Kirkhaven
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, New York.
- Location
- 254 Alexander Street, Rochester, New York 14607
- CMS Provider Number
- 335668
- Inspections on file
- 16
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Kirkhaven during CMS and state inspections, most recent first.
Two residents experienced alleged staff-to-resident abuse that was not promptly reported to leadership, and the involved CNA and LPN were allowed to continue providing care after the allegations were voiced or witnessed. One cognitively intact resident reported that a nurse put hands in their face, pushed their head into a pillow, and cut their hair, and the receiving nurse did not escalate the allegation while the accused nurse continued care. Another resident with severe cognitive impairment sustained a laceration after being grabbed and pushed into a chair by a CNA, who remained on the unit providing care for a period of time after the incident. In both cases, available video surveillance was not reviewed as part of the initial investigations and was only examined days later following surveyor inquiry, and in one instance not all footage was reviewed.
A resident with vascular dementia, heart disease, and diabetes, who required staff assistance with showering and personal hygiene, did not receive scheduled weekly showers and shaving over an extended period. The care plan and CNA Kardex called for weekly Monday evening showers and weekly facial hair removal with an electric razor, but facility records showed multiple days with no documented hygiene care and no showers documented for more than two weeks. Observations found the resident with significant facial hair growth, and the resident reported not having received a shower. There was no documentation of care being provided, refused, or reattempted, and staff interviews revealed gaps in understanding where to document shaving care and reliance on providing care only if time allowed or by passing it to the next shift.
A cognitively impaired resident with Alzheimer’s disease, epilepsy, and high fall risk, who required supervision or touching assistance for ambulation, was care planned for fall precautions including staff awareness of location and supervised use of a four-wheeled walker. Despite this, the resident was later found on the floor between two lounges with a large forehead hematoma and knee soreness, after having received only medication assistance and no toileting or ambulation help, and with no documented supervision, monitoring, or timeline of when the resident was last seen. Incident documentation cited ambulation without assistance and non-compliance with safety recommendations but lacked CNA or other staff witness statements and did not show that routine safety checks were integrated into the care plan or carried out. Separately, on three resident-use floors, hot liquids at burn-capable temperatures were observed to be accessible to residents, including those with cognitive impairment requiring supervision, demonstrating a broader failure to control environmental burn hazards.
The facility failed to maintain sufficient nursing staff on multiple units, resulting in delayed toileting, missed or delayed showers and grooming, prolonged call light response times, and late medication administration. Staffing records showed repeated gaps between scheduled and actual CNA and nurse coverage, with some shifts operating below the facility’s own staffing plan and a high turnover of CNAs. Residents reported waiting hours for assistance with bedpans and toileting, going without showers for extended periods, and not being helped out of bed, while strong urine odors and residents in soiled clothing or with poor hygiene were observed on several units, including a dementia unit. Staff described being unable to complete incontinence checks, showers, two‑person transfers, and required medication cart checks due to chronic understaffing, and the staffing coordinator acknowledged that typical CNA coverage per unit was below target and insufficient to meet resident needs.
Two residents with dementia and incontinence were not provided with appropriate hygiene or a clean environment before meals. One resident was observed with feces on their hands, clothing, and assistive device, and later ate a meal in the dining room with visible fecal debris under their fingernails and no hand hygiene performed, despite multiple staff entering and leaving the room without providing care. Another resident was observed eating while wearing feces-soiled clothing with a strong fecal odor, and was later found in bed without a pillowcase, on a partially removed sheet, in a room with urine odor and an unclean floor; this resident also received a meal without hand hygiene. Staff interviews confirmed that care was not provided before meals and that expectations included nail care during showers, hand hygiene prior to meals, ensuring residents were clean and in clean clothing, and maintaining properly made beds.
The facility failed to consistently follow its meal ticket system and honor resident preferences and listed substitutions for three residents at risk for malnutrition. One cognitively intact resident on a mechanical soft diet was served a vegetable documented as a dislike and not listed on the ticket. Another resident on a consistent carbohydrate, mechanical soft diet received a tray with pasta and other items that did not match the ordered sandwiches, eggs, soup, and specified substitutions, and did not receive the alternative items when refusing the main dish. A third cognitively intact resident repeatedly received beverages and meals that did not match the meal ticket, including missing salad and cranberry juice and being served unlisted apple juice. Staff, including CNAs, an LPN manager, the RD, and the DON, acknowledged that meal tickets should guide tray accuracy and that dislikes should not be served.
A resident with chronic pain syndrome, depression, and anxiety, who required staff help with personal hygiene, was not provided with scheduled bed baths, shaving, or hair washing despite repeated requests. Documentation did not show that these services were offered or refused, and staff cited staffing challenges as a barrier. The resident expressed feeling dirty and dissatisfied, and facility leadership was unaware of the lack of care until the survey.
Several residents with cognitive and physical impairments were observed with unkempt hair and overgrown facial hair, and reported not receiving needed assistance with shaving and hair washing despite requesting help. Staff interviews revealed that due to staffing shortages, grooming care was sometimes not provided, and refusals of care were not consistently documented as required by facility policy.
