Kings Harbor Multicare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bronx, New York.
- Location
- 2000 E Gunhill Road, Bronx, New York 10469
- CMS Provider Number
- 335644
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kings Harbor Multicare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and significant neurological diagnoses vomited undigested food after an evening meal and was described by staff as alert, talking, and not in distress. Facility policy required that such changes in condition be fully assessed, with vital signs documented and prompt notification of the RN supervisor and physician. An LPN later stated that vital signs were taken and stable, but there was no documentation of these vital signs in the record and no notification to the RN supervisor or physician at the time of the vomiting. Later that evening, while being turned in bed, the resident accidentally struck their head on a closet, developed a forehead laceration and hematoma, and then experienced a sudden decline requiring emergency intervention. Interviews with the RN supervisor and DON confirmed that the lack of documentation and failure to notify after the vomiting episode did not comply with facility policy or professional standards.
A resident with severe impaired cognition and a history of osteopenia reported pain and inability to stand, but was transferred by an LPN and CNA before being assessed or receiving pain medication. The resident was later diagnosed with an acute pelvic fracture at the hospital. The facility's investigation found no documented pain assessment or administration of pain relief prior to the transfer, highlighting a failure in adhering to the facility's pain management policy.
The facility was found to have non-GFCI outlet receptacles within six feet of sinks, potentially creating an electrical hazard. This issue was observed in multiple resident rooms and floors during a facility tour, with the Director of Maintenance present and acknowledging the deficiency.
The facility failed to ensure proper installation and coverage of the automatic sprinkler system, with deficiencies noted in several areas including Stairwell D, the emergency laundry storage room, and the Soiled Utility Room. Sprinklers were improperly installed in the kitchen, Staff Restroom, and resident's Shower Room, not adhering to NFPA standards.
A facility failed to report a resident-to-resident abuse incident to the Department of Health within the required 2-hour timeframe. The incident involved a resident hitting another with a grabber, and although staff were aware and reported it internally, the external report was delayed until the next day. Both residents had cognitive impairments, and the facility's policy mandates immediate reporting of such incidents.
The facility failed to submit resident assessments to CMS within the required timeframe due to an error in the submission process. Nine assessments were delayed because the IT Support person submitted the same file twice, leading to one batch being overlooked. This issue was identified during a survey, and the facility's Administrator acknowledged it as an honest mistake.
During a Life Safety Recertification survey, unmounted power strips and an extension cord were found in use in various administrative areas and the Nursing Office, violating NFPA 70 standards. The Director of Maintenance acknowledged the temporary use of the extension cord and stated that power strips would be mounted.
A resident with dementia and a history of aggressive behavior was allegedly slapped by a CNA during care. The facility's policy to report combative behavior was not followed, and care instructions lacked guidance on handling aggression. The CNA was terminated after the incident was reported by another staff member.
A medication error occurred when an RN administered insulin to the wrong resident, who was not on insulin therapy. The RN failed to verify the resident's identity, leading to the administration of 24 units of Lantus insulin. The resident, who has Type 2 Diabetes Mellitus but no insulin order, was alert and responsive with normal vital signs. The error was discovered when the resident informed the RN, prompting immediate notification to the LPN, Nursing Supervisor, and Medical Doctor.
