their funds. Interviews with the Business Office Manager and the Long-Term Care and Business Office Coordinator revealed that the facility's mail handling procedures involved opening residents' mail and depositing checks into facility-managed accounts without resident consent. The Business Office Manager was unable to provide documentation or explain how the checks were deposited without the resident's endorsement. The Administrator, who was new to the facility, was unaware of the issue and stated that residents' mail should not be opened without consent. The facility was unable to provide bank statements or transaction details related to the resident's funds, indicating a lack of proper documentation and oversight in managing resident finances. This deficiency highlights a significant breach of the resident's rights and the facility's responsibility to safeguard personal property.
Failure to Conduct Psychology Consult for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary behavioral health care and services to maintain their mental and psychosocial well-being. Specifically, a psychology consult for the resident, who had a history of acute stress reaction, alcohol dependence, and cocaine abuse, was not conducted as per the physician's order. The resident had expressed a need to talk to a psychology therapist about past traumas, including the loss of parents, homelessness, and a train accident resulting in limb loss. Despite the psychiatrist's recommendation for a psychology consult and the resident's request, the consult was not completed. Interviews with the Director of Nursing and the Registered Nurse/Unit Manager revealed that there was no documentation of a completed psychology consult for the resident. The consultant psychologist confirmed that they did not receive a referral for the resident and did not recall consulting with them. The failure to conduct the psychology consult as ordered and recommended by the psychiatrist led to the deficiency, as the resident did not receive the necessary behavioral health services to address their mental health needs.
Improper Drug Labeling and Storage in Medication Room and Cart
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards, as observed during a recertification survey. An insulin pen for a resident, which had an open date of September 10, 2024, and a use-by date of November 6, 2024, was found in the medication storage room refrigerator on unit 4, despite being past its use-by date. The Registered Nurse Unit Manager acknowledged that expired insulin pens should be removed, but the pen remained in the refrigerator. Additionally, a controlled medication, Phenobarbital, was found in the locked drawer of a medication cart on unit 4, contrary to the facility's policy that required controlled medications to be returned to a double-locked cabinet after medication passes. Interviews with nursing staff revealed a lack of adherence to the facility's medication storage policies. Registered Nurse #21 admitted to keeping the Phenobarbital in the cart, and the Director of Nursing confirmed that controlled medications should be returned to the medication room after each shift. The Pharmacy Consultant Supervisor noted that during a recent audit, expired medications were identified, but it was the responsibility of the nurses to discard them. The inability of staff to access the controlled medication box in the medication room further highlighted issues with medication management and storage practices within the facility.
Misappropriation of Resident's Funds by Dialysis Transportation Worker
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving a transportation worker associated with a dialysis center. The resident, who was not on dialysis, reported that the transportation worker withdrew a total of $5,900 from their cash app account under the pretense of assisting them in finding an apartment. The incident was reported to law enforcement, but the facility did not ensure that the transportation worker did not have access to residents who were not on dialysis. The facility's investigation did not include interviews with other residents transported by the worker or a written statement from the accused worker. The resident involved had a diagnosis of Congestive Heart Failure, Cerebral Infarction, and Ataxia following other Cerebrovascular Disease, with intact cognition as per their MDS assessment. Despite the resident's report of the incident, there was no documented evidence of an abuse care plan being initiated to protect the resident from further abuse. The Director of Nursing acknowledged that the transportation worker was not an employee of the facility but worked for the dialysis center, and the facility could not conclude misappropriation due to a lack of evidence regarding the conversations between the resident and the worker.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
The facility failed to ensure the rights of a resident to be free from abuse and misappropriation of property. During a discharge planning meeting, a resident alleged that a dialysis transportation worker withdrew a total of $5,900 from their cash app account. The incident was reported to law enforcement, but there was no documented evidence that other residents transported by the same worker were interviewed. Additionally, there was no written statement from the accused transportation worker, and no abuse care plan was initiated to protect the resident from further abuse. The resident involved had a diagnosis of congestive heart failure, cerebral infarction, and ataxia following other cerebrovascular disease, with an intact cognition score. The facility's investigation summary documented that the resident reported the transportation worker had been taking their money under the pretense of assisting with finding an apartment. The resident showed an application on their phone revealing the transactions. Despite the facility's acknowledgment of the theft, the allegation was neither substantiated nor unsubstantiated, and the facility did not conclude misappropriation due to a lack of evidence regarding the conversation between the resident and the transportation worker.
Deficiencies in Timely Medical Care and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate medical care for two residents, leading to deficiencies in quality of care. Resident #1, who had a history of Parkinson's Disease, Essential Hypertension, and Type 2 Diabetes, experienced episodes of vaginal bleeding. Despite a pelvic ultrasound revealing an enlarged uterus with fibroids, the facility did not secure a timely gynecological appointment. The resident's condition was monitored, but appointments were repeatedly canceled due to the resident's transfer status, ultimately resulting in the resident being transferred to the hospital after significant delays and family intervention. Resident #4, admitted with conditions including Acute Chronic Respiratory Failure and Stage 4 kidney disease, was prescribed an intravenous antibiotic for an infection. However, the antibiotic treatment was not initiated until three days after admission, following notification by the resident's family representative. The delay in starting the prescribed medication was due to a failure in the medication reconciliation process upon the resident's admission to the facility. Interviews with facility staff, including the Director of Nursing, Registered Nurse, and Primary Physician, revealed lapses in communication and procedural adherence. The Director of Nursing acknowledged the expectation for accurate medication reconciliation, while the Primary Physician could not explain the delay in starting the antibiotic. These deficiencies highlight the facility's failure to provide care in accordance with professional standards and the residents' medical needs.
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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