Medications, including blister packs and injectable vials for multiple residents, were left unsupervised on an office desk in an unlocked office. The medications, removed from medication carts and awaiting return to the pharmacy, were accessible to unlicensed personnel such as CNAs. Facility policy requires all medications to be secured in locked rooms or carts and only accessible to authorized staff, which was not followed in this instance.
A resident with multiple chronic conditions did not have administration of several prescribed medications and required monitoring tasks properly documented, with blank entries found in the eMAR and no evidence of provider notification or follow-up. Facility policy required nurses to document all medication administration and report omissions, but interviews confirmed these steps were not followed.
A resident with dementia and agitation refused multiple doses of haloperidol over several weeks, and staff did not notify the medical provider as required. Additionally, after the resident became agitated and attempted to exit through a window, there was no documentation of provider notification or care plan update. Interviews revealed inconsistent practices among staff regarding timely communication of medication refusals and significant behavioral events.
A facility failed to conduct a required Level II PASARR assessment for a resident with Down Syndrome and acute respiratory failure, despite hospital documentation indicating the need for such an assessment. The resident was admitted without the necessary evaluation, and interviews revealed that the admission office and social work department did not ensure the assessment was completed, contrary to facility policy.
A resident with chronic respiratory failure and a tracheostomy did not receive appropriate respiratory care due to the absence of a physician's order for supplemental oxygen and inadequate documentation. The resident was observed using oxygen via a tracheostomy collar without proper orders, and the care plan lacked instructions for the Airvo machine. Staff were not trained to manage the resident's respiratory needs, and the facility failed to ensure proper monitoring and maintenance of the resident's equipment.
During a survey, deficiencies were found in the facility's kitchen regarding food storage and labeling practices. Observations revealed undated food items in coolers, including pureed eggs, bacon, pancakes, pumpkin souffle, and vanilla pudding. The facility's policy requires food to be dated and discarded after 72 hours if undated. Interviews with the Food Service Director/Registered Dietitian confirmed the importance of these practices to prevent foodborne illness, yet a follow-up visit found further undated items, indicating non-compliance with food safety standards.
The facility failed to maintain an effective infection control program, with staff not adhering to required precautions during high-contact care for residents on enhanced barrier precautions. A resident with diabetes had their blood sugar checked by an LPN without gloves, and another resident with a cholecystostomy tube received care without proper gown use. Additionally, infection control policies were not reviewed as required, and there was a lack of ongoing infection surveillance due to the absence of an Infection Preventionist.
A resident's advance directive wishes were inconsistently documented, with their MOLST form indicating DNR while physician orders showed Full Code. Staff interviews revealed confusion in determining and documenting the resident's preferences, leading to a failure in honoring the resident's end-of-life care wishes.
Two residents continued to smoke against the facility's non-smoking policy, yet their care plans did not address this non-compliance or related safety concerns. One resident with chronic respiratory failure and a tracheostomy smoked daily, while another with a below-the-knee amputation and pulmonary disease smoked cigars twice weekly. Staff interviews confirmed the lack of documentation in their care plans regarding smoking habits and safety measures.
Two residents in the facility did not receive care according to their care plans and professional standards. A resident with Huntington's disease experienced multiple falls without proper RN assessment, and another resident with a recent amputation was not consistently wearing a physician-ordered compression wrap. The facility's failure to ensure proper assessments and adherence to care plans resulted in deficiencies in care.
A resident's hearing aids were broken and not repaired for two months, despite being essential for communication. The facility's care plan and physician's orders documented the need for hearing aids, but communication issues and workload management led to delays in coordinating repairs. The DON acknowledged the delay was excessive.
A resident experienced significant weight loss due to the facility's failure to conduct timely nutritional assessments upon admission and readmission. Despite documented weight loss, a comprehensive nutrition assessment was delayed until months later. Interviews revealed a lack of clarity and communication among staff regarding assessment requirements.
Two residents with dementia in an LTC facility experienced deficiencies in care planning and intervention. One resident exhibited repeated physical aggression without individualized interventions, while another displayed sexual behaviors without appropriate care plan updates. Staff interviews revealed a lack of awareness and documentation, contributing to ongoing issues.
A resident with dysphagia on a mechanical soft diet received an inappropriate food item, a lettuce and tomato salad, leading to difficulty swallowing and coughing. The resident's care plan did not include necessary aspiration precautions, despite being at high risk. Facility staff confirmed the resident should not have received the salad, and the care plan should have included aspiration precautions.