Failure to Assess, Document, and Notify After Resident Vomiting Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and facility policy when a resident experienced vomiting after dinner. The resident had significant neurological diagnoses, including subdural hematoma, hydrocephalus, and dementia, and was documented as having severely impaired cognition and requiring extensive assistance with eating and bed mobility. On the evening in question, the resident ate dinner in their room with assistance and later vomited a small amount of undigested food, with vomitus observed on clothing and bed linens. Staff interviews and documentation show that the resident was described as alert, talking, and not in distress at that time. According to the facility’s policies on Notification of Changes and Falls/Occurrences, any accident, incident, or significant change in condition requires immediate notification of the physician and, as appropriate, the resident’s representative, as well as supportive documentation including vital signs, full physical assessment, and therapeutic interventions. The LPN reported in an investigative statement that vital signs were taken after being informed of the vomiting and that the resident was stable, but there was no documented evidence in the medical record that vital signs were recorded. There was also no documented evidence that the RN supervisor or the physician were notified of the vomiting episode, despite the facility’s policy and the RN supervisor’s later statement that such a change in condition should have been reported. Later that same evening, during bed linen changes, the resident was turned in bed and accidentally hit their head on the closet, resulting in a laceration and hematoma to the forehead. The LPN then notified the RN supervisor, who assessed the resident, noted changes in communication and mental status, obtained vital signs showing hypotension and bradycardia, and initiated emergency measures when the resident became unresponsive and pulseless. Subsequent interviews with the RN supervisor, DON, and Medical Director confirmed that the LPN did not notify the supervisor at the time of the vomiting and did not document the vital signs taken after the vomiting episode. The deficiency centers on the lack of timely notification and incomplete documentation following the resident’s vomiting, contrary to professional standards and the facility’s own policies.
Failure in Pain Management for Resident with Acute Pelvic Fracture
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the events surrounding a resident with severe impaired cognition and a history of osteopenia and prior falls. On the morning of the incident, the resident reported pain and an inability to stand to a Certified Nursing Assistant (CNA). Despite this, the resident was transferred by a Licensed Practical Nurse (LPN) and the CNA before being assessed by a Registered Nurse Supervisor or receiving any pain medication. This transfer occurred prior to any documented pain assessment or administration of pain relief, which was contrary to the facility's policy requiring pain assessment by a Registered Nurse using a Pain Assessment Tool. The resident was later transferred to the hospital, where they were diagnosed with an acute pelvic fracture. The facility's investigation revealed that the resident had a history of osteopenia and previous fractures, which increased their risk for further fractures. However, there was no documented evidence of a pain assessment or administration of pain medication before the hospital transfer. The LPN claimed to have administered pain medication but failed to document it, and the Registered Nurse Supervisor only assessed the resident after they had been moved to a chair. Interviews with the staff involved revealed a lack of adherence to the facility's pain management policy. The CNA and LPN transferred the resident without a prior assessment, and the LPN did not check the resident's hip due to the resident wearing pants. The Director of Nursing acknowledged that the resident's pain was new and should have been assessed before any movement. The facility's investigation concluded that there was no evidence of abuse, neglect, or mistreatment, but the deficiency in pain management was evident.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was identified as being directly affected by the alleged gap in practice. The facility did not ensure that pain management is provided to resident who require such services consistent with professional standards of practice and the comprehensive person-centered care plan. - An investigation was conducted and concluded that there was no evidence to support that abuse, neglect or mistreatment may have occurred. - Resident #1 was transferred to the hospital on [DATE] and readmitted to Kings Harbor on 2/15/24. - Upon resident #1 readmission from the hospital: - A Pain Assessment was completed - Resident #1 was evaluated by PMD and Tylenol 325mg q 6 hours for 14 days was ordered for pain management. - Care Plan #131A Pain Management was updated. - Resident #1 was monitored for pain and the effectiveness of pain management. - LPN #1 was educated on medication administration and documentation. - RN #1 was educated on pain assessment, pain management and updating Care Plan when change in resident condition is noted. - CNAs, LPNs and RNs of the Manor service were educated on reporting new onset of pain and deferring transfer/movement of resident prior to assessment by RN. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All residents with new onset of pain in the last 30 days will be reviewed by the RNM/RNS to ensure that a pain assessment is conducted, PMD was notified, appropriate pain management was implemented, and pain care plan was updated. In the event that non-compliance was identified, it will be immediately corrected to comply with F697. Responsible Party: RNM/RNS 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? An Ad Hoc QA/PI Meeting with the Administrator, DON, Medical Director, Director of QA/PI, and Staff Development was held to discuss the systemic changes that will be made to ensure that the deficient practice does not occur. 1. The Policy and Procedure for Pain Assessment, Education and Management was reviewed to assure compliance with F697 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and revised accordingly. The change in policy includes: - Pain assessment and Pain Management care plan update shall be performed: a. On admission/re-admission b. Quarterly and Annually for CCP Meeting c. Upon significant change in residents’ condition d. Upon any incident or accident as part of the assessment of the resident e. For any new complaint of pain identified by resident or staff f. Prior to initiation of a pain medication regime or change in pain medication regime g. Upon a change in the resident’s pain medication h. At any other time based on nursing or physician assessment Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all RNs and LPNs on pain assessment, management and care plan update. Highlights of the lesson plan include: - It is the policy of Kings Harbor to assess and manage resident’s pain upon admission/readmission and continually throughout their stay to assure the highest level of pain control and resident comfort. - When and how to perform pain assessment - Communicating with the medical provider when pain is identified - Documentation of pain assessment and management - Updating pain care plan as indicated in the Pain policy Responsible Party: Inservice Coordinator/Designee 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility’s compliance with ensuring that all residents with new onset of pain are assessed and managed and that all appropriate documentations are completed. Responsible Party: QA/PI 2. All residents with new onset of pain will be reviewed to ensure that they are assessed, and appropriate management is implemented weekly x 4 weeks and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Nursing Team Leaders/ADON 3. The results of the pain audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the pain audit will be presented and discussed at the facility monthly by QA/PI. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 21, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.
Non-GFCI Outlets Near Sinks Pose Electrical Hazard
Penalty
Summary
The facility failed to ensure compliance with the National Electric Code NFPA 70, 2011 edition, by not installing ground-fault circuit interrupter (GFCI) type outlet receptacles within six feet of sinks, which could potentially create an electrical hazard. This deficiency was observed during a facility tour conducted over several days, where outlet receptacles not of the GFCI type were found in resident rooms P436, M409, M401, and throughout all five resident floors. These observations were made in the presence of the Director of Maintenance, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2011 NFPA 101, the observed electrical outlets in rooms P346, M409, M401, and other identified resident floors will be converted to approved GFCI outlets by the Engineering Staff. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by the deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that all electrical outlets are located within 6 feet of any water source. All identified outlets that are not compliant will be converted to approved GFCI outlets. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering reviewed and revised the facility policy on Electrical Outlet Testing to include, “GFCI to be used within 6 feet of water source.” b. All Engineering staff will be informed and educated regarding the revised policy on Electrical Outlet Testing. The education will include proper installation, usage, and testing of GFCIs. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: a. The Director of Engineering will include in the Environment of Care audit tool to inspect and test all GFCI receptacles. b. Audits will be performed monthly by the Engineering staff to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering
Improper Sprinkler Installation and Coverage
Penalty
Summary
The facility failed to ensure proper installation and coverage of the automatic sprinkler system as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a recertification survey, it was observed that the sprinkler coverage was inadequate at the bottom landing of Stairwell D near a discharge door and in the emergency laundry storage room located in the basement. Additionally, a pendent sprinkler in the Soiled Utility Room was installed closer than four inches from the wall, which does not comply with the minimum distance requirements. Further deficiencies were noted during a tour of the kitchen, where a sidewall sprinkler was improperly installed on the ceiling of the dessert refrigerator. On the 3rd Floor of the Manor building, a sidewall sprinkler was also incorrectly installed on the ceiling of the Staff Restroom, and a pendent sprinkler was positioned closer than four inches from the wall in the resident's Shower Room. These observations indicate a failure to adhere to the specified guidelines for sprinkler installation, potentially compromising the effectiveness of the fire protection system.