Livingston Hills Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Livingston, New York.
- Location
- 2781 Route 9, Livingston, New York 12541
- CMS Provider Number
- 335389
- Inspections on file
- 29
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 49
Citation history
Health deficiencies cited at Livingston Hills Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was not allowed to manage his or her own financial affairs, in violation of regulatory requirements.
Residents did not receive mail on Saturdays because the activities department, responsible for sorting and distributing mail, was not available on that day. All residents present at a council meeting confirmed the lack of Saturday mail delivery, and staff interviews verified that mail was only distributed Monday through Friday, contrary to facility policy.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
Surveyors found that the facility lacked sufficient documentation of completed annual mandatory education for nurses and nurse aides, as required by the facility assessment. Staff reported no effective system to notify them of required training, and education records were incomplete. Education materials were left for staff to complete independently, but there was no consistent auditing or tracking. Leadership changes and missing prior records contributed to the deficiency, and there was no specific training provided for care of residents with dementia versus those with mental illness.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as evidenced by observations and records.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
The facility failed to maintain a documented plan describing the process for conducting QAPI and QAA activities, as required for quality assurance and performance improvement.
Surveyors observed ongoing fly and insect activity in multiple resident rooms, staff areas, and the kitchen, with no evidence of a maintained pest control management book. The Director of Maintenance confirmed recent pest treatment by a vendor, but documentation of the service was not available at the time of the survey.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents according to their care plans.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency.
The facility did not ensure residents were aware of the grievance process or provide consistent access to anonymous grievance submission. On one unit, no suggestion/grievance box was available, and most residents interviewed were unaware of how to file a grievance or who the grievance official was. Staff interviews revealed inconsistencies in knowledge about the grievance process and the location of grievance boxes.
Multiple residents did not have complete or accurate care plans addressing their clinical needs. For example, a resident with dementia and fall risk had floor mats in use without care plan documentation or provider order, and the call bell was not within reach as required. Another resident with edema lacked care plan goals or interventions, and a resident with a chronic wound had no care plan for wound care, despite ongoing treatment. Facility leadership confirmed these omissions.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident with significant cognitive and physical impairments was repeatedly observed wearing only a hospital gown in a common area because their personal clothing was not returned from the off-site laundry service. The resident reported this was a recurring issue, and staff confirmed that missing laundry was a known problem, sometimes requiring replacement if a grievance was filed. This failure prevented the resident from retaining and using their personal possessions, impacting their dignity.
The facility did not ensure that survey results and advocate agency information were readily accessible to residents and visitors, as required by policy. Residents reported not knowing where to find survey results, and observations showed the binder was either obstructed, missing, or not clearly marked, with staff unaware of proper signage or binder location.
A resident admitted with vascular dementia, depression, and metabolic encephalopathy did not have a baseline care plan developed and implemented within 48 hours of admission, as required by facility policy. Staff confirmed the absence of the care plan and were unable to explain why it was not completed.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with multiple medical and psychiatric conditions was found to have a bare room with no furniture or home-like touches, and a mattress placed on the floor, without any supporting care plan or physician order. Staff interviews revealed the changes were made due to safety concerns, but there was no documentation or care planning to justify the removal of furniture or the altered room setup.
A resident with cancer, diabetes, and heart failure developed a large, tender bruise on the left leg after a fall, but the bruise was not promptly assessed or reported. Required weekly skin checks were not documented as completed, and staff interviews confirmed that new skin issues should have been reported immediately to the charge nurse. The DON acknowledged that the necessary assessments and documentation were not performed as ordered.
A resident experienced a decline in range of motion or mobility because the facility did not provide appropriate care to maintain or improve ROM, and there was no documented medical reason for the decline.
Two disposable razors and an unlabeled electric razor were found accessible in a shared bathroom used by two residents—one with severe cognitive impairment and one with multiple chronic conditions. Staff interviews confirmed that razors should not have been left in the bathroom, as both residents required staff assistance or supervision for personal hygiene, and the presence of razors posed a risk for self-harm.
A resident with end stage renal disease did not have consistent documentation or communication of dialysis care as required by facility policy. Nursing staff failed to complete and log dialysis communication sheets for multiple treatment dates, and the communication book was missing during the survey. The electronic medical record also lacked documentation for several dialysis sessions, and staff were unable to provide the required records upon request.
Nurse staffing information was not posted in a location accessible to all residents and visitors on multiple days, as required by facility policy and regulations. Observations confirmed the absence of posted staffing data in key areas, and a staffing coordinator stated the information was not posted due to time constraints during the survey.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not ensure access to resident medical records from before a system transition, failing to follow its compliance and ethics program for record retention. The Administrator, acting as Corporate Compliance Officer, was aware of the issue but did not report it to relevant committees or IT staff, resulting in incomplete medical record accessibility for residents admitted prior to the transition.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure that an effective training program was developed, implemented, or maintained for all new and existing staff members, as required by regulations.
The facility failed to appoint a licensed Nursing Home Administrator, relying instead on an unlicensed acting administrator. Despite extensions granted by the state, the licensed administrator was only present for limited hours weekly, leading to a deficiency in management and operational oversight.
The facility failed to implement effective Quality Assurance measures, resulting in recurring deficiencies in maintaining a safe environment, food safety, and infection control. Despite having a Quality Assurance Performance Improvement plan, there were no documented procedures for performance monitoring or corrective actions, leading to repeated issues identified in surveys.
The facility failed to uphold residents' rights and dignity by not providing appropriate clothing and privacy. A resident was left in a hospital gown for days due to a lack of fitting clothes, another was exposed in a gown visible from the hallway, and a third resident wandered with soiled clothing. Staff admitted difficulties in providing suitable clothing, relying on donated items and hospital gowns.