Failure to Timely Report, Remove Staff, and Review Video in Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to respond promptly and thoroughly to allegations of abuse and to protect residents from potential abuse. Facility policy required that all alleged abuse be immediately addressed, that any employee suspected of abuse be sent off duty until the investigation was complete, and that a safe environment be provided. In multiple instances, staff did not immediately report allegations to leadership, did not promptly remove the alleged perpetrators from resident care, and did not fully utilize available video surveillance as part of the initial investigations. For one cognitively intact resident with diagnoses including anxiety, hypertension, and chronic pain, an investigation dated 02/20/2026 documented an allegation that an LPN placed hands in the resident’s face, pushed their head into a pillow, and cut their hair. The resident’s written statement indicated the staff member placed hands in front of their face and pushed their face and head into a pillow, and that after reporting this to another LPN, they were told the staff member would not return, but the staff member did re-enter the room and continued to provide care. The resident identified the LPN from photographs and was observed to be upset and anxious during the identification. The LPN who received the report documented that the resident voiced concerns during the night shift at 2:30 AM, but the allegation was not reported to leadership at that time, and the alleged LPN continued to provide care, including giving the resident a shower after the allegation was voiced. For another resident with severe cognitive impairment and diagnoses including dementia, stroke, and COPD, an incident report documented that a CNA grabbed the resident and pushed them backward into a chair, causing a three-centimeter laceration to the left forearm. The incident occurred between approximately 1:30 AM and 1:45 AM, but the CNA was not immediately removed from resident care and remained on the unit providing care until later in the shift. A nurse manager reported witnessing the CNA grab the resident by the arms and push the resident into a chair, resulting in injury, and acknowledged the CNA should have been removed immediately. In both residents’ cases, video surveillance was available but was not reviewed as part of the initial investigations; for the first resident, video was only reviewed about five days later after surveyor inquiry and not all footage was reviewed, and for the second resident, video playback was not completed until several days later, also after surveyor inquiry, with the initial investigation lacking review of this available evidence.
Failure to Provide and Document Scheduled Hygiene, Shaving, and Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary activities of daily living (ADL) care, specifically hygiene, shaving, and showers, for a resident who was unable to perform these tasks independently. The resident had vascular dementia, heart disease, and diabetes, with a Minimum Data Set showing moderately impaired cognition and a need for staff assistance with showering and personal hygiene, and no documented rejection of care. The comprehensive care plan and CNA Kardex specified weekly evening showers on Mondays and weekly facial hair removal with an electric razor, with staff to assist. Observations on two separate days showed the resident with several days of beard growth and later with one-quarter to one-third inch facial hair across the entire face, and the resident reported being due for a shave and shower and stated they had not received a shower. Record review of the Personal Hygiene Support Provided report from early February through mid-March showed no documentation of hygiene care on three specified Mondays, and the Treatment Administration Record showed no showers documented for the resident over a 17‑day period. There was no documentation in the electronic health record, including POC entries or nursing progress notes, that hygiene care was provided, refused, or reattempted on the identified dates, and no evidence that staff identified or followed up on missed hygiene care. Interviews with a CNA, an LPN, the RN Manager, and the DON revealed expectations that CNAs check the Kardex, reattempt care, notify nurses of refusals, and that missed care be reported and documented, but also showed that the CNA did not know where shaving care was documented and that nurses would only provide shaving or hygiene care if time allowed or by asking the next shift. These actions and inactions resulted in the resident not receiving scheduled hygiene care and the facility not ensuring completion, documentation, or reattempts when care was missed.
Failure to Prevent Fall Injury and Control Hot-Liquid Burn Hazards
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision and individualized interventions to prevent accidents for a cognitively impaired resident and across multiple resident-use floors. One resident with diagnoses including Alzheimer’s disease, epilepsy, and hypertension had a Minimum Data Set showing severely impaired cognition and a need for supervision or touching assistance when walking. The resident’s comprehensive care plan, last revised in February 2026, identified a high risk for falls related to dementia and impaired mobility, with interventions such as following the facility fall protocol, staff awareness of the resident’s location in common areas, supervision with a four-wheeled walker, and ensuring needs were anticipated and met. However, on an evening in January 2026, the resident was found sitting on the floor in the doorway between two lounges with a large hematoma on the left forehead and redness and soreness of the left kneecap, requiring transfer to the emergency department for further evaluation. The LPN who discovered the resident reported that the only care provided prior to the incident was medication assistance and that no toileting or ambulation assistance had been given. The incident documentation identified predisposing factors such as ambulating without assistance and non-compliance with safety recommendations, but there was no documentation of staff supervision, monitoring, or the resident’s location prior to the fall. The incident report did not include additional staff or CNA witness statements or a documented timeline indicating when the resident was last observed before being found on the floor. Although an intervention to complete routine safety checks was noted in the incident report, it was not incorporated into the comprehensive care plan, and there was no documented evidence that routine safety checks were implemented following the incident or upon the resident’s return from the hospital. Additionally, the deficiency extended across three resident-use floors where hot liquids at temperatures capable of causing burns were accessible to residents, including those with cognitive impairment requiring supervision, indicating that the environment on those floors was not kept as free of accident hazards as possible.
