Loretto Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Syracuse, New York.
- Location
- 700 East Brighton Avenue, Syracuse, New York 13205
- CMS Provider Number
- 335136
- Inspections on file
- 22
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Loretto Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with metastatic cancer, heart failure, malnutrition, and multiple existing pressure ulcers was readmitted from the hospital with detailed wound care orders and documented wounds to the sacrum, coccyx, buttock, heels, feet, ankle, and leg. On readmission, nursing documented only "impaired skin" without a full skin assessment in the Skin and Wound module, and physician orders addressed only the sacral wound VAC and heel offloading, omitting treatments for other documented ulcers. Over subsequent days, multiple electronic "Skin Issue" notes showed numerous skin areas "not evaluated," some of which were later disavowed by the RNs listed as authors, and the comprehensive care plan reflected only potential, not actual, skin impairment. Later weekly and post-hospital assessments documented numerous unstageable and Stage 4 pressure ulcers, but treatment orders were obtained for only some of these wounds, with no documented physician orders for several identified areas, including certain ankle, toe, thigh, and amputation-site ulcers. Interviews with RNs and the DON confirmed that facility policy required a head-to-toe skin assessment and Braden Scale within 24 hours of admission/readmission and same-day wound treatment orders, but in this case, assessments and documentation were incomplete and treatment orders were missing or delayed for multiple pressure ulcers.
Multiple failures were observed in maintaining a clean and safe environment, including dirty linens and soiled briefs left in resident rooms, stained ceiling tiles and privacy curtains, unclean window shades, and a soiled wheelchair. Staff interviews revealed inconsistent cleaning practices and unclear responsibilities for maintaining cleanliness and infection control in resident areas and equipment.
Surveyors identified that food was frequently served cold, bland, or overcooked, with test trays showing improper temperatures and lack of flavor. Multiple residents reported dissatisfaction with meal quality, and staff interviews confirmed ongoing complaints about food temperature and palatability. Facility policies required regular audits and proper food handling, but food preparation and delivery practices led to inconsistent results.
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records by posting detailed identifying information in public areas. Staff confirmed that this practice violated resident rights and HIPAA regulations.
The facility failed to ensure residents were informed about the grievance process, including the ability to file anonymous grievances. Eleven residents were unaware of the grievance officer and the process for filing grievances, leading to a deficiency in honoring residents' rights.
The facility failed to ensure proper labeling and storage of medications, including unlabeled nicotine patches, expired medications, insulin without open dates, and personal food items stored with medications. Additionally, a medication room refrigerator had significant ice buildup, affecting proper medication storage.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Pantry storage areas were soiled with food spills, and refrigerators were not cleaned. Additionally, the main kitchen tray line had cold food tables with food items at improper temperatures, and the Food Service Supervisor admitted that temperatures were not checked consistently.
The facility failed to ensure a safe, clean, and comfortable environment for residents in 6 of 14 units. Issues included overflowing laundry, dirty bathrooms, broken equipment, pest control problems, and unclean water/ice machines. Staff reported laundry and cleaning backlogs due to staffing issues, leading to undignified conditions for residents.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical and nursing needs. One resident with nicotine dependence was observed smoking outside without appropriate interventions in their care plan. Another resident with hemiplegia was observed without necessary pressure reduction devices, and a third resident with diabetes and stroke was seen without required pressure reducing boots.
The facility failed to ensure residents received necessary services for personal care and hygiene, leading to issues such as unkempt hair, excessive facial hair, unkept fingernails, poor meal positioning, and missed showers. Multiple residents reported discomfort and inadequate care, which was corroborated by staff interviews and observations.
The facility failed to ensure that residents received food and drink at palatable and safe temperatures. Observations and interviews revealed that cold food items on test trays were above the required temperature, making them unpalatable. Staff acknowledged the issues, and the facility's policy on food temperature control was not followed.
A resident with hemiplegia was unable to use the cold water in their bathroom sink due to the sink's placement and their physical limitations. Staff confirmed the resident's difficulty, and the facility's management acknowledged the issue, stating that all residents should have access to both hot and cold water for activities of daily living.
A resident with chronic obstructive pulmonary disease and respiratory failure experienced social isolation due to the facility's failure to consistently refill their portable oxygen tank. Despite policies requiring certified nurse aides to fill the tanks every shift, the task was often neglected, leading to the resident being confined to their room and missing activities and appointments.
The facility failed to conduct annual performance reviews for two certified nurse aides who had been employed for over 12 months. Interviews with staff revealed inconsistencies and a lack of clarity regarding the evaluation process, leading to the deficiency.