The facility failed to protect residents' personal property, as belongings sent for laundering were not returned timely. Despite policies for labeling and inventorying items, these were not consistently followed, leading to missing items for four residents. Staff interviews revealed inconsistencies in the process, contributing to the deficiency.
The facility failed to resolve grievances in a timely manner for three residents, as grievances were not documented or addressed through the facility's process. Residents were unaware of who handled grievances, and staff interviews revealed inconsistencies in the grievance process, including inaccessible grievance forms and unclear procedures for inventorying belongings. This led to unresolved issues such as missing personal items.
The facility failed to develop and implement comprehensive care plans for three residents. Two residents on anticoagulants lacked documented interventions, and another resident with significant weight loss did not have physician supervision documented. This was contrary to the facility's policy requiring timely and individualized care plans.
The facility was found to have insufficient nursing staff competencies, failing to conduct proper evaluations for licensed staff. A resident with multiple inhalers expressed concerns about timely access to a rescue inhaler, while another resident's PICC line dressing was improperly maintained. Staff interviews revealed gaps in training and competency assessments, with no documented policies or procedures in place.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist for several residents, as required by policy. Despite observations of normal resident interactions, documentation revealed missing reviews for multiple months. Interviews indicated a misunderstanding of review frequency requirements among staff.
The facility failed to properly label and store medications and biologicals, as observed during a survey. Urine specimens were stored with insulin, and several medications lacked expiration dates. The controlled substance cabinet lock was broken, and staff reported inconsistent directives due to frequent changes in leadership.
During a survey, deficiencies in food safety and sanitation were observed in the facility's main kitchen and a kitchenette. Issues included dented cans, an uncalibrated thermometer, and unclean equipment. Additionally, the South Unit kitchenette had a split refrigerator gasket and soiled cabinets, indicating a failure to meet professional food service standards.
A resident with cerebral palsy and other health conditions was unable to get out of bed due to the facility's failure to provide an appropriate wheelchair. Despite the resident's repeated requests and their ability to self-propel, they were only offered unsuitable options, leading to a violation of their right to self-determination and choice.
A resident with severe cognitive impairment had inconsistent documentation of their advance directive, specifically their code status, in a LTC facility. The Medical Orders for Life-Sustaining Treatment indicated a Do Not Resuscitate/Do Not Intubate status, while social work notes documented a Cardio-Pulmonary Resuscitation status. Observations and staff interviews revealed that the code status was not consistently documented across the resident's chart, ID bracelet, and electronic records, leading to a deficiency.
A resident with chronic respiratory conditions experienced a significant change in health status, requiring hospitalization and new respiratory treatments. Upon return, the facility failed to update the care plan to include these changes, as confirmed by staff interviews. This oversight led to a deficiency in care planning.
A facility failed to complete a baseline care plan for a resident with a fractured back, diabetes, and chronic bladder inflammation within 48 hours of admission, as required by policy. The resident, who had moderate cognitive impairment, did not have their care plan completed and signed until several days later. Interviews with staff revealed inconsistencies in understanding and executing the policy, indicating a systemic issue in policy adherence.
A facility failed to update a resident's Comprehensive Care Plan following changes in their psychotropic medication regimen. Despite adjustments in the resident's sertraline dosage, the care plan was not revised to reflect these changes, as required by facility policy. The oversight was identified during a recertification survey, with the DON acknowledging the need for person-centered care plans that include non-pharmacological interventions and monitoring.
A resident with Alzheimer's and heart disease was not provided with prescribed compression stockings due to non-compliance and oversight in care planning. Despite having a standing order for the stockings to manage edema, staff did not apply them, citing the resident's tendency to remove them. The facility's policy for comprehensive care planning was not followed, and leadership changes contributed to the oversight.
A resident with a history of chronic obstructive pulmonary disease and other conditions was found using tobacco in their room, violating the facility's smoking policy. The care plan did not address the resident's non-compliance, and staff were aware but did not consistently enforce the policy. Tobacco products were confiscated from the resident's room, indicating a failure to prevent unsupervised access.
A resident with significant cognitive impairment and multiple diagnoses experienced a 17.45% weight loss over several months without adequate medical supervision. Despite dietary notes indicating weight loss and dehydration, the physician was not notified, and the resident's meals were observed to be unappetizing and insufficient. Facility policies requiring notification of significant condition changes were not followed.
A resident was prescribed Aripiprazole without a documented indication for use, violating facility policy. Despite monthly medication regimen reviews, the necessary documentation was missing, as confirmed by staff interviews and record reviews.
The facility was found to have improper disposal of garbage and refuse, with one dumpster leaking a black oily liquid and a build-up of leaves around another dumpster, indicating inadequate maintenance and cleanliness.
A resident with a PICC line experienced improper infection control practices, as the dressing was found peeling and soiled, and the line was not properly managed. Despite the facility's policy, the dressing was not dated, and a port was left uncapped. The resident had a history of osteomyelitis and other conditions, and the issue was addressed by the nurse upon notification.