Insufficient Nursing Staff Leading to Delayed Care, Missed ADLs, and Untimely Nursing Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all units to meet residents’ daily needs for ADL care, toileting, incontinence care, grooming, bathing, supervision, and timely nursing tasks. The facility assessment showed a licensed capacity of 147 beds with an average daily census of 136 residents and a staffing plan that called for two LPN medication nurses and four CNAs per unit on day and evening shifts, and one LPN and two CNAs per unit on night shift, plus additional RN/LPN managers and supervisors. Review of staffing records and timecards from early February through mid-March revealed repeated discrepancies between scheduled and actual staffing, including missing time punches and staffing levels below the facility’s stated plan. On multiple dates, units operated with fewer CNAs than planned, including days when only two CNAs were assigned to a 34-resident dementia unit and nights when listed CNAs and a nurse had no documented punches. A facility list showed that 50% of CNAs employed over a roughly three‑month period were no longer employed. On the second floor, with a census of 24 residents, the nurse manager reported staffing of one nurse manager, two LPNs, and two CNAs on day shift. A resident reported waiting four hours for a bedpan after activating the call light early in the morning, ultimately soiling themselves and not receiving assistance until therapy staff arrived. Another resident stated they were told they would have to wait to get out of bed due to lack of staff, and a visitor reported the unit was often staffed with only one CNA and one nurse, especially on Mondays and weekends. On the third floor, with 37 residents, there was a strong urine odor in a hallway, and residents reported that nothing was on time, including meals and medications. Observations showed a resident in bed in a hospital gown with a breakfast tray still in front of them late in the morning, and other residents with several days of facial hair growth, greasy and unwashed hair, and reports of missed showers, including one resident who stated they had not received a shower for two months and that the facility was short staffed. On the fourth floor, with 36 residents, day shift staffing consisted of two nurses and two CNAs. A resident reported waiting up to an hour for toileting assistance and said staff expressed frustration when the resident was incontinent. A strong urine odor was noted in the hallway, and another resident stated call light response times were hours due to short staffing, that at times only one CNA was available for the entire floor, and that staff told them to wait until the next shift for care. On the fifth floor dementia unit, with 34 residents, observations showed multiple residents in the dining room in pajamas or hospital gowns with a strong urine odor throughout the unit. Staffing at one point included two LPNs, one CNA, and an RN manager working as a CNA. Residents were observed with uncombed hair, unchanged appearance over several hours, stained pajamas with fecal odor, and visible fecal matter under fingernails while later eating without hand hygiene. Staff interviews on this unit described being unable to complete rounds and incontinence checks before meals, missed showers, delayed toileting and two‑person transfers, and late medications due to staffing shortages. Additional interviews across the facility reinforced that staffing levels were frequently below target and insufficient to meet resident needs. A special Resident Council meeting revealed residents waited two to three hours for care, staff worked in multiple roles due to shortages, residents were not always assisted out of bed and therefore missed activities, and weekend staffing was described as the worst. A CNA stated there was never enough staff, sometimes only one CNA was available, residents required full bed changes at the start of shift, showers were missed, and staff had to leave their own assignments to assist with two‑person transfers. An LPN reported being called to assist in the kitchen, which delayed medication administration, and another LPN stated that tasks such as checking medication carts for loose or unlabeled pills were not completed because higher priority care needs took precedence under staffing shortages. The staffing coordinator acknowledged the facility frequently operated below target staffing levels, often with only two to three CNAs per unit on day and evening shifts and one CNA on nights, and admitted these levels were not sufficient to meet resident needs and that they did not know how to resolve the staffing issues. Leadership interviews confirmed that staffing had not been a focus of the QAPI committee, and the DON acknowledged that current staffing was not ideal and was affected by call‑offs, requiring staff to work in multiple roles.
Failure to Maintain Resident Dignity and Hygiene Before Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated in a dignified manner and provided with appropriate hygiene before meals. One resident with severe cognitive impairment, Alzheimer’s dementia with agitation, anxiety disorder, and GERD required assistance with toileting and personal hygiene and had no documented refusals of care. Nursing notes showed the last nail care was provided nearly a month prior to the survey observations. On one observation, this resident was in bed with a meal tray present, with a golf ball-sized amount of feces on the rolling walker, visible fecal matter under the fingernails of the left hand, and feces smeared on the front of the gown, which was undone and hanging off one shoulder. During this same observation sequence, a CNA entered the room, donned a glove, removed the feces from the walker but left a visible smear on the surface, and exited without providing any hygiene care to the resident. A second CNA, identified as assigned to the resident, entered only to remove the meal tray and did not return to provide care. An LPN entered briefly, stated they would return with topical cream, and did not return. Later that day, the resident was observed in the dining room with dark brown debris still visible beneath the fingernails of both hands. A meal tray was placed in front of the resident without any hand hygiene being performed, and the resident began eating and retrieving dropped food from their lap with their hands. A CNA interview confirmed the resident should not have been allowed to eat with dirty fingernails and that hygiene should have been provided prior to the meal. A second resident, with vascular dementia, history of falls, and prior stroke, had moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance with toileting, personal hygiene, and dressing. The care plan noted possible non-compliance with care and directed staff to reapproach as needed, and nursing notes contained no documentation of refusals of care. This resident was observed eating lunch in the dining room wearing visibly soiled pajama pants and a white shirt, with a strong feces odor present. A CNA later stated the resident had been soiled prior to lunch, care was not provided before the meal due to short staffing, and that a significant amount of stool extending up the resident’s back was found when the resident was taken back to the room after lunch. On another observation, the same resident was found in bed on a pillow without a pillowcase, with a partially removed fitted sheet hanging off the bed, a urine odor in the room, and a sticky, unclean floor; the call light was on the floor next to the bed. When a CNA brought the resident a meal tray and assisted them to a seated position, no hand hygiene was performed before the meal, despite the CNA acknowledging that training included anticipating resident needs and performing hand hygiene. The DON and RN Manager stated expectations that residents receive care prior to meals, be clean and in clean clothing, have hand hygiene before meals, and have properly made beds to promote a homelike environment.