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2010 NFPA 13, the Director of Engineering contacted the Fire Safety Sprinkler Company to: 1. Install the lacking fire sprinklers at the bottom landing of stairwell D and the emergency laundry storage room. 2. Appropriate sprinkler will be installed in the soiled utility room, 3rd floor Manor building staff restroom and the residents shower room. 3. The facility has signed a contract for installation and work has commenced. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility states that all residents have the potential to be affected by deficient practice. b. The contracted company reviewed sprinkler coverage throughout the facility and no additional areas were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. All Engineering staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as overview of requirements for sprinkler coverage as per K351. b. The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put into practice: a. The Director of Engineering has reviewed and revised the Environment Care Audit tool to ensure proper sprinkler coverage. b. Audits will be performed monthly by the Engineering Director/designee x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected by the Engineering Department or our contracted sprinkler company as needed. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident physical abuse to the New York State Department of Health within the required 2-hour timeframe. The incident involved two residents, one of whom hit the other on the shoulder with a grabber. The incident occurred at approximately 1:40 PM, and the facility's Administrator was made aware of it by 1:55 PM. However, the report was not submitted to the Department of Health until the following day at 12:31 PM. Resident #193, who was hit, was admitted with diagnoses including end-stage renal disease, cerebral infarction, and polyneuropathy, and was cognitively impaired. Resident #325, who committed the act, was admitted with diagnoses including Alzheimer's disease, unspecified dementia, and major depressive disorder, and was severely impaired in cognition. The incident was witnessed by a Certified Nursing Assistant who reported it to a Registered Nurse, who then informed the Assistant Director of Nursing and the Director of Nursing. Despite the facility's policy requiring immediate reporting of abuse allegations, the Assistant Director of Nursing did not receive instructions from the Director of Nursing to report the incident until the next day. Both the Director of Nursing and the Administrator acknowledged the requirement to report such incidents within 2 hours but could not recall why the report was delayed. This failure to report in a timely manner constitutes a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #193 and resident #325 were identified as being directly affected by the alleged gap in practice. The facility did not ensure that an alleged violation involving resident-to-resident physical abuse was reported immediately, but no later than 2 hours after allegations were made to the State Survey Agency. - An investigation was conducted and concluded that the altercation was sudden in nature and was not premeditated. - Resident #193 and #325 were separated. Resident #325 was transferred to another unit. - Resident #193 and #325 were assessed and monitored. - Resident #193 and #325 medical provider and family were notified of the incident. - Resident #193 and #325 were seen and evaluated by the psychologist. - Resident #325 was seen and evaluated by the psychiatrist. - Social Services provided emotional support to residents #193 and #325. - The incident was reported to the NYS-DOH on 7/29/24. - RN #4 was re-educated on actual/alleged abuse reporting to ensure that the NYS-DOH is notified within 2 hours after the incident/allegation. - CNA #7 was re-educated on abuse prevention and reporting. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All incidents and accidents for the preceding 30 days were reviewed by the Assistant Directors of Nursing to ensure that any incidents of alleged or actual abuse or incidents involving serious injury were reported timely to the DON and Administrator, as required, to the state agency and all other required agencies (i.e. law enforcement when applicable). In the event that non-compliance was identified, the incident will be immediately reported to all required entities and staff involved re-inserviced on the required timeframes to report. Responsible Party: Assistant Directors of Nursing 3. What measures will be put in place or what systemic changes will you make to ensure that the deficient practice does not occur? 1. The Policy and Procedure for Abuse- Prohibition Protocol, Types of Abuse, Response/Reporting Prevention/Response/Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI, and Medical Director and revised accordingly. The change in policy includes: - Any alleged violations involving mistreatment, neglect, or abuse, including serious injuries of an unknown source must be reported to the Administrator/Designee, or department director immediately. An immediate investigation must be made and the findings of such investigation must be reported to the NYSDOH via Electronic Incident Reporting form within 2 hours of occurrence/discovery. Responsible Party: Administrator, DON, Medical Director, QA/PI 2. The Policy and Procedure for Abuse Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI, and Medical Director and found to be in compliance. Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 3. Inservice education will be provided by the Inservice Coordinator/designee to all staff on abuse, neglect, and mistreatment including injuries of unknown origin regarding reporting requirements related to violations involving abuse to the NYSDOH and NYPD, immediately. Education on Abuse Prohibition Protocol will continue to be provided to staff upon hire and annually thereafter. Highlights of the lesson plan include: - The facility staff must immediately report all alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property to the RNM/RNS/ADON. An investigation is to immediately follow. - The RNM/RNS/ADON will immediately notify the DON who will notify the Administrator. - Upon notification, the Assistant Director of Nursing/Designee must report alleged violations of mistreatment, neglect, and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYSDOH and as appropriate to other required agencies (i.e., NYPD). Responsible Party: Inservice Coordinator/Designee 4. The Residents Occurrence Log-In form (SAFETY-967) was reviewed and revised to ensure that actual/allegation of abuse is reported to the NY-DOH within 2 hours of the incident/allegation. Revision of form included adding: - Reportable (Y/N) - Date/Time Reported to DOH - Date/Time Reported to Other Agency Responsible Party: QA/PI 4. How will the corrective action(s) be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility’s compliance with ensuring that all accidents and incidents are investigated, and abuse is reported timely as per NYSDOH and Federal reporting guidelines. Responsible Party: QA/PI 2. All accidents/incidents and grievances involving alleged abuse or serious injuries will be audited daily by the Assistant Director of Nursing/designee for 30 days and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Assistant Director of Nursing/Designee 3. The results of the accidents and incidents audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the accidents and incidents audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.
Delayed Submission of Resident Assessments
Penalty
Summary
The facility failed to ensure timely submission of resident assessments to the Centers for Medicare and Medicaid Services (CMS) system, as required by their policy. During a recertification survey, it was found that nine resident assessments were not submitted within the mandated 14 days of completion. The assessments for these residents had completion dates ranging from October 24, 2024, to November 1, 2024, but were not submitted until December 6, 2024. This delay was contrary to the facility's policy, which mandates timely submission of all Minimum Data Sets to CMS via the Internet Quality Improvement and Evaluation System. The issue arose due to an error in the submission process. The Assistant Director of Nursing, responsible for resident assessments, stated that a batch scheduled for submission on November 6, 2024, was accidentally missed. The Information Technology Support person confirmed that they had mistakenly submitted the same file twice, leading to one batch being overlooked. This error was not identified until the surveyor pointed it out during the survey. The Administrator acknowledged the mistake, noting it was the first occurrence of such an issue at the facility.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 were identified as being affected by the alleged gap in practice. The facility did not ensure that residents MDS were submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 MDS assessments were submitted immediately to Centers for Medicaid and Medicare Services system and accepted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. The MDS Coordinators reviewed all resident comprehensive, discharge and significant change assessment for the last 3 months for timely completion and submission. All MDS were completed, submitted and accepted. Responsible Party: MDS Coordinators 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? 1. The Policy and Procedure titled MDS 3.0 Submission was reviewed to assure compliance with F640 by the Administrator in conjunction with the Assistant Director of RA, Chief Information Officer and Director of QA/PI and revised accordingly. The changes in policy include “It is the Policy of Kings Harbor Multicare Center to ensure that all MDSs are submitted to CMS via IQIES within 14 days of completion” and “RA Coordinator will ensure receipt of the IQIES validation report from MIS on a daily basis.” Responsible Party: Administrator, Assistant Director of RA, Chief Information Officer, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all MDS Coordinators and Information Technology support personnel on the policy titled “MDS 3.0 Submission” revised 12/2024. Responsible Party: Inservice Coordinator/Designee 3. An Audit tool will be created to ensure that all batch MDS assessments are submitted within the 14 day requirement. Responsible Party: Director of QA/PI 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. All MDS batches will be audited to ensure submission within 14 days of completion, weekly x 4 weeks and then bi-weekly x 5 months. Responsible Party: Assistant Director of RA 2. The results of the MDS submission audit will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 3. Results of the MDS submission audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator.