Failure to Honor Resident's Right to Manage Financial Affairs
Penalty
Summary
The facility failed to honor a resident's right to manage his or her own financial affairs. This deficiency was identified based on the surveyor's findings that the resident was not permitted to exercise control over personal financial matters as required by regulation. No additional details regarding the specific actions or inactions by staff, the resident's medical history, or the resident's condition at the time of the deficiency are provided in the report.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. According to facility policy, residents have the right to send and receive mail, including letters, packages, and other materials delivered by means other than the postal service. However, during a surveyor-led Resident Council meeting, all residents present reported that mail was not delivered to them on Saturdays. Interviews with staff confirmed that mail was only delivered Monday through Friday, as the activities department, responsible for sorting and distributing mail, was not available on Saturdays. The administrator was unaware of the specific mail delivery schedule and deferred to the activities director for details. This practice affected all residents in the facility.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Incomplete Staff Education and Competency Documentation
Penalty
Summary
The facility did not have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services necessary to assure resident safety and to help residents attain or maintain their highest practicable well-being, as determined by resident assessments and individual care plans. Observations, record reviews, and interviews revealed that documentation of completed annual mandatory education for nursing staff was incomplete and varied among staff members. The facility assessment identified required staff training and competencies, including resident rights, abuse prevention, infection control, dementia care, and other specialized care needs, but education records for several nurses and nurse aides were found to be incomplete. Interviews with staff indicated there was no effective system in place to notify staff of required education, and staff reported a lack of time to complete mandatory training. Education materials were left near the time clock for staff to complete on their own, but there was no consistent auditing or tracking of completion. The Director of Nursing, who also served as the Nurse Educator, acknowledged that education organization and tracking were lacking, and that annual evaluations had not been completed. The facility had recently undergone changes in leadership, and previous education records were missing, requiring the creation of a new tracking system. Staff also reported that there was no specific education provided for care of residents with dementia versus those with mental illness.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always served meals that met their documented dietary needs and preferences.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Lack of QAPI and QAA Process Plan
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or evidence outlining the procedures or steps the facility uses to carry out QAPI and QAA functions as required.
Failure to Maintain Pest-Free Environment and Effective Pest Control Program
Penalty
Summary
Surveyors identified that the facility failed to maintain a pest-free environment and did not have an effective pest control program in place across both resident units. Persistent fly activity was observed in multiple locations, including resident rooms, the main kitchen, staff areas, and the North Unit activity room, throughout the survey period. Specific instances included flies in the rooms of several residents, in a staff office, and small flying insects in a resident bathroom. Additionally, there was no evidence of a maintained Pest Control Management book, and the Director of Maintenance reported that although a vendor had recently treated for flies, documentation of the service had not yet been received.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals and drinks served to residents.
Failure to Ensure Resident Awareness and Access to Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and did not provide all residents with the option to file grievances anonymously, as required by facility policy and regulation. Specifically, on the South Unit, there was no suggestion/grievance box available for residents to submit anonymous grievances, and the box that was previously there had been removed after a resident attempted to tamper with it. Additionally, there was no suggestion/grievance box located by the social work office as stated in the facility's policy, nor were there boxes in other common areas such as the lobby, dining room, or therapy gym. Only the North and East Units had visible suggestion/grievance boxes across from the nurse's station. During a surveyor-led Resident Council meeting, seven out of eight residents reported they did not know how to file a grievance within the facility, and all eight were unaware of who the grievance official was. Interviews with facility staff, including the Director of Social Services, Administrator, and DON, revealed inconsistencies in their knowledge of the location of grievance boxes and the process for anonymous grievance submission. The Director of Social Services stated that residents were verbally informed of the grievance official upon admission, but this information was not included in admission paperwork. The Administrator and DON both assumed that grievance boxes were available on all units, but this was not the case, leading to a lack of access and awareness for residents regarding the grievance process.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for multiple residents, as required by policy and regulation. For one resident with dementia, major depressive disorder, and atrial fibrillation, the care plan for fall risk did not include the use of floor mats, despite their presence in the resident's room, and there was no documented provider order for their use. Additionally, the resident was observed in bed late in the morning, not yet cleaned up or gotten up for the day, with the call bell on the floor and floor mats in place, contrary to the care plan's directive to keep the call bell within reach and the environment safe and clutter-free. Another resident with malignant neoplasm of the kidney, type 2 diabetes, and heart failure had a care plan for edema that lacked documented goals or interventions. A third resident with inflammatory spondylopathies, chronic pain syndrome, cellulitis, and a venous or arterial ulcer had ongoing wound care orders and was being followed on wound rounds, but there was no comprehensive care plan addressing wounds, open areas, or impaired skin integrity. Interviews with facility leadership confirmed that care plans should include goals and person-centered interventions for each area of care, and that a care plan should have been in place for the resident's wound.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Resident Denied Access to Personal Clothing Due to Laundry Service Failure
Penalty
Summary
A deficiency was identified when a resident with diagnoses of Parkinson's Disease, major depressive disorder, and schizophrenia was observed on multiple occasions sitting in a common area wearing a hospital gown, which was untied in the back. The resident reported that their personal clothing had not been returned from the off-site laundry service, resulting in them having no clothing to wear. The resident stated that this issue with missing laundry occurred frequently. Facility staff interviews confirmed that laundry was sent to an outside service, with each resident's items placed in a labeled mesh bag. Staff acknowledged that articles of clothing were sometimes missed and later relocated, and that the facility would replace items if a grievance was filed. The facility's policy allows residents to keep and use their personal belongings as long as it does not interfere with others' rights or safety. However, the failure to ensure the timely return of the resident's clothing resulted in the resident being unable to use their personal possessions, which did not honor their right to dignity and respect.