Failure to Follow Meal Tickets, Preferences, and Substitutions for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure its system for individualized meal service, including use of meal tickets, honoring resident preferences, and providing listed substitutions, was consistently followed. For one resident with severe protein-calorie malnutrition, weight loss, and chronic pain, the care plan and medical orders called for a regular, mechanical soft diet with thin liquids. During a meal observation, this resident was served green beans, which were documented as a dislike and were not listed on the meal ticket. The resident reported that the meal tray frequently contained incorrect items. Another resident with severe protein-calorie malnutrition, adult failure to thrive, and muscle weakness was on a consistent carbohydrate, mechanical soft diet with thin liquids. Observation showed this resident received a lunch tray with pasta, spinach, pie, and applesauce, despite the meal ticket specifying a mechanical soft chicken salad sandwich on white bread, sautéed spinach, three boiled eggs, a mechanical soft peanut butter and jelly sandwich, unsweetened applesauce, and tomato soup. The meal ticket also directed staff to offer chicken salad, tuna salad, or grilled cheese if the resident did not accept the meal. The tray did not include the ordered sandwiches, boiled eggs, or tomato soup, and the listed substitutions were not provided when the resident stated they did not eat pasta and requested tuna fish. A third resident, cognitively intact and at risk for malnutrition, had medical orders and a care plan for a regular diet with regular texture and thin liquids. During one observation, the resident’s tray contained apple juice, which was not on the meal ticket, and the resident stated the meal usually did not match the ticket. In a subsequent observation, the meal ticket listed salad, salad dressing, and cranberry juice, but the tray again contained apple juice and lacked the salad, dressing, and cranberry juice. Staff interviews confirmed that dietary and nursing staff were responsible for checking meal tickets, ensuring accuracy of trays, and not serving items listed as dislikes, and that items identified as dislikes should be removed if present on the tray.
Failure to Provide Resident with Requested Grooming and Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with chronic pain syndrome, major depressive disorder, and anxiety disorder, who was cognitively intact and required staff assistance with personal hygiene, was not provided with adequate grooming and hygiene care. The resident's care plan specified the need for limited assistance with activities of daily living, including personal hygiene, and directed staff to document refusals and reapproach as needed. Despite these directives, there was no documentation that the resident received scheduled bed baths, shaving, or hair washing over a one-month period, nor was there evidence of refusals for these services. Observations and interviews revealed that the resident repeatedly requested assistance with shaving and hair washing, expressing frustration and stating that the lack of care made them feel dirty and grubby. Staff interviews confirmed that due to staffing challenges, they were sometimes unable to provide scheduled showers, bed baths, or grooming assistance. The resident reported asking multiple staff members, including a supervisor, for help with shaving and a shampoo cap, but did not receive the requested assistance. Progress notes and the bath list lacked documentation of these services being offered or refused. Further interviews with nursing management and facility administration indicated that staff were expected to offer and document personal hygiene care, and to reapproach residents if care was initially refused. However, the administrator and DON were unaware that the resident was not receiving assistance with shaving and hair washing. The resident continued to report feeling unclean and dissatisfied with their care, and the medical director acknowledged the potential for psychosocial harm resulting from the lack of person-centered care.
Failure to Provide Assistance with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, to residents who were unable to perform these tasks independently. Multiple residents were observed with overgrown facial hair, oily and uncombed hair, and there was a lack of documented evidence that staff offered or provided assistance, or that residents refused such care. In several cases, residents expressed dissatisfaction and frustration, stating they had requested help with shaving and hair washing but did not receive it. Staff interviews revealed that due to staffing challenges, they were sometimes unable to assist residents with scheduled showers, bed baths, or shaving, and refusals of care were not consistently documented or reported as required by facility policy. Residents affected included individuals with cognitive impairments, chronic pain, depression, and other medical conditions that limited their ability to perform personal hygiene independently. For example, one resident with chronic pain syndrome and major depressive disorder was observed multiple times with unkempt hair and overgrown facial hair, and stated they felt dirty and had repeatedly asked for assistance without receiving it. Another resident with vascular dementia and anxiety disorder was observed with thick, overgrown facial hair and uncombed hair, and reported having asked staff for help with shaving but eventually gave up after not receiving assistance. In both cases, there was no documentation of refusals or evidence that care was offered as required. Staff interviews further confirmed that some certified nursing assistants did not provide grooming care due to insufficient staffing and were unclear about documentation requirements for refusals of care. Supervisory staff acknowledged that residents should receive assistance with personal hygiene according to their care plans and that refusals should be documented and reported. However, observations and record reviews indicated that these procedures were not consistently followed, resulting in residents not receiving the necessary services to maintain good grooming and personal hygiene.
Medications Improperly Stored in Unlocked Office Accessible to Unauthorized Staff
Penalty
Summary
Surveyors observed that medications, including blister packs and injectable vials prescribed for multiple residents, were left unsupervised on an office desk in an unlocked office on one of the residential units. The medications had been removed from medication carts and were intended to be returned to the pharmacy, but instead were stored in the office for approximately a week. During this time, the office door was open, and unlicensed personnel, including certified nursing assistants, were present in the office and had access to the medications. The Registered Nurse Manager acknowledged that medications were not supposed to be stored in the office and that the Director of Nursing was aware of their presence. Facility policy requires all medications to be stored in locked rooms or medication carts, inaccessible to residents and visitors, and only accessible to authorized personnel. The Director of Nursing confirmed that medications awaiting return to the pharmacy should be secured in a locked medication room and that certified nursing assistants should not have access to medications. The observed practice of storing medications in an unlocked office with access by unauthorized staff was not in accordance with facility policy or regulatory requirements.