Non-compliance with NFPA 70 Standards for Electrical Systems
Penalty
Summary
During the Life Safety Recertification survey conducted from (MONTH) 4, 2024, through (MONTH) 10, 2024, the facility was found to be non-compliant with NFPA 70 standards regarding the use of extension cords and power strips. Specifically, surveyors observed unmounted power strips in use within the IT Room, Accounting Office, and other administrative areas. Additionally, in the Nursing Office located in 2West, a green extension cord was found under a desk, powering equipment. These observations indicate that the facility did not ensure that electrical systems were used in accordance with the National Electrical Code, as required by NFPA 101:9.1.2 and NFPA 70:400.8. At the time of the survey findings, the Director of Maintenance acknowledged the use of the extension cord, stating it was a temporary measure, and assured that all power strips would be mounted. However, the report does not provide any further details on corrective actions or the impact of these deficiencies on residents or staff. The deficiency highlights a failure to adhere to established electrical safety standards, which are critical for ensuring the safety and functionality of electrical systems within the facility.
Plan Of Correction
Plan of Correction: Approved December 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2012 NFPA 101 and 2011 NFPA 70, the Director of Engineering immediately instructed the Engineering staff to: 1. Mount the unmounted power strip in use in the IT room, Accounting office and other administrative areas. 2. Remove the extension cord in the 2 West Nursing office. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that extension cords in use are appropriate and power strips in use are mounted in accordance with the 2011 National Electric Code. All findings were deemed to be in compliance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering, Administrator and QA Director created a policy on use of extension cords and power strips. b. All staff will be informed and educated regarding this new policy, use of extension cords and power strips. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur, i.e. what quality assurance program will be put into practice: a. The Director of Engineering will develop an audit tool to monitor use of extension cords and power strips. b. Audits will be performed monthly by the Engineering staff x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as observed during an abbreviated survey. The incident involved a Certified Nursing Assistant (CNA) who allegedly slapped a resident in the face after the resident, who was known to be combative and cognitively impaired, held onto the CNA's hand tightly. The facility's policy requires that any physical or verbal outburst from residents be reported immediately to a nurse or supervisor, which was not done in this case. The resident involved had a history of dementia, alcohol abuse, and delirium, and was assessed as cognitively impaired, requiring supervision or assistance with mobility and toileting. The care plan for the resident included interventions for managing aggressive behavior, but it was noted that instructions to notify a nurse and seek assistance if the resident became combative were omitted from the resident's care instructions. This omission contributed to the incident, as the CNA did not follow the appropriate protocol when the resident became aggressive. Interviews with staff revealed that the CNA involved in the incident did not report the resident's combative behavior to a nurse, as required by the facility's policy. Another CNA witnessed the incident and reported it later in the day. The facility's investigation concluded that abuse may have occurred, and the CNA was terminated. The incident was reported to law enforcement, but no arrest was made.
Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of insulin to the wrong resident. On the night of the incident, a Registered Nurse (RN) was asked by a Licensed Practical Nurse (LPN) to administer insulin to a specific resident. However, the RN, who was preoccupied and under pressure, did not verify the resident's identity by checking the wristband or the Electronic Medical Administration Record. Instead, the RN administered 24 units of Lantus insulin to a different resident who was not on insulin therapy. The resident who received the incorrect insulin dose had a diagnosis of Type 2 Diabetes Mellitus but was not prescribed insulin. Following the administration, the resident was alert and responsive, with vital signs within normal limits. The resident reported feeling unwell the following day, which could have been related to the insulin dose. The error was discovered when the resident informed the RN that they were not supposed to receive insulin, prompting the RN to notify the LPN, Nursing Supervisor, and Medical Doctor. The facility's policy on insulin administration requires nurses to review medication orders, identify residents, and follow the rights of medication administration. The RN involved in the incident did not adhere to these protocols, leading to the medication error. The RN's employment was subsequently terminated following the incident. The Medical Doctor confirmed that the resident did not sustain any harm from the insulin dose, and the resident was monitored with intravenous dextrose administered as a precaution.
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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