Failure to Provide Accessible Survey Results and Advocate Agency Information
Penalty
Summary
The facility failed to ensure that residents could easily view the results of the most recent survey and access information about advocate agencies, as required by facility policy and regulatory standards. Although the policy stated that survey results would be posted in a place readily accessible to residents, family members, and legal representatives, observations and interviews revealed that this was not consistently implemented. During a Resident Council Meeting, all residents present reported not knowing where to find the survey results. A walkthrough showed that the binder containing survey results was placed on a second shelf in the lobby, partially obstructed by a sign listing visiting hours, and there were no signs indicating the availability of survey results in the lobby or on any of the facility's units or hallways. Further interviews with facility staff, including the administrator, receptionist, and DON, confirmed that the survey results were sometimes kept in the administrator's office and not always available in the lobby as intended. Staff were unaware of any signage indicating the location of the survey results, and at one point, the binder was missing from its usual location in the lobby. These actions and inactions resulted in residents and visitors not having clear or consistent access to the survey results or information about advocate agencies, contrary to facility policy and regulatory requirements.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The facility's policy, last revised in May 2024, requires that every resident have an interdisciplinary baseline care plan initiated within 48 hours of admission. However, record review and staff interviews revealed that for a resident admitted with vascular dementia, depression, and metabolic encephalopathy, there was no documented evidence of a baseline care plan in the medical record. The resident's Minimum Data Set assessment indicated severe cognitive impairment, but the resident was usually able to understand and be understood by others. Despite these needs, the baseline care plan was not located, as confirmed by the Regional Nursing Coordinator and the DON, who acknowledged the requirement but could not explain the omission. This failure was cited under 10 NYCRR 415.11.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Lack of Care Planning and Documentation for Room Modifications
Penalty
Summary
A deficiency was identified when a resident's room was found to be devoid of home-like touches and furniture, with the mattress placed directly on the floor and no decorations or personal items present. The resident, who had diagnoses of type 2 diabetes mellitus, dementia, and schizoaffective disorder, was assessed as severely cognitively impaired but able to communicate. Observations confirmed the lack of furniture and home-like environment, and documentation review revealed no physician order or care plan supporting the removal of the bed frame, furniture, or the placement of the mattress on the floor. Interviews with facility staff indicated that the furniture and bed frame had been removed due to the resident's behaviors and safety concerns, such as attempts to take apart the bed frame. However, staff were unaware of any care plan or physician order authorizing these changes, and the care plan did not reflect the current room setup. The lack of documentation and care planning for these significant environmental modifications resulted in the resident not receiving care and services in accordance with their preferences, choices, values, and beliefs.
Failure to Timely Assess and Report Large Bruise Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of malignant neoplasm of the kidney, type 2 diabetes mellitus, and heart failure did not receive timely assessment and reporting of a large bruise on the left outer leg, extending from the knee to midcalf. The resident was cognitively intact and required one-person assistance for bathing, dressing, and toilet use. The bruise was first documented by physical therapy on 7/15/2025 as being tender to the touch, and the resident reported pain in the left knee. The resident also reported to staff that they had fallen, and this was communicated to the medical provider. However, the Accident and Incident Report indicated the fall occurred on 7/08/2025 or 7/09/2025, suggesting a delay in recognition and reporting. Further review revealed that weekly skin checks, as ordered, were not documented as completed on 7/01/2025 or 7/08/2025 in the Treatment Administration Record. Interviews with staff confirmed that all ordered care should be provided and documented, and that new bruises or skin issues identified by CNAs should be reported immediately to the charge nurse. The Director of Nursing acknowledged that weekly skin checks should have been completed and signed for, and that the bruise should have been reported promptly. The lack of timely assessment and documentation led to the deficiency.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care was provided unless a decline was for a documented medical reason. This resulted in a resident experiencing a decline in ROM or mobility without evidence that the decline was medically unavoidable.
Failure to Remove Razors from Shared Bathroom Creates Accident Hazard
Penalty
Summary
Surveyors identified that the facility failed to ensure the resident environment was free from accident hazards for one of nine residents reviewed. Specifically, two disposable razors and an unlabeled electric razor were found in the shared bathroom of a semi-private room. One resident in this room had multiple sclerosis, COPD, and tachycardia, was cognitively intact, and required set-up assistance for personal hygiene. The roommate had Alzheimer's disease, major depressive disorder, and COPD, with severe cognitive impairment and required supervision for personal hygiene. Despite these conditions, razors were accessible in the shared bathroom on multiple observations. Interviews with staff confirmed that razors should not have been left in the bathroom, as staff are responsible for shaving both residents. The LPN acknowledged the risk of residents using the razors to harm themselves and indicated the razors would be removed. The DON stated that personal belongings, including razors, should not be left in shared bathrooms for infection control reasons and due to the risk posed to residents, especially those with mental health issues or who are ambulatory.