Failure to Document and Administer Medications per Professional Standards
Penalty
Summary
Surveyors identified that the facility failed to provide services meeting professional standards of quality for one resident. Specifically, there were multiple instances of missing documentation for the administration of several prescribed medications, including those for pain, diabetes, hypertension, atrial fibrillation, and depression, as well as missing documentation for vital signs and blood sugar checks. The resident in question had diagnoses of diabetes, congestive heart failure, and atrial fibrillation, and was prescribed high-risk medications such as anticoagulants, hypoglycemics, and psychotropics. The facility's policy required nurses to document all medication administration in the electronic medication administration record (eMAR), notify supervisors of omissions, and ensure all medications and treatments were signed off at the end of each shift. Review of the resident's eMAR for February revealed blank entries for several medications and required monitoring tasks on specific dates and times, with no corresponding nursing progress notes indicating whether the medications were administered, refused, or if a provider was notified. Interviews with facility leadership confirmed the resident was present in the facility during the times in question, but the reason for the missing documentation could not be determined, as the nurses responsible were no longer employed. The DON and nurse manager confirmed that blank boxes on the eMAR indicated medications were not given and that refusals or omissions should have been documented and reported according to policy.
Failure to Notify Medical Provider of Repeated Medication Refusals and Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident with dementia, cerebral infarction, and diabetes, who was prescribed haloperidol for agitation, refused multiple doses of the medication over a period of time. Specifically, from early June to mid-July, the resident refused haloperidol on numerous occasions—29 out of 55 opportunities in June and 17 out of 28 in the first half of July. Despite these frequent refusals, there was no documented evidence that a medical provider was notified about the pattern of refusals, as required by facility policy and physician orders. On July 11, the resident exhibited increased agitation, wandering behaviors, and attempted to exit a bedroom window, resulting in the resident being placed on 15-minute checks. The incident was documented in a 24-hour nursing report and discussed with the DON, but there was no progress note entered in the electronic health record regarding the event, nor was the comprehensive care plan updated. Additionally, there was no documented evidence that a medical provider was notified about the resident's increased agitation and elopement attempt. Interviews with facility staff revealed inconsistent understanding and implementation of the notification process for medication refusals and significant behavioral incidents. The DON acknowledged that a progress note and care plan update should have been completed and expected eventual provider notification, though no specific timeframe was established. Other nursing staff and providers indicated that they would expect prompt notification of refusals and significant incidents, but the medical provider and nurse practitioner confirmed they were unaware of the extent of medication refusals and the elopement attempt until after the fact.
Failure to Conduct Required Level II PASARR Assessment
Penalty
Summary
The facility failed to refer a resident with an intellectual disability to the appropriate state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASARR) assessment. This deficiency was identified during a recertification survey. The resident, who had diagnoses including Down Syndrome and acute respiratory failure with hypoxia, was admitted without the necessary Level II assessment, despite documentation from the admitting hospital indicating that such an assessment was required. The facility's policy required a Level II assessment for residents with serious mental illness or intellectual/developmental disabilities experiencing significant changes, but this was not completed for the resident. Interviews with facility staff revealed that the admission office and the Director of Social Work were responsible for reviewing documentation and ensuring that necessary assessments were completed. However, the previous Director of Social Work did not ensure that the resident's paperwork was reviewed and that the Level II assessment was conducted. The current Administrator acknowledged that the resident should have had a Level II assessment to determine the appropriateness of their placement and to ensure they received necessary services related to their diagnosis.
