Long Beach Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Long Beach, New York.
- Location
- 375 East Bay Drive, Long Beach, New York 11561
- CMS Provider Number
- 335432
- Inspections on file
- 15
- Latest survey
- March 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Long Beach Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A recertification survey revealed that a five-story building lacked fireproofing on steel structural supports and did not have a fire-rated ceiling assembly, classifying it as a Type II (000) Unprotected, Non-combustible structure. This construction type is not permitted to exceed two stories in height according to the Life Safety Code.
The facility's permanently installed generator was non-functional, as confirmed by the Director of Maintenance. A portable generator was temporarily used to provide emergency power, wired into the building's transfer switch room. The facility was in the process of acquiring a new generator.
The facility did not ensure that HVAC shafts were enclosed with a minimum one-hour fire resistance rating, as required by NFPA standards. Observations during a survey revealed that vertical ventilation ducts on multiple floors lacked proper fire-rated construction and dampers, compromising fire safety compliance.
A recertification survey identified deficiencies in a facility's kitchen operations, including improper dishmachine temperatures, inadequate drying of washed items, and unsanitary storage conditions. Dietary staff were unaware of proper procedures, and the Director of Food Services was not informed of issues, leading to potential contamination risks.
The facility failed to maintain effective infection control, with staff handling medications with bare hands, incorrect isolation signage for a resident with scabies, and unclean medication storage areas. These deficiencies highlight lapses in following infection prevention protocols, potentially risking contamination and transmission of infections.
The facility failed to properly label and store medications on two medication carts, with opened insulin pens and an ophthalmic solution lacking documented open dates. This affected three residents, including one with severe cognitive impairment and another with intact cognition. Staff interviews confirmed the requirement for open dates to ensure timely disposal, as per facility policy.
A facility failed to implement a Pharmacist's recommendations for a resident's insulin management. The attending Physician initially agreed to the recommendations but later decided not to implement them due to clinical reasons, without documenting the rationale. This led to a deficiency as the facility's policy requires such recommendations to be acted upon and documented.
The facility did not submit a CHRC 105 Form within the required 30-day period after receiving a negative determination for a prospective employee. The oversight occurred because the employee was not hired and thus not in the payroll system, leading to a delay in termination from the CHRC system.
Two residents with pressure ulcers did not receive necessary treatment due to improper air mattress settings. One resident's mattress was set to an incorrect weight, while another's mattress was unplugged, rendering it non-functional. Nursing staff, including the Wound Care RN and DON, acknowledged the oversight and emphasized the importance of correct settings and functionality.
A resident received the wrong enteral formula due to a lack of labeling and failure to update the feeding solution as per the physician's order. The nursing staff did not label the feeding bottle with the necessary details, and there was a lack of awareness about the change in the feeding solution order, despite being aware of the change in flow rate.
Fire Safety Deficiency in Building Construction
Penalty
Summary
During a recertification survey, it was observed that a five-story building did not meet the fire safety requirements as per the NFPA 101 Life Safety Code. Specifically, the steel structural supports above the suspended ceiling on floors 1-4 were not provided with fireproofing material. Additionally, there was no documentation to confirm that the inlay drop ceiling was a fire-rated listed assembly. These observations were made during the life code survey conducted over two days. The lack of fireproofing on the steel structural members and the absence of a fire resistance-rated ceiling assembly led to the classification of the building as a Type II (000) Unprotected, Non-combustible structure. According to the Life Safety Code, buildings of this construction type are prohibited from being more than two stories in height. The findings were communicated to the facility's Administrator, Corporate Director of Maintenance, and Director of Maintenance during the Life Safety Code exit conference.
Deficiency in Emergency Power System
Penalty
Summary
The facility was found to have a deficiency related to its emergency power system during a recertification survey. It was observed that the permanently installed generator set within the building was non-functional. This was confirmed through an interview with the Director of Maintenance, who stated that the in-house generator had stopped working and was not repairable. As a temporary measure, a portable generator was being used to provide emergency power, which was wired into the transfer switch room of the building. The facility was in the process of procuring and installing a new permanently installed generator.