Failure to Consistently Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards and the facility's own policy. Specifically, nursing staff did not consistently complete, review, or log dialysis communication sheets for a resident between early April and late July. The facility's policy required staff to document pre- and post-dialysis information, including vital signs and continuity of care notes, in a communication book that should accompany the resident to and from dialysis. However, during the survey, the communication book could not be located, and only a few dates were documented in the log, despite evidence in the electronic medical record that the resident had attended additional dialysis sessions for which no communication documentation was available. The resident involved had diagnoses of end stage renal disease, essential hypertension, and adjustment disorder, and was cognitively intact. The care plan specified regular dialysis sessions and required monitoring and communication with the dialysis center. Interviews with nursing staff and the DON revealed uncertainty about the location of the communication book and inconsistent documentation practices. Requests for additional documentation covering a broader date range were not fulfilled, and the missing records were not located in the electronic medical record as expected. This lack of consistent documentation and communication failed to meet the facility's policy and professional standards for dialysis care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in an area accessible to all residents and visitors, as required by both facility policy and regulatory requirements. Specifically, nurse staffing levels for each shift were not posted in the facility on several dates, including July 21 through July 25, 2025, and July 28 through July 29, 2025. Observations confirmed that the required information was not displayed at the reception desk, in the lobby, or on any units or hallways. During an interview, the staffing coordinator acknowledged that the information was supposed to be posted at the receptionist's desk but admitted it was not done due to lack of time while the survey team was onsite. The facility's policy, last revised in September 2024, mandates that nurse staffing information be posted daily at the beginning of each shift in a clear and readable format in a prominent location accessible to residents and visitors.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Implement Compliance Program for Medical Record Retention
Penalty
Summary
The facility failed to effectively communicate and implement the standards of its compliance and ethics program, specifically regarding the retention and accessibility of resident medical records. During the survey, it was found that medical records dated prior to November 2024 were not accessible due to issues with transitioning between electronic medical record systems. The facility's policy requires retention of all medical records for the period required by law, but this was not followed, as records from the previous system were not available for residents admitted before November 2024. Interviews revealed that the Administrator, who also served as the Corporate Compliance Officer, was aware of the lack of access to these records but did not identify it as a concern or communicate the issue to the Corporate Compliance Committee, the Quality Assurance Performance Improvement Committee, or the Corporate Information Technology Nurse. The Corporate Information Technology Nurse and the Operator both stated they would have expected the Administrator to report the issue for continuity of care. The failure to ensure access to all required medical records was not addressed or escalated as required by the facility's compliance and ethics program.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for all new and existing staff members. This deficiency was identified based on the lack of evidence that staff received adequate training as required by regulations. The report notes that the training program was either not in place, not properly implemented, or not maintained for both new hires and current employees. No specific residents or patient conditions are mentioned in the report, and there are no details provided about individual staff members or the direct impact on resident care.
Deficiency in Administrator Licensing and Oversight
Penalty
Summary
The governing body of the facility failed to implement policies ensuring that professional staff were licensed, certified, or registered according to Federal and State laws. Specifically, the facility did not appoint a licensed and currently registered Nursing Home Administrator to provide full-time, onsite oversight. The facility had been operating with an unlicensed acting administrator, Assistant Administrator #1, whose role was extended multiple times due to unsuccessful recruitment efforts for a permanent licensed administrator. Despite the New York State Department of Health's approval for Assistant Administrator #1 to act as an unlicensed administrator, the facility did not have a licensed Nursing Home Administrator present onsite as required. During the recertification survey, it was observed that the Nursing Home Administrator was not present in the building, and all administrative queries were directed to Assistant Administrator #1, who was not licensed. Interviews with staff, including a Licensed Practical Nurse, revealed confusion and lack of clarity regarding the oversight of Assistant Administrator #1. The facility's documentation confirmed that Assistant Administrator #1 was acting in the capacity of an administrator without the necessary licensure, and the licensed administrator was only present for limited hours weekly. This situation led to a deficiency in the facility's management and operational oversight.
Failure in Quality Assurance and Recurring Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This was evidenced by repeat deficiencies in maintaining a safe, clean, comfortable, and homelike environment, food procurement and safety, and infection control. The facility did not have documented evidence of written procedures for developing, monitoring, and evaluating performance indicators, nor did it have procedures for developing corrective actions to prevent quality of care, quality of life, or safety problems. Additionally, there was no evidence of procedures for obtaining feedback, data collection, or monitoring adverse events. The deficiencies were identified during recertification and abbreviated surveys, where it was noted that previously approved Plans of Correction for the cited deficiencies were not implemented, as the same issues were found in the current survey. The facility's Quality Assurance Performance Improvement plan was intended to evaluate and improve the residents' experience and care quality, but lacked documented procedures for performance monitoring and corrective action development. Interviews with facility staff revealed that while there were daily meetings and tracking sheets for department heads, there was no structured system for addressing and preventing recurring deficiencies.
Failure to Uphold Resident Dignity and Rights
Penalty
Summary