A resident with severe cognitive impairment and behavioral symptoms due to Alzheimer's disease was not provided with preferred person-centered activities. Despite the care plan's emphasis on specific music and activities, the resident was often left alone in their room with inappropriate music or no stimulation, leading to episodes of yelling and anxious restlessness. Staff interviews revealed inconsistent understanding and implementation of the care plan.
The facility failed to ensure resident dignity and hygiene for two residents. One resident was left in soiled sheets and vomit for hours despite activating the call bell, while another resident was observed with unshaven stubble, greasy hair, and an overflowing bag of dirty clothes in their room. Staff interviews confirmed that these conditions were undignified and that call bells were often not answered timely.
A resident with chronic conditions did not have an active discharge plan and was not included in care plan meetings, despite expressing interest in a lateral transfer to local nursing facilities. The facility failed to follow up on the transfer request and did not communicate the status to the resident.
The facility failed to provide adequate supervision and a safe environment for two residents. One resident fell due to unlocked bed brakes, and another resident with a history of inappropriate behaviors roamed unsupervised. Care plans and interventions were not consistently followed, leading to preventable incidents.
A resident with Alzheimer's disease and osteoarthritis did not receive adequate pain management following a fall that resulted in a hip fracture. Despite complaints of pain, there was no documented evidence of pain evaluation or management from the time of the fall until the resident was sent to the hospital. Staff interviews revealed that the nurses did not contact the provider for pain medication orders, and the family was not properly informed about the resident's condition.
The facility failed to ensure that three LPNs had the necessary competencies and skills to care for residents, as evidenced by incomplete online training, lack of annual competencies, and missing documented orientation competencies. A resident reported improper ostomy care, and staff confirmed the lack of ongoing education and competency testing.
A resident with Alzheimer's disease and osteoarthritis experienced a fall and had x-rays ordered for their left knee and hip. The x-ray results, indicating a minimally displaced fracture, were not promptly communicated to the medical provider. The delay in notification resulted in the resident experiencing pain and the family being unaware of the injury until they inquired about the results two days later.
Failure to Assess and Treat Multiple Pressure Ulcers on Readmission
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident with multiple pressure ulcers received timely and complete assessment and treatment consistent with professional standards and facility policy. The resident was readmitted from the hospital with several documented pressure ulcers and specific wound care recommendations, including treatment to the sacrum, buttock, both feet, and leg wounds, as well as use of a wound VAC to the sacrum. The hospital discharge summary and the facility’s own readmission packet listed multiple pressure ulcer locations, including both heels, right lateral foot, left ankle, sacrum, coccyx, and left buttock. However, on admission, the RN admission assessment only documented “impaired skin” with a direction to see Skin and Wound for updates, and there was no documented skin assessment in the Skin and Wound section. Physician orders on readmission addressed only the sacral wound VAC and heel offloading boots, with no documented treatment orders for the other pressure ulcers identified in the hospital records and readmission packet. In the days following readmission, the electronic record contained multiple “Skin Issue” notes indicating that 25 skin issues were “not evaluated,” and several of these notes were later disavowed by the RNs whose names appeared on them. The facility’s Skin and Wound policy required pressure injury risk assessment and documentation upon admission/readmission, weekly for three weeks, and then quarterly or with changes in condition, and required that all residents with pressure injuries on admission be documented in the Skin and Wound module and reported to the provider or wound nurse. Despite this, there was no evidence that all of the resident’s wounds were assessed and entered into the Skin and Wound module upon readmission, and the comprehensive care plan only reflected a potential for skin integrity alteration, without documenting the resident’s actual existing pressure ulcers. The DON later confirmed that they did not see any wound pictures from the admission date and that they expected a full head-to-toe assessment and Braden Scale within 24 hours, with corresponding treatments and interventions. On 12/05/2025, a weekly wound assessment documented eight unstageable pressure ulcers and moisture-associated skin damage, including unstageable wounds with 100% eschar on the left heel, right 5th toe, right rear ankle, and right lateral ankle, as well as large gluteal and buttock wounds. Physician orders obtained that day addressed only the left buttock and a right rear hip blister, with no documented treatment orders for the right lateral ankle, right rear ankle, or right 5th toe. After a subsequent hospitalization, the resident returned