Failure to Ensure Fire-Resistant HVAC Shafts
Penalty
Summary
The facility failed to ensure that the heating and ventilating shafts were enclosed with a minimum fire resistance rating of at least one hour, as required by the 2012 NFPA 101 and NFPA 90A standards. During the recertification survey, it was observed that the HVAC ductwork serving residents' toilet rooms and soiled utility rooms did not meet the necessary fire resistance requirements. Specifically, vertical ventilation ducts passing through floors on the 2nd, 3rd, and 4th floors were not enclosed with one-hour fire-rated construction within the interstitial spaces above the suspended ceilings. Additionally, there were no fire-rated dampers installed at the floor level where the ducts penetrated the floor. These deficiencies were identified during a life code survey conducted over two days, and the findings were communicated to the facility's Administrator, Corporate Director of Maintenance, and Director of Maintenance during the Life Safety Code exit conference. The lack of proper fire resistance measures in the HVAC system represents a failure to comply with the specified fire safety standards, potentially compromising the safety of the facility's environment.
Sanitation and Storage Deficiencies in Kitchen Operations
Penalty
Summary
The facility was found to have deficiencies in its sanitation practices during a recertification survey. The high-temperature dishmachine was observed to have a final rinse temperature below the required 180 degrees Fahrenheit, with readings of 122 and 121 degrees Fahrenheit. Dietary staff, including Dietary Aide #1 and Dietary Aide #2, were not aware of the proper procedures for operating the dishmachine or monitoring the chemical sanitization process. The Director of Food Services was not informed of the low temperatures, which should have prompted immediate action to address the issue. Additionally, the facility failed to ensure that washed cooking equipment and trays were properly dried before storage. Observations revealed that wet trays, plates, and domes were being stacked and stored without adequate air-drying, leading to potential contamination. The Director of Food Services acknowledged the lack of sufficient space and drying racks to allow for complete air-drying of items before storage. The facility also had issues with cleanliness and storage in the kitchen and storage areas. One of the air circulation fans in the walk-in refrigerator was dusty with black build-up, and the dry goods storage room floor was unclean. Non-food items were improperly stored directly on the floor in the paper goods storage room. The Director of Food Services confirmed that these practices were against the facility's policies, which require a clean environment and proper storage of items.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 I. Immediate Corrective Action While no residents were identified as being harmed by the deficient practices, immediate corrective actions were taken to address observed sanitation and food safety issues: - The dish machine was taken out of service immediately. Dishes were sanitized using the approved 3-compartment sink method with chemical sanitizer until the dish machine was repaired and recalibrated. - All wet dishes and utensils that had been improperly stored were rewashed, properly air-dried, and stored in a sanitary manner. - The dirty air circulation fan in the walk-in refrigerator was cleaned and sanitized. - The dry goods storage room was cleaned, with all debris and spilled food removed. - The dirty condiment tray was discarded. - All items improperly stored on the floor in the paper goods storage area were relocated to appropriate shelving. - Staff involved were counseled and re-educated on proper food safety protocols and dish sanitization procedures. II. Identification of other residents Although no direct resident harm was identified, all residents who receive food prepared in the facility could have been affected by the improper sanitization of dishware and unsanitary kitchen conditions. - All noncompliant practices were corrected on the spot. III. Systemic Changes - The facility policies titled Dish Machine Procedure and Storeroom/Food Delivery Procedures were reviewed and found to be in compliance with the regulations. - Staff were re-educated on dish machine operation, temperature requirements, and procedures for chemical sanitization. - The kitchen staff were re-educated on dishware and food storage and maintaining the cleanliness of the kitchen overall. - All dietary staff were in-serviced on how to read temperature gauges and test chemical concentrations when needed. - A No Wet Nesting policy was reinforced, and staff are now required to inspect items for dryness prior to storage. All dietary staff were educated on the No Wet Nesting policy. - A weekly cleaning schedule was developed and assigned to staff for: - Walk-in refrigerator cleaning (including fan guards). - Dry goods and paper goods storage areas. - Removal of expired, open, or improperly stored items. - Nothing on the Floor signage was placed in all storage areas. IV. QA Monitoring - An Audit Tool has been developed to track compliance with the facility policies titled Dish Machine Procedure and Storeroom/Food Delivery Procedures such as: - Documentation of daily dish machine temperature checks. - Weekly sanitation inspections of all food preparation and storage areas. - Monitoring of dish storage for signs of wet nesting or improperly dried items. - This audit will be conducted by the Food Service Director/Designee weekly for three months. - Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Food Service Director
Infection Control Deficiencies in Medication Handling and Isolation Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a recertification survey. During a medication administration observation, an LPN handled medications with bare hands for a resident, which is a breach of infection control protocols. The LPN acknowledged the error but did not initially discard the contaminated medications. Additionally, another LPN failed to sanitize their hands after picking up an electrical cord from the floor before preparing medications for a resident, and an RN did not sanitize their hands before applying wound medication to a resident with pressure ulcers. The facility also failed to implement correct isolation precautions for a resident diagnosed with scabies. Incorrect signage was posted outside the resident's room, leading to confusion among staff about the necessary precautions. The Director of Nursing Services, responsible for posting the signage, admitted the error, and staff interviews revealed a lack of understanding of the differences between Enhanced Barrier Precautions and contact isolation precautions. This miscommunication could have led to inadequate protection for staff and visitors entering the resident's room. Furthermore, the facility did not maintain cleanliness in the medication storage areas. An observation revealed that the medication refrigerator in one unit had dirty drug labels and debris, which the nursing staff failed to address. The Director of Nursing Services confirmed that the nursing staff was responsible for ensuring the cleanliness of the medication refrigerator, and the presence of debris could pose an infection control risk due to potential contamination of stored medications.