Deficiency in Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as evidenced by the lack of a physician's order for supplemental oxygen use and inadequate documentation in the resident's medical record. The resident, who had chronic respiratory failure and a tracheostomy, was observed wearing oxygen via a tracheostomy collar without a corresponding order or documentation. The resident's care plan did not include instructions for the use of the Airvo machine or the supplemental oxygen via the tracheostomy collar when the resident was out of their room. The facility's Airvo 2 policy required specific maintenance and usage protocols, but there was no evidence that nursing staff had been trained to care for the resident's Airvo machine. The resident expressed concern about the lack of trained staff following the departure of the respiratory therapist. Observations revealed that the Airvo machine's water bag was empty, and the resident's oxygen tank was depleted, indicating a lack of proper monitoring and maintenance. Interviews with staff, including LPNs and the Director of Nursing, confirmed the absence of a current order for the resident's oxygen use and a lack of understanding of the Airvo machine's function. The resident was responsible for managing their own tracheostomy care, including changing the inner cannula and self-suctioning, with staff present. The facility's failure to ensure proper respiratory care and documentation for the resident resulted in a deficiency in meeting professional standards of practice.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
During a Recertification Survey conducted from December 2, 2024, to December 9, 2024, deficiencies were identified in the facility's main kitchen regarding the storage, preparation, distribution, and serving of food in accordance with professional standards for food service safety. Observations made on December 2, 2024, revealed multiple undated food items in the breakfast preparation cooler, including a two-quart container of cooked pureed eggs, a pan of cooked bacon, and a pan of cooked pancakes. Additionally, the cold production cooler contained eight undated dishes of pumpkin souffle and an uncovered metal bowl of undated vanilla pudding. The facility's policy on prepared foods and leftovers mandates that refrigerated prepared food items and leftovers should be discarded after 72 hours if undated, to prevent potential foodborne illness. Interviews with the Food Service Director/Registered Dietitian confirmed the importance of dating food items to ensure timely disposal and prevent contamination. Despite the policy and daily checks by staff, a follow-up visit on December 3, 2024, found an undated two-quart plastic container of chicken salad in the cold production cooler. The Food Service Director/Registered Dietitian reiterated that all food items should be labeled and dated once opened or removed from their original containers to maintain food safety. These findings indicate a failure to adhere to the facility's food safety policies, potentially compromising the safety and quality of food served to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a recertification survey. A nurse performed a blood sugar check on a resident with diabetes, dementia, and depression without wearing gloves, acknowledging the importance of gloves to prevent cross-contamination but admitting to forgetting to wear them. Another resident, who was on enhanced barrier precautions due to conditions including cholecystitis and a cholecystostomy tube, received wound care and high-contact care from staff who did not wear the required gowns, despite clear signage indicating the need for enhanced precautions. Additionally, a resident with neuromuscular dysfunction of the bladder and an indwelling urinary catheter, also on enhanced barrier precautions, received care from a certified nursing assistant who was unaware of the precautionary requirements and did not wear a gown. The CNA did not understand the significance of the blue star indicator for enhanced precautions, leading to non-compliance with infection control protocols. The Director of Nursing confirmed the necessity of wearing gowns and gloves for high-contact care and acknowledged the lapses in infection control practices. The facility's infection prevention and control policies were not reviewed or updated as required, with some policies lacking dates of last review or revision. The facility also failed to maintain ongoing surveillance and documentation of infections and antibiotic use from September to November 2024, due to the absence of a designated Infection Preventionist during that period. The Director of Nursing and Administrator attempted to maintain tracking and surveillance, but the lack of a formalized process contributed to the deficiencies observed.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directive wishes were consistently documented and honored. The resident, who had a history of stroke, anxiety, and depression, was alert and oriented. Their Medical Orders for Life Sustaining Treatment (MOLST) form indicated a Do Not Resuscitate (DNR) preference, while the current physician orders in the electronic medical record indicated a Full Code status. This inconsistency was not addressed in the interdisciplinary progress notes, and there was no documentation of a change in the resident's advance directive wishes since the MOLST form was completed. Interviews with facility staff revealed a lack of clarity and consistency in determining and documenting the resident's advance directive wishes. The Director of Nursing admitted to entering a Full Code order based on a possible email from the Social Worker but could not recall the details. The Director later stated that the resident verbalized a preference for Full Code, yet this was not reflected in the MOLST form or the comprehensive care plan, which both indicated a DNR status. This discrepancy highlights a failure in the facility's process for managing and documenting advance directives, leading to a potential risk of not honoring the resident's end-of-life care preferences.
Failure to Address Smoking Non-Compliance in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents who continued to smoke against the facility's non-smoking policy. Resident #4, who had chronic respiratory failure, anxiety, and a tracheostomy, was cognitively intact and used a wheelchair. Despite being aware of the facility's non-smoking policy, Resident #4 smoked daily and was considered safe to smoke independently. However, their care plan did not address their non-compliance with the smoking policy, safety concerns, or any ongoing education or cessation efforts. Interviews with staff revealed that the resident had a pass to smoke outside independently, but their non-compliance was not documented in their care plan. Similarly, Resident #53, who had a below-the-knee amputation, pulmonary disease, and congestive heart failure, was cognitively intact and continued to smoke despite acknowledging the facility's no-smoking policy. The resident's care plan also lacked information on their non-compliance, safety concerns, or cessation efforts. Interviews indicated that the resident smoked cigars outside twice weekly and kept smoking supplies hidden to avoid confiscation. The facility's staff, including the Administrator and Director of Nursing, acknowledged the need for smoking-related issues to be documented in the residents' care plans, but this was not done for either resident.
Deficiencies in Resident Care and Assessment
Penalty
Summary
The facility failed to provide care in accordance with professional standards and resident care plans for two residents. Resident #81, who has a cognitive communication deficit and Huntington's disease, experienced multiple falls, including one with a major injury. Despite the facility's policy requiring a Registered Nurse (RN) assessment after falls, there was no documented evidence that an RN assessed Resident #81 after two unwitnessed falls. The first fall occurred on 08/05/2024, where the resident was found on their knees, and the second on 08/20/2024, where the resident was found sitting on the floor with a possible head injury. Neuro checks were initiated for the second fall, but not all were completed, and there was no follow-up on a possible elbow fracture. Resident #53, who had a recent right below-the-knee amputation, was not consistently wearing a physician-ordered compression wrap to reduce swelling. Observations on multiple occasions revealed the resident without the compression wrap, and the resident reported that staff were too busy to apply it. The resident's care plan did not include the requirement for the compression wrap, and there was no documentation of the resident refusing the wrap. The resident experienced pain, which they attributed to the lack of compression wrap, and staff interviews confirmed that the wrap was often not applied as ordered. The Director of Nursing acknowledged the deficiencies, stating that RNs should assess residents after falls and that the compression wrap should be applied as ordered. However, due to the acute nature of the unit, orders were not always completed promptly. The facility's failure to ensure proper assessments and adherence to care plans resulted in deficiencies in the care provided to Residents #81 and #53.