on 12/16/2025 with documentation of 10 pressure ulcers, including unstageable wounds on both 5th toes, both heels, left rear ankle, right ankle amputation site, and left buttock fold, and Stage 4 pressure ulcers on the sacrum and right buttock. Physician orders dated 12/17/2025 implemented treatments for the heels, left and right buttock, and sacrum, but there was no documented evidence of treatment orders for the right rear thigh blister, unstageable right ankle amputation site, unstageable left rear ankle, or unstageable right and left dorsum 5th toes. Interviews with nursing staff and the DON confirmed that facility expectations were for skin assessments within 24 hours of admission/readmission and same-day implementation of wound treatments, but in this case, assessments were incomplete or not documented, and treatment orders were missing or delayed for multiple documented pressure ulcers. The resident’s clinical profile included kidney cancer with metastasis, heart failure, and malnutrition, and the most recent MDS prior to these events documented intact cognition, partial/moderate assistance needs for mobility, and existing unstageable pressure ulcers, a deep tissue injury, and moisture-associated skin damage. Despite this high-risk profile and the facility’s own policy requiring Braden Scale assessments and care plan interventions based on risk, the comprehensive care plan did not reflect the resident’s actual pressure ulcers, and there was no evidence that all wounds were entered into the Skin and Wound module or that weekly evaluations and complete treatment orders were consistently obtained. Nursing staff reported issues with the new Skin and Wound electronic application and uncertainty about why orders were not obtained for all wounds, while also acknowledging that treatments should have been ordered for all identified pressure areas during their assessments. The DON stated that for every pressure ulcer beyond Stage 1, the wound nurse and wound provider were to be involved and monitor weekly, but the documentation reviewed by surveyors showed gaps in assessment, documentation, and timely ordering of treatments for several of the resident’s pressure ulcers at multiple points in time.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment across several resident units. Observations included dirty linens and a soiled brief left on the floor next to a resident's bed, stained ceiling tiles, and unclean privacy curtains in resident rooms. In one instance, a resident's family reported frequently seeing soiled briefs on the floor and dirty linens on the overbed table. Staff interviews confirmed that soiled linens and incontinence products should not be left on the floor, as this poses a contamination and infection control issue, but acknowledged that such items had been found and removed in the past. Additional deficiencies were observed in the maintenance and cleanliness of resident areas and equipment. Stained ceiling tiles were noted in multiple rooms, with maintenance records showing repeated tile replacements due to recurring leaks. Privacy curtains were found to be soiled, and documentation of their cleaning was inconsistent or missing. In one lounge area, bed components and electrical items were left scattered, and staff acknowledged that repairs should not have been conducted in resident areas. Window shades with visible stains were reported by a resident, who expressed embarrassment about their condition, and there was no record of cleaning or replacement for these items. Wheelchair cleanliness was also found to be lacking, with one resident's wheelchair armrests observed to be soiled with food particles. Staff interviews revealed confusion about cleaning responsibilities and schedules, with some staff believing cleaning was the responsibility of the night shift, while others stated that all staff were expected to clean dirty wheelchairs when noticed. Housekeeping logs and schedules for deep cleaning and wheelchair maintenance were inconsistent, and there was a lack of clear documentation regarding the cleaning or replacement of soiled items.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service. During the survey, test trays from two lunch meals were evaluated and found to have food items that were either not flavorful, overcooked, or served at improper temperatures. Specifically, hot foods such as pot roast and potatoes were sometimes below the recommended temperature, while cold items like juice and gelatin were above the safe cold temperature range. Residents at a council meeting reported that food was often cold, overcooked, and not palatable. Observations and interviews with staff confirmed that residents frequently complained about the quality and temperature of the food, and that alternate meals were sometimes provided when complaints were made. The facility's policies required that meals be nourishing, palatable, and served at safe and appetizing temperatures, with regular audits and test trays to monitor compliance. However, interviews revealed that food was prepared in advance, sometimes up to five days, and reheated on the units, which may have contributed to temperature inconsistencies. Staff acknowledged that food sometimes appeared overcooked or dry, and that delays in tray delivery and issues with food positioning on plates could affect temperature. Documentation and staff statements indicated that test tray temperatures were sometimes out of range, and that flavor and presentation were not consistently maintained.