Plan Of Correction
Plan of Correction: Approved April 15, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action - Resident #32: Medications dispensed by hand were discarded immediately upon identification, and a new, properly handled dose was administered. Licensed Practical Nurse #1 received immediate re-education on infection control standards during medication administration. - Resident #133: The Enhanced Barrier Precautions (EBP) signage was removed and replaced with the correct Contact Isolation signage per physician order [REDACTED]. - Resident #50: Registered Nurse #3 was re-instructed on proper hand hygiene protocols. Resident’s wound site was reassessed with [REDACTED]. No harm identified. - Unit 4 Medication Refrigerator: The medication refrigerator was immediately cleaned and disinfected. All outdated or damaged labels were removed, and the area was sanitized according to facility policy. RN Supervisor was counseled on proper oversight. - Resident #3: Licensed Practical Nurse #2 sanitized their hands after being prompted by the surveyor. Nurse was immediately reminded of hand hygiene protocol prior to medication handling. II. Identification of other residents - Any resident receiving wound care and/or medication has the potential to be affected by this deficiency. - All residents on any level of Infection Control Precautions were assessed for the correct signage on their room door. - All signage matched the physicians’ orders. - All medication storage room refrigerators were assessed and found to be clean. III. Systemic Changes - The facility policies titled Medication Administration Guidelines, Pressure Injury/Pressure Ulcer Assessment, Prevention and Management, Infection Prevention Control Program, Contact Precautions, Enhanced Barrier Precautions and Medication Refrigerator Cleaning were reviewed and found to be in compliance with the regulations. - All licensed nurses will be educated on proper infection prevention policies and practices during medication administration and wound treatment, as well as medication storage room refrigerator cleaning procedures. - The Infection Preventionist will be educated on utilizing precaution signage according to physician’s orders. - A copy of the attendance sheet will be filed for reference and validation. IV. QA Monitoring - Existing medication pass and wound treatment competencies will be used to audit infection prevention/control practices during these service provisions. Each licensed nurse will be assessed monthly for three months. - An Audit Tool has been developed to monitor the placement of appropriate infection precaution signage on resident room doors. An Audit Tool has been developed to assess the cleanliness of medication storage room refrigerators. - Five licensed nurses will be audited weekly for one month using the two audits (Medication Pass and Wound Treatment Competencies). Further audits will be conducted on 5 nurses monthly for 2 months. - The placement of appropriate infection precaution signage on resident room door will be audited weekly for one month, then monthly for 2 months. - The cleanliness of medication storage room refrigerator will be audited weekly for one month, then monthly for 2 months. - Audit findings will be compiled, analyzed and brought to the QAPI Committee. - During the quarterly QAPI Committee meeting, the audit results will be reviewed and assessed for continuance, based on compliance and incidence of negative findings. Responsible Party: Director of Nursing
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on two of the three medication carts reviewed during the survey. Specifically, an opened insulin pen and an ophthalmic solution bottle were found without documented open dates on the Unit 4 West medication cart. The facility's policy requires that multi-dose vials be dated upon opening and discarded within 28 days unless otherwise specified by the manufacturer. Resident #92, who had intact cognition, was receiving insulin injections, and Resident #98, who had severe cognitive impairment and impaired vision, was using the ophthalmic solution. The lack of open dates on these medications meant that staff could not determine when they should be discarded, potentially affecting their efficacy and safety. Additionally, on the Unit 2 East medication cart, an opened Humalog insulin pen for Resident #436 was also found without an open date. This resident had intact cognition and was taking hypoglycemic medication. Interviews with nursing staff and the pharmacist confirmed that insulin pens should be discarded 28 days after opening, and all open medications should have the open date documented. The Director of Nursing Services reiterated that nurses are responsible for ensuring proper labeling and storage of medications, and discontinued medications should be removed from the medication cart.