The facility failed to protect and promote the rights of residents, as evidenced by several deficiencies observed during a recertification survey. Three residents were affected by the facility's failure to provide appropriate clothing and maintain their dignity. One resident was unable to access their clothing, and staff reported difficulty in finding clothes that fit. This resident expressed dissatisfaction with wearing a hospital gown for several days due to the lack of available clothing. Another resident was observed in a hospital gown with their back and buttocks exposed, visible from the hallway for over an hour. This lack of privacy and dignity was noted during multiple observations. Additionally, a third resident was found wandering the unit with a noticeable odor of feces and wearing soiled clothing, indicating a lack of proper hygiene and care. Interviews with staff revealed that the facility relied on donated clothing and hospital gowns for residents without personal clothing. Staff acknowledged the difficulty in finding appropriate clothing for residents, particularly those with larger sizes, and admitted that the situation should not have occurred. The facility's failure to provide adequate clothing and maintain residents' dignity and privacy was a clear violation of residents' rights.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to ensure the protection of residents' personal property from loss or theft, as evidenced by the experiences of four residents whose belongings sent out for laundering were not returned in a timely manner. The facility's policy on Personal Property Theft and Loss Risk, dated October 2023, mandates the safekeeping of personal property and requires labeling and inventorying of residents' belongings. However, observations and interviews revealed that these procedures were not consistently followed, leading to missing items for Residents #1, 34, 73, and 108. Resident #1, who was cognitively intact, reported that clothing sent to laundry was missing for approximately three weeks. Resident #73, also cognitively intact, mentioned missing personal laundry but did not file a grievance, believing the facility would not take action. Resident #34, with significant cognitive impairment, and Resident #108, who was cognitively impaired, also experienced issues with missing belongings. The facility's grievance records for April 2024 showed only one grievance related to missing items, which was resolved, indicating a lack of formal complaints despite the ongoing issue. Interviews with staff revealed inconsistencies in the process of labeling and inventorying residents' belongings. Certified Nurse Aide #1 and Licensed Practical Nurses #3 and #4 described a process where belongings were supposed to be labeled and inventoried by the receptionist or Laundry Person #1, but this was not consistently done. The inventory sheets were not regularly checked or updated, especially when residents were transferred between units. The facility's failure to adhere to its own policies and procedures contributed to the deficiency in safeguarding residents' personal property.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that grievances were resolved in a timely manner for three residents, as observed during a recertification survey. The facility's grievance policy, dated 10/01/2022, required grievances to be documented and resolved by the appropriate party. However, grievances from residents were not documented or resolved through the facility's grievance process. For instance, one resident reported missing personal laundry but did not file a grievance due to a belief that it would not lead to any resolution. Another resident experienced a delay of approximately three weeks before some of their missing clothing was returned, and they had not filed a grievance either. During a Resident Council Meeting, residents expressed that they were unaware of who was responsible for handling grievances and noted that staff often promised to look into issues without providing resolutions. Interviews with staff revealed inconsistencies in the grievance process, such as the location and accessibility of grievance forms. A Certified Nurse Aide mentioned that they would report missing laundry to maintenance or housekeeping, but did not fill out grievance forms. A Licensed Practical Nurse indicated that grievance forms were kept in their office, and the box for forms was obstructed by a linen cart, making it difficult for residents to access. The facility's grievance process was further complicated by unclear procedures for inventorying residents' belongings. Staff interviews revealed that belongings were supposed to be inventoried upon admission, but this process was not consistently followed. Additionally, there was confusion about who should be notified if items went missing, with some staff believing it was the responsibility of the Social Worker or Maintenance. This lack of clarity and follow-through in the grievance process contributed to the facility's failure to address and resolve residents' grievances effectively.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, as identified during a recertification survey. Specifically, two residents who were on anticoagulant medications did not have care plans that included interventions for the use of these blood thinners. Additionally, another resident experienced significant weight loss, but the care plan did not document physician supervision or interventions to address this issue. These deficiencies were identified through observations, record reviews, and interviews. The facility's policy on Comprehensive Care Plans, dated September 2023, mandates that each resident should have an interdisciplinary care plan initiated within 48 hours of admission. This care plan should address priority problems and needs, be current, realistic, and time-specific, and involve the resident and/or family in the planning process. However, the facility did not adhere to this policy for the residents in question, as evidenced by the lack of documented interventions for anticoagulant use and the absence of physician supervision for significant weight loss.
Deficiency in Nursing Staff Competency and Care Quality
Penalty
Summary
The facility was found to have insufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. Specifically, the facility failed to conduct proper competency evaluations for licensed nursing staff, which are necessary to assess the knowledge, skills, and abilities required for their roles. This deficiency was evidenced by several observations and interviews during the recertification survey. One resident, admitted with atherosclerotic heart disease, cachexia, and severe protein-calorie malnutrition, was observed to have multiple inhalers in their room. The resident expressed a lack of confidence in the staff's ability to provide timely access to a rescue inhaler, leading them to keep it within reach. Additionally, the facility's medication room was found to have a 24-hour urine specimen stored alongside medications, including insulin, which is a breach of proper storage protocols. Further observations revealed issues with the care of another resident who had a peripherally inserted central catheter (PICC) line. The dressing was found to be peeling, soiled, and undated, indicating a lack of proper maintenance. Interviews with staff highlighted gaps in training and competency evaluations, with some staff unable to recall when they last received training or competency assessments. The facility lacked documented policies and procedures, and there was no process in place to assess the competencies of new hires, contributing to the overall deficiency in staff competency and care quality.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, as required by their policy. This deficiency was identified during a recertification survey, which included observations, record reviews, and interviews. The survey found that the drug regimens for four residents were not reviewed monthly, as evidenced by gaps in the documented reviews. The facility's policy required a comprehensive medication regimen review to be performed monthly by a consultant pharmacist, with findings and recommendations reported to the director of nursing and other relevant parties. Resident #23, who was admitted with diagnoses including fatty liver and fibromyalgia, had missing monthly reviews for several months. Similarly, Resident #78, with chronic systolic congestive heart failure and major depressive disorder, also had months without documented reviews. Resident #30, with significant medical conditions such as the absence of a right leg and atherosclerosis, and Resident #67, diagnosed with unspecified dementia and major depressive disorder, both had missing reviews for multiple months. Despite these lapses, the residents were observed interacting normally with staff and other residents, without signs of overmedication or medication-related issues. Interviews with facility staff, including the Director of Nursing and a registered nurse, revealed a misunderstanding of the review frequency requirements. The Director of Nursing believed reviews should occur on admission, quarterly, or with changes in condition, while the registered nurse mentioned reviews were done on admission and with medication changes. The pharmacist confirmed that reviews were conducted monthly and emailed to the Director of Nursing, but the documentation did not reflect consistent monthly reviews for the residents in question.