Violation of Resident Privacy and Confidentiality
Penalty
Summary
The facility did not ensure the privacy and confidentiality of residents' personal and medical records for eight residents. Specifically, personal identifying information for these residents was posted in public areas on multiple floors, including dining rooms and near kitchen areas. The information included details such as room numbers, names, lab information, primary payor, bed status, diet, diet and liquid texture, and aspiration risks. These postings were observed on several occasions during the survey period, and the information was visible to anyone in those areas. Interviews with various staff members, including registered nurses, the Director of Social Work, the Director of Nursing, and the Director of Health Information, confirmed that the posted information was a violation of resident rights and the Health Insurance Portability and Accountability Act (HIPAA). Staff acknowledged that the information should have been covered and only accessible to authorized personnel. Despite annual and orientation training on HIPAA, the facility's practice of posting detailed resident information in public areas was not compliant with privacy regulations.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility did not ensure that information on filing grievances was available to residents, as evidenced by the statements of 11 anonymous residents during a Resident Council meeting. These residents were unaware of who the grievance officer was and did not know they could file grievances anonymously. The facility's policy stated that residents would be informed of their right to file grievances at admission and that this information would be posted throughout the facility. However, the residents reported that they were told to report concerns to their social worker and did not always receive follow-up on their grievances. Additionally, the compliance officer's contact information was not documented on the posted signs, and the residents were not aware of the process for filing anonymous grievances. Interviews with the Director of Nursing, Director of Social Work, and the Administrator revealed inconsistencies and gaps in the grievance process. The Director of Nursing stated that grievances could be filed through various means, including anonymously, but the residents were not aware of these options. The Director of Social Work was unaware of a process for filing anonymous grievances, and the Administrator believed that the compliance officer's number was in the resident handbook, but this information was not readily accessible to the residents. These findings indicate a failure to properly inform and facilitate the grievance process for residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
Deficiencies in Medication Labeling and Storage
Penalty
Summary
The facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles. Specifically, the medication cart on Unit 3 had nicotine patches without resident labels, and Unit 4 had expired medications. Unit 8 had insulin without a labeled open date, and Unit 10 had inhalers not in the correct pharmacy box and without labeled open dates, as well as unlabeled eye medications. Additionally, Unit 13 had personal food items stored with resident medications, and the medication room on Unit 5 had a refrigerator with significant ice buildup. During observations and interviews, it was found that the nicotine patch on Unit 3 was not labeled, which could lead to medication errors. On Unit 13, a glazed donut was found stored in the medication cart, which was confirmed by the Unit Manager to be inappropriate. Unit 4 had three bottles of expired medications, and the LPN confirmed that these should have been checked and removed. Unit 8 had two vials of open insulin without labeled open dates, and the LPN acknowledged the importance of knowing the open date for effectiveness. Further observations revealed that Unit 10 had two inhalers and other medications without labeled open dates, which should have been discarded due to the lack of labeling. The medication room on Unit 5 had a refrigerator with significant ice buildup, and the temperature logbook indicated that the refrigerator was not maintained within the required temperature range. The RN Unit Manager confirmed the importance of maintaining appropriate temperatures for medication storage.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in four of fourteen food preparation and pantry storage areas and in the main kitchen. Specifically, the pantry storage areas on multiple units were soiled with food spills, and the refrigerators were not cleaned of food debris and spills. Observations revealed that the coolers and refrigerators in these areas had old food spills, sticky floors, and visibly soiled surfaces. The Director of Housekeeping stated that the housekeeping staff and Nurse Manager were responsible for keeping these areas clean, but the required cleanliness was not maintained. Additionally, the main kitchen tray line had cold food tables with food items at temperatures ranging from 40 to 55 degrees Fahrenheit, which did not meet the facility's policy requirement of 45 degrees or lower. The Food Service Supervisor admitted that the temperatures of the food items were not checked consistently throughout the day, and several food items were found to be out of the acceptable temperature range. The food items, including chicken, pears, pureed burger, pureed hot dog, ground hot dog, ground chicken, American cheese, and pureed macaroni and cheese, were all intended for meal service but were not within the acceptable temperature ranges, indicating a failure in maintaining proper food safety standards.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 14 resident units reviewed. On Unit 3, room conditions included overflowing laundry bags, visibly dirty bathrooms with strong urine odors, and sticky floors. Residents reported a lack of staff to wash clothes, leading to dirty laundry piling up and causing odors. Certified nurse aides confirmed that laundry was often backed up due to staffing issues, resulting in residents wearing the same clothes for multiple days, which was not dignified and could lead to infection or fall risks. On Unit 4, room conditions included an unsecured alternating pressure mattress machine due to a missing hook and a missing ceiling tile. Despite work requests being submitted, these issues remained unresolved for weeks. Housekeeping staff were responsible for cleaning resident rooms but did not recall any missing or broken ceiling tiles. On Unit 11, observations included broken windowsills, brown matter smeared on walls, sticky floors, and urine odors. Staff interviews revealed that both housekeeping and nursing staff were expected to clean any messes they saw, but there was a lack of clarity on who was responsible for specific tasks. Pest control issues were observed on Units 4 and 10, with fruit flies present in dining areas and resident rooms. Additionally, water/ice machines on Units 8 and 13 were found to have dried white matter, active leaks, and build-up, despite maintenance staff claiming they were cleaned recently. These deficiencies indicate a failure to maintain a safe, clean, and comfortable environment for residents, as required by facility policies and state and federal regulations.