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action - Resident #92: The opened [MEDICATION NAME] pen was immediately removed and replaced with a properly labeled pen reflecting the current date of opening. Medication administration was not interrupted, and the resident was not harmed. - Resident #98: The discontinued [MEDICATION NAME] Ophthalmic Solution was immediately discarded upon identification. Resident’s active medications were reviewed to ensure no expired or discontinued medications remained on hand. - Resident #436: The improperly labeled Humalog insulin pen was discarded, and a new insulin pen with a documented open date was initiated per physician order. Resident continued to receive timely insulin administration without clinical consequence. II. Identification of other residents - A facility-wide audit of all medication carts and medication storage areas was conducted on 3/21/2025 by the Director of Nursing (DON) and Unit Nurse Managers. - The audit focused on: All multi-dose vials, insulin pens, and ophthalmic solutions in use. Verification that each item was appropriately labeled with the date opened. Removal if any expired or discontinued medications are observed. - There were no negative findings from this review. III. Systemic Changes - The facility policy titled Storage of Medications was reviewed and found to be in compliance with the regulations. - All licensed nurses will be re-educated on the proper handling of open and/or expired medications including: All medications that require discarding within a specific time frame or shortened expiration dates once opened (e.g., 28 days after opening) must be labeled with the date opened upon first use. All discontinued medications must be removed from the cart or storage area immediately. A medication must not be used unless it is properly labeled. - A copy of the attendance sheet will be kept on file for validation. - The Pharmacy Consultant will reinforce labeling and storage requirements in monthly audits and report deficiencies in real time to the DON. IV. QA Monitoring - The RN Supervisor will conduct weekly medication cart and medication refrigerator audits for 4 weeks, verifying: - All opened medications have a clear, legible open date. - No expired or discontinued medications are present. - After 4 weeks of 100% compliance, audits will continue monthly for 3 months, then be reviewed for integration into routine quarterly pharmacy audits. - Results will be reported to the QAPI Committee monthly. Any trends in noncompliance will prompt immediate re-education and performance improvement plans. Responsible Party: Director of Nursing
Failure to Implement Pharmacist's Recommendations for Insulin Management
Penalty
Summary
The facility failed to ensure that irregularities reported by the Pharmacist were acted upon for a resident reviewed for unnecessary medications. Specifically, the attending Physician agreed to the Pharmacist's recommendations to evaluate sliding scale insulin coverage and decrease finger sticks for blood glucose readings for a resident, but these recommendations were not implemented. The facility's policy requires that recommendations from the Pharmacist be acted upon and documented, but this was not done in this case. The resident involved had severe cognitive impairment and was receiving insulin injections. The Pharmacist recommended discontinuing sliding scale insulin and reducing fingerstick orders, which the attending Physician initially agreed to. However, the Physician later decided not to implement these changes due to clinical reasons, including the resident's history of episodes of high and low blood sugar, recent start of an oral diabetic medication, and recent removal of enteral tube feeding. The Physician did not document their rationale for not implementing the recommendations in the resident's medical record. Interviews with facility staff revealed that the nursing supervisors were responsible for reviewing the Medication Regimen Review forms and contacting the attending Physician, but they could not recall reviewing the recommendations for the resident. The Medical Director and Director of Nursing Services stated that the attending Physician should have documented their rationale for not implementing the Pharmacist's recommendations. This lack of documentation and action led to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action The attending physician has reviewed the pharmacist’s Medication Regimen Review (MRR) recommendations dated 1/6/2025 and 2/5/2025 and provided retrospective clinical rationale for not implementing certain recommendations. II. Identification of other residents A facility-wide audit of all residents with pharmacist Medication Regimen Reviews completed within the past 90 days was initiated and completed on 3/30/2025. No negative findings resulted from this review. III. Systemic Changes The facility policy titled Medication Regimen Reviews was reviewed and found to be in compliance with the regulations. All providers will be educated on the requirement to follow through on agreed to pharmacist recommendations documented in the monthly Medication Regimen Review. The Director of Nursing (DON) or designee will verify that pharmacist recommendations are routed to the attending physician and that responses are tracked through a MRR Response Tracking Log. Attending physicians were provided written notification and guidelines reminding them of the regulatory requirement to act on pharmacist recommendations and document rationale if no change is made. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled Medication Regimen Reviews. Audits will be conducted monthly by the Medical Director for three months. The audit includes: Verification that the attending physician reviewed and responded to each pharmacist recommendation. Confirmation that any agreed-upon recommendations were implemented and documented in the resident’s medical record. Identification of any discrepancies or lack of documentation of physician rationale. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Medical Director