Delayed Repair of Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure timely repair of hearing aids for Resident #11, who was cognitively intact but hard of hearing and relied on hearing aids for communication. The resident had not had their hearing aids for two months due to them being broken, which was confirmed during an observation and interview. The resident's care plan and physician's orders documented the need for hearing aids, yet the Treatment Administration Record noted the aids were broken and awaiting repair for an extended period. Communication breakdowns contributed to the delay in repairing the hearing aids. An email from the Quality Assurance and Performance Improvement Coordinator to the Long Term Care Management Provider indicated the need for repair, but follow-up was lacking. The Coordinator admitted to being overwhelmed with responsibilities, resulting in the hearing aids being overlooked. The Director of Nursing acknowledged that the coordination for repair should have been expedited, as two months was an excessive delay.
Failure to Conduct Timely Nutritional Assessments
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status for a resident, identified as Resident #127, during a recertification survey and complaint investigation. The deficiency was primarily due to the lack of timely nutritional assessments by a registered dietician upon the resident's initial admission and subsequent readmission to the facility. The facility's policy required comprehensive nutrition assessments on admission, annually, quarterly, and as needed, but these were not conducted for Resident #127. The resident, who had a history of stroke, dysphagia, and adult failure to thrive, experienced a significant weight loss of 26.6% over approximately three months, which was not identified or addressed in a timely manner. Resident #127's medical records revealed a series of documented weights that indicated a significant weight loss, yet no comprehensive nutrition assessment was performed until November 2024, several months after the resident's admission and readmission. The registered dietician, who only worked one day a week, did not conduct a nutrition assessment upon the resident's readmission in September 2024, as it was not triggered by the facility's system. The dietician acknowledged that the resident's weight loss met the criteria for significant weight loss but chose to use the resident's status in November as a new baseline for monitoring. Interviews with facility staff, including the registered dietician and the food service director, revealed a lack of clarity and communication regarding the need for comprehensive nutrition assessments following the resident's admissions. The food service director noted that the initial weights obtained by the facility might have been inaccurate, and a comprehensive assessment could have identified these discrepancies. The facility administrator acknowledged an ongoing performance improvement project related to the timely identification of weight losses, indicating awareness of the issue but not addressing the deficiency at the time of the survey.
Deficiency in Dementia Care Planning and Intervention
Penalty
Summary
The facility failed to provide appropriate services to two residents diagnosed with dementia, leading to deficiencies in maintaining their highest practicable mental and psychosocial well-being. Resident #34, with a diagnosis of dementia, experienced multiple incidents of physical aggression towards other residents. Despite these incidents, the care plan lacked individualized interventions to manage behavioral symptoms effectively. The facility's investigations into these incidents revealed that the same interventions were repeatedly used without success, and no new interventions were added to the care plan after the initial incidents. Resident #89, also diagnosed with dementia, exhibited behaviors of a sexual nature, including removing clothes and being intrusive to other residents' spaces. The care plan did not include any interventions to address these behaviors or prevent further occurrences. Despite documented incidents of sexual contact with another resident, the care plan was not updated to reflect the resident's history of sexual behaviors or potential triggers. Staff interviews indicated a lack of awareness and documentation regarding the resident's behaviors, further highlighting the deficiency in care planning. The facility's failure to update and individualize care plans for both residents resulted in repeated incidents of aggression and inappropriate behaviors. The lack of effective interventions and documentation in the care plans contributed to the ongoing issues, as staff continued to use unsuccessful strategies. The deficiency in care planning and intervention highlights the facility's inability to adequately address the needs of residents with dementia, leading to repeated incidents and potential harm.
Failure to Provide Appropriate Diet Consistency for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that food was prepared in a consistency to meet the needs of a resident with dysphagia, as per the recommendations of a speech-language pathologist and physician orders. Specifically, Resident #22, who had a history of dysphagia and was on a mechanical soft diet, received a food item that was not appropriate for their dietary needs. During an observation, the resident was seen eating a lettuce and tomato salad, which is not suitable for a mechanical soft diet, leading to difficulty swallowing, coughing, and spitting the food out. The resident's meal ticket did not include the salad, indicating a failure in adhering to the prescribed diet. Additionally, the facility did not include aspiration precautions in the resident's care plan, despite the resident being at high risk for aspiration. The facility's policies on modified textured diets and aspiration precautions were not followed, as the resident's care plan and physician's orders did not reflect the necessary precautions for aspiration risk. Interviews with facility staff, including a registered dietician, a certified nursing assistant, and a speech-language pathologist, confirmed that the resident should not have received the salad and that the care plan should have included aspiration precautions.
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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