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with professional standards, as observed during a recertification survey. Specifically, urine specimens were improperly stored in the same refrigerator as insulin pens and vials, and a purified protein derivative solution was found without an open date and was expired. Additionally, several medications, including eye drops, ear drops, Vitamin D, and insulin pens, were found in the medication cart without expiration dates. The controlled substance cabinet's inside lock was also broken, compromising the security of controlled drugs. Licensed Practical Nurses reported a lack of clear directives due to frequent changes in the Director of Nursing, leading to inconsistent practices. The facility's policies required separate storage for lab specimens and medications, but these were not followed, as evidenced by the co-mingling of urine specimens with medications. The Nurse Educator acknowledged the ongoing process of creating and implementing nurse competencies, indicating that current staff training and oversight were insufficient to ensure compliance with medication labeling and storage standards.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during a recertification survey. Observations in the main kitchen and one of the unit kitchenettes revealed several deficiencies. In the main kitchen, a #10-sized can of mashed potatoes had a V-shaped dent in the top seam, and two #10-sized cans of red pepper strips had metal touching metal at the top seam. Additionally, the slicer, stainless steel utility cart, handwashing sink, and the floor under the cooking equipment line were soiled with food particles and dirt. The food temperature thermometer was found to be out of calibration, reading 25 degrees Fahrenheit when tested using the standard ice-bath method. In the South Unit kitchenette, the refrigerator door gasket was split and uncleanable, and the drawers and cabinets were soiled with food particles. These observations were confirmed through staff interviews, where it was acknowledged that the dented cans should have been segregated, and the kitchen equipment required cleaning. The deficiencies indicate a lack of proper food storage, preparation, and cleanliness, which are essential for maintaining food safety standards.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that Resident #80's right to self-determination and choice was upheld, as evidenced by the resident's inability to get out of bed due to the lack of an appropriate wheelchair. Resident #80, who has cerebral palsy, morbid obesity, and congestive heart failure, was observed in bed on multiple occasions and expressed that they had repeatedly requested a suitable wheelchair for months. The resident was provided with a geriatric chair, which they refused because they could not self-propel it, and a standard wheelchair that was too narrow for comfort. Despite having moderate cognitive impairment, the resident was alert and oriented, with full upper body strength, and expressed a desire to attend the gym, which was not possible without the appropriate wheelchair. Interviews with facility staff revealed a misunderstanding of the resident's needs and preferences, as both a Certified Nurse Aide and a Licensed Practical Nurse stated that the resident refused to get out of bed. The Director of Rehabilitation acknowledged that the resident had plateaued in therapy and was no longer receiving it, but also noted that a custom-sized bariatric wheelchair could be ordered for residents with special needs. The lack of an appropriate wheelchair and the discontinuation of therapy contributed to the resident's inability to exercise their right to self-determination and choice, as outlined in the facility's policy and New York State regulations.
Inconsistent Documentation of Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically their code status, was consistently documented and easily identifiable by all staff. The resident in question, who had severe cognitive impairment and was diagnosed with unspecified dementia, early onset Alzheimer's disease, and type 2 diabetes, had conflicting documentation regarding their code status. While the Medical Orders for Life-Sustaining Treatment indicated a Do Not Resuscitate/Do Not Intubate status, social work progress notes documented a Cardio-Pulmonary Resuscitation code status. Observations and interviews revealed that the resident's code status was not consistently documented across various records, including the resident's electronic chart and identification bracelet. Staff interviews indicated that the code status should be available in the resident's chart, on their ID bracelet, and in the electronic records. However, the resident was observed without an ID bracelet, and the Medical Order for Life-Sustaining Treatment was not initially scanned into the electronic system. The facility's policy required that advance directives be maintained in the care plan, as a physician order, and on the resident's ID band. Despite this, there was a delay in updating the electronic records with the Medical Order for Life-Sustaining Treatment, which was only scanned into the system after the deficiency was identified. Staff interviews highlighted inconsistencies in the process of updating and maintaining accurate records of the resident's code status, contributing to the deficiency.
Failure to Update Care Plan for Significant Change in Resident's Condition
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set assessment for a resident who experienced a significant change in health status. The resident, who was admitted with chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes, was sent to the hospital due to a change in respiratory status. Upon returning to the facility, the resident was diagnosed with respiratory bronchiolitis interstitial lung disease and required oxygen and inhaler use. Despite these changes, the facility did not update the resident's care plan to reflect the new respiratory needs, including the use of inhalers and nebulizer treatments. Interviews with facility staff revealed that the care plan should have been updated within 48 hours of the resident's readmission from the hospital. The LPN acknowledged that documentation for the resident's respiratory issues was missing from the care plan, and the MDS Coordinator confirmed that the care plans and Minimum Data Set should have been updated due to the significant change in the resident's condition. This oversight resulted in a deficiency as the facility did not adhere to its policy of updating care plans for significant changes in a resident's condition.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with a fractured back, diabetes, and chronic bladder inflammation, had moderate cognitive impairment but was able to understand and be understood by others. The baseline care plan for this resident was not completed and signed until several days after admission, which is a violation of the facility's policy that mandates the completion of such plans within 48 hours. Interviews with facility staff revealed a lack of clarity and consistency in the understanding and execution of the baseline care plan policy. The Minimum Data Set Coordinator acknowledged that baseline care plans were not always completed within the required timeframe. Additionally, the Director of Nursing displayed uncertainty about the exact timeframe for completing these plans, indicating a possible systemic issue in policy adherence and staff training. This deficiency was identified during a recertification and abbreviated survey, highlighting a failure in the facility's processes to ensure timely and effective care planning for new admissions.