Failure to Timely Submit CHRC 105 Form for Non-Hired Employee
Penalty
Summary
The facility failed to submit a Criminal History Record Check (CHRC) 105 Form within the required 30-day time frame to the New York State Department of Health (NYSDOH) after receiving a negative determination letter for a prospective employee, identified as Employee #6. The facility received a Final Denial-b Letter from the NYSDOH on January 14, 2025, indicating that Employee #6 was not eligible for hire. However, the facility did not submit the necessary 105 Form to terminate Employee #6 from the CHRC system until February 14, 2025, which exceeded the 30-day requirement. The Human Resources Coordinator explained that the oversight occurred because Employee #6 was never hired and thus was not included in the facility's payroll system, which is used to generate weekly termination reports. This led to Employee #6 being overlooked in the termination process. The Administrator acknowledged that the Human Resources Coordinator should have submitted the 105 Form within the 30-day period following the receipt of the Final Denial-b Letter, as Employee #6 was never intended to be hired.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action For Employee #6, who received a Final Denial-B letter on 1/14/2025, the facility submitted the required CHRC 105 Form on 2/14/2025. Although delayed, the employee had no contact with residents, was not entered into the payroll system, and was never employed by the facility. The potential employee affected by the deficient practice had his Form 105E processed prior to the beginning of the recertification survey. The employee record has been updated to reflect the final CHRC action and the associated submission date to NYSDOH. The Human Resources Coordinator was counseled and received additional education regarding CHRC reporting timelines and the proper handling of applicants who are denied clearance but never hired. II. Identification of other employees CHRC records were reviewed and there were no other outstanding Final Denial Letters found. III. Systemic Changes The facility policy titled State Mandated Criminal History Record Check was reviewed and found to be in compliance with the regulations. The two facility Authorized Persons have been educated as to the requirement to take the necessary action when in receipt of a Final Denial Letter, within 30 days of receipt of the letter. IV. QA Monitoring An Audit Tool was developed to track compliance with the facility policy titled State Mandated Criminal History Check. This audit will be conducted by either of the Authorized Persons every other week. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Responsible person: Administrator
Failure to Ensure Proper Air Mattress Functionality for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for two residents. The first resident, who was admitted with a pressure ulcer and had a high risk for developing additional ulcers, was found to have an air mattress weight setting that did not correspond with their actual weight. This discrepancy was observed during a survey, and the Wound Care Registered Nurse acknowledged the mistake, stating that the correct weight setting is crucial for wound healing. The Director of Nursing Services confirmed that it is the responsibility of the nursing staff to ensure the air mattress settings are correct. The second resident, who was at risk for pressure ulcer development and acquired an unstageable pressure ulcer while in the facility, was found lying on an air mattress that was not plugged into a power outlet, rendering it non-functional. This was discovered during an observation, and the issue was rectified by plugging the mattress into the outlet. The Wound Care Registered Nurse and the Director of Nursing Services both stated that all nursing staff, including Certified Nursing Assistants, are responsible for ensuring that the air mattress is plugged in and functioning properly.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action Despite routine checks of functionality and of the adjustment knob by nursing staff, the air mattress setting was inadvertently not aligned with the resident’s current weight. Resident #123: The air mattress was immediately adjusted to match the resident’s actual weight of 95.6 lbs. Resident #50: The air mattress was immediately plugged into the power outlet and confirmed to be fully functional. Staff involved were re-inserviced on their responsibilities regarding equipment operation. Care plan and treatment orders were reviewed and reinforced. II. Identification of other residents A facility-wide audit of all residents with physician orders [REDACTED]. The audit included verification of: - Current weight settings vs. resident weight. - Functionality (power connection) of each air mattress. - Staff awareness regarding equipment monitoring. III. Systemic Changes A mandatory in-service training will be conducted for all licensed nurses and CNAs on: - Importance of matching air mattress settings to resident weight. - Daily functionality checks (including ensuring the mattress is plugged in and operating properly). - Documentation and escalation protocols if discrepancies are noted. The policy on Air Mattress was reviewed and found to be appropriate. A modification has been made whereby an Air Mattress Check q shift has been added to the Treatment Accountability Record (TAR), requiring a nurse signature. IV. QA Monitoring An audit tool was developed for all residents on air mattresses for: - Correct weight settings - Proper power/functionality - Accuracy of related documentation Audit results will be submitted to the Director of Nursing weekly. Any non-compliance identified will be addressed with immediate re-education and progressive disciplinary action if warranted. Audit frequency will be weekly for 1 month, monthly for 2 months until 100% compliance. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Person Responsible: Wound Care Coordinator
Failure to Administer Correct Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the correct treatment and services to prevent complications. Specifically, a resident was administered the wrong enteral formula, Glucerna 1.5, instead of the prescribed Glucerna 1.2. The bottle containing the enteral formula lacked a label with the resident's name, flow rate, and the time and date of administration, which is against the facility's policy. This oversight was observed during a survey, where it was noted that the feeding had been started the previous day and was leaking at the time of observation. The resident in question had a history of significant weight loss and was on a feeding tube, with a physician's order to change the formula to provide additional calories and protein. However, the nursing staff failed to update the feeding solution as per the new order. Interviews with the nursing staff revealed a lack of awareness regarding the change in the feeding solution order, although they were aware of the change in flow rate. The Director of Nursing Services confirmed that the tube feeding bottle should have been labeled correctly, and the nurses were expected to verify the physician's orders before administration.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action The incorrect tube feeding formula (Glucerna 1.5) on Resident #123 was identified. The correct formula (Glucerna 1.2) as per the physician's updated order dated 3/13/2025 was initiated. The licensed nurse responsible for the deficient practice was identified and received disciplinary action. The resident's weight, tolerance to feeding, and nutritional intake were reassessed by the interdisciplinary team, including the Registered Dietitian and primary care provider. II. Identification of other residents A comprehensive audit was initiated and completed for all residents receiving enteral nutrition to: - Verify that the formula being administered matches the most current physician order. - Ensure that all enteral feeding containers are clearly labeled with resident identifiers, prescribed formula, flow rate, and time of administration. No negative findings were identified from this review. III. Systemic Changes The Enteral Nutrition Administration policy was reviewed and revised to reinforce: - The requirement that nurses must verify both the formula and flow rate against the physician’s most current order before administering or hanging tube feedings. - Mandatory labeling of every tube feeding bottle with the resident’s name, formula, flow rate, and time started. Mandatory in-service training will be conducted for all licensed nursing staff, focusing on: - Interdisciplinary communication related to order changes (e.g., from dietary to nursing). - Proper verification of tube feeding orders and documentation procedures. - Risks of administering incorrect formulas (e.g., weight loss, aspiration, metabolic imbalance). Nursing shift-to-shift handoff documentation was revised to include a checklist for enteral nutrition administration, including verification of the formula, rate, and labeling compliance. IV. QA Monitoring A Tube Feeding Audit Tool has been developed and will be utilized by the RN Supervisor or Designee as follows: - Weekly audits for four weeks to verify accurate formula administration, proper labeling, and correct documentation. - Thereafter, audits will be conducted monthly for three months or until sustained compliance is achieved. Audit results will be reported to the Director of Nursing. Staff found non-compliant will receive immediate re-education and may be subject to progressive disciplinary measures as needed. The Director of Nursing will continue to oversee adherence to the enteral nutrition protocols as part of ongoing performance improvement. Audit findings will be presented to the QAPI Committee during the quarterly meeting for review and determination of whether to continue with the audits. Responsible Party: Director of Nursing
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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