Failure to Update Comprehensive Care Plan After Medication Changes
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised after each assessment and in response to changes in medication for a resident. Specifically, the care plan for a resident with diagnoses of unspecified dementia with agitation, major depressive disorder, and hypertension was not updated following changes in their psychotropic medication regimen. The resident's Minimum Data Set indicated moderate cognitive impairment, and the facility's policy required care plans to be modified to reflect new diagnoses, medications, or abnormal labs. However, despite changes in the resident's sertraline dosage, the care plan was not updated to reflect these changes. The Medication Administration Records showed a series of dosage adjustments for sertraline, but the comprehensive care plan was last updated in December 2023, documenting a daily dose of 175 milligrams, which was no longer accurate. The Director of Nursing acknowledged that the care plan should have been person-centered and revised to include non-pharmacological interventions and monitoring, reflecting the resident's current needs and interventions. This oversight was identified during a recertification survey, highlighting a deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Apply Compression Stockings for Resident with Edema
Penalty
Summary
The facility failed to ensure that a comprehensive assessment and appropriate care were provided to a resident, specifically regarding the application of compression stockings. Resident #89, who was admitted with Alzheimer's Disease, Atherosclerotic Heart Disease, and depression, had a standing order for compression stockings to manage bilateral lower extremity edema. However, during the recertification survey, it was observed that the resident was not wearing the prescribed compression stockings, and staff confirmed that they were never applied because the resident would remove them due to their severe cognitive impairment. The facility's policy required comprehensive care plans to be developed and interventions to be specific and timely, yet this was not adhered to in the case of Resident #89. Interviews with the Director of Nursing and a Licensed Practical Nurse revealed that the order for compression stockings had not been reviewed or discontinued despite the resident's non-compliance. The facility had experienced several leadership changes, which contributed to the oversight. A new Nurse Practitioner had recently started and was expected to assess residents' needs, but the deficiency had already occurred.
Resident's Non-Compliance with Smoking Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who was observed using tobacco in their room without supervision. The resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes, was found to be non-compliant with the facility's smoking policy. The policy prohibited smoking within the facility and possession of tobacco products by residents. Despite this, the resident was observed using chewing tobacco in their room, which was against the policy. The facility's comprehensive care plan for the resident did not include interventions to address the resident's potential or actual non-compliance with the smoking policy. Although the care plan acknowledged the resident as a smoker who was only allowed to smoke under supervision at designated times, it failed to address the resident's possession and use of tobacco products in their room. Interviews with staff revealed that the resident sometimes had cigarettes and chewing tobacco in their possession, and staff had to remind the resident of the policy. However, the resident often became irate when reminded and continued to keep tobacco products in their room. Staff interviews and observations indicated that the resident's possession of tobacco products posed a potential hazard, as other residents could mistake the tobacco spittoon for a drink. The facility's staff, including CNAs and LPNs, were aware of the resident's non-compliance but did not consistently enforce the policy or develop a plan to address the issue. The Director of Nursing confirmed that tobacco products were confiscated from the resident's room, highlighting the facility's failure to prevent the resident from accessing and using tobacco products unsupervised.
Failure to Provide Adequate Medical Supervision for Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #63, received adequate medical supervision for significant weight loss. Resident #63, who was admitted with traumatic subdural hemorrhage, urinary calculus, and scoliosis, experienced a 17.45% weight loss between December 2023 and April 2024. Despite the resident's significant cognitive impairment and the need for total assistance with meals, there was no documented evidence that the physician was notified of the weight loss. The dietary notes from January and April 2024 indicated significant weight loss and dehydration, yet the physician's note from March 2024 did not address these concerns. Observations during a lunch period revealed that Resident #63's meal portions were small and unappetizing, with the meat appearing undercooked and other items tasting unpleasant. The facility's policies required notification of changes in a resident's condition, such as significant weight loss, but this protocol was not followed. The registered dietician stated that care plans were based on resident preferences and interdisciplinary team input, yet the care plan interventions to monitor and report signs of malnutrition were not effectively implemented for Resident #63.
Failure to Document Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the use of the antipsychotic medication Abilify. The resident, who had diagnoses including chronic systolic congestive heart failure and major depressive disorder with psychotic symptoms, was prescribed Aripiprazole in two different dosages without an indication for use documented in the physician's orders. This lack of documentation did not comply with the facility's policy, which required a written diagnosis or indication for each medication order. The deficiency was identified during a recertification survey, where it was noted that the medication regimen reviews did not contain a reason for the medication order. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, revealed that medication regimen reviews were conducted on admission, quarterly, or when there were changes in condition. However, the reviews provided did not include the necessary documentation for the prescribed medication. The pharmacist confirmed that reviews were completed monthly and sent to the Director of Nursing, but the required indication for the medication was still missing.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations during a recertification survey. One of the three dumpsters was found to be leaking a black oily liquid from the bottom, and there was a build-up of brown leaves on the ground around another dumpster. These observations were made during a site visit, indicating improper maintenance and cleanliness of the dumpster area.
Infection Control Deficiency in PICC Line Management
Penalty
Summary
The facility failed to adhere to infection control practices for a resident with a peripherally inserted central catheter (PICC) line. The facility's policy required that dressings remain clean, dry, and intact, and be changed every 5-7 days or as needed. However, during the survey, it was observed that the dressing on the resident's PICC line was peeling, with curled and soiled edges, and was not dated. Additionally, the double lumen lines were improperly managed, as they were dangling and tucked behind the resident. The resident involved had a history of osteomyelitis, obstructive and reflux uropathy, and systemic lupus erythematosus, with moderate cognitive impairment. Despite the facility's policy and the physician's orders, the dressing change was not performed correctly, and the dressing was not dated. Furthermore, the white port of the PICC line was found uncapped, which was immediately rectified by the nurse upon notification. The Director of Nursing acknowledged the oversight and mentioned that the nurse responsible was experienced in changing central line dressings.
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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