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in meeting their medical and nursing needs. Resident #201, who had a history of nicotine dependence, was observed smoking outside the facility grounds multiple times. Despite the facility's tobacco-free policy, no interventions were added to the resident's care plan following these incidents. The resident's care plan lacked specific interventions for nicotine dependence, and there were no documented assessments or sign-out sheets for the resident's off-unit activities, raising concerns about their safety and compliance with facility policies. Resident #62, who had diagnoses including stroke with hemiplegia and chronic obstructive pulmonary disease, was observed multiple times without the necessary pressure reduction booties, positioning pillow, or palm guard as outlined in their care plan. The resident reported that the pressure reduction booties had been removed from their room several months ago and had not been replaced. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan, which could lead to potential skin breakdown and discomfort for the resident. Resident #150, who had diagnoses including diabetes and stroke, was observed out of bed in their wheelchair without the required pressure reducing boots or LNard boots. Despite the care plan and physician orders specifying the use of these boots to prevent pressure ulcers, the resident was seen wearing only nonskid socks. Staff interviews indicated a lack of awareness and adherence to the care plan, with discrepancies between the care plan and the actual care provided. This failure to follow the care plan could result in the resident developing pressure ulcers, which the boots were intended to prevent.
Deficiencies in Personal Care and Hygiene for Residents
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, ten residents were observed with various deficiencies in personal care. For example, Resident #62 had unkempt hair, excessive facial hair, and unkept fingernails, while Resident #117 had unkept fingernails. Resident #124 had greasy hair, excessive facial hair, and unkept fingernails, and Resident #150 remained in bed due to mechanical lift battery issues and was poorly positioned for meals. Additionally, Resident #133 was frequently observed poorly positioned in bed for breakfast meals, leading to difficulties in eating and potential aspiration risks. The resident expressed that staff often did not have time to properly position them for meals, which was corroborated by multiple observations and interviews with staff members who acknowledged the issue but did not consistently address it. Resident #215 was not toileted as planned and had excessive facial hair, while Resident #305 was not toileted for over five hours. Resident #325 had greasy hair and was not toileted as planned. Resident #384 and Resident #414 did not receive showers as planned, with Resident #414 also having excessive facial hair. These observations were supported by interviews with the residents and staff, as well as a review of the facility's policies and care plans. For instance, Resident #124, who had diagnoses including epilepsy and contractures of both hands, was observed with greasy hair and long, sharp fingernails despite the care plan indicating they should receive regular grooming and personal hygiene assistance. The resident expressed discomfort due to the lack of grooming, which was not adequately addressed by the staff. Resident #384, who had diagnoses including hemiplegia and diabetes, reported not receiving a scheduled shower and experiencing a strong smell of urine in their room. The resident's call light was not answered for nearly an hour, and there were multiple instances of emesis in the room that were not promptly cleaned. Interviews with staff revealed inconsistencies in providing scheduled showers and addressing residents' hygiene needs. The facility's policies on personal hygiene, meal service, and activities of daily living were not consistently followed, leading to deficiencies in the care provided to the residents.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility did not ensure that residents received food and drink that were palatable, flavorful, and at an appetizing temperature. During the recertification and abbreviated surveys, it was observed that cold food items on test trays were not within the required temperature parameters. Specifically, on two separate occasions, cold food items such as pureed coleslaw, pureed pasta salad, vanilla milkshake, juice, and salad were found to be above the required temperature of 41 degrees Fahrenheit, making them unpalatable. Additionally, a fish sandwich was observed to be dried out and not flavorful. Interviews with residents and staff confirmed the issues with food quality and temperature. One resident stated that lunch and dinner meals did not taste good, while the Director of Food Services and the Director of Clinical Nutrition acknowledged that the cold food items were not within acceptable temperature ranges and were not palatable. The facility's policy on food temperature control and correction was not adhered to, as evidenced by the infrequent test trays and the prolonged meal service time of 2-2.5 hours, which likely contributed to the temperature issues.
Failure to Accommodate Resident's Needs
Penalty
Summary
The facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for a resident with hemiplegia affecting the dominant side. The resident, who was cognitively intact and required substantial assistance with activities of daily living, was unable to use the cold water in their bathroom sink due to the sink's placement and the resident's physical limitations. The bathroom entrance was narrow, making it difficult for the resident to enter using a wheelchair, and the cold water handle was positioned too close to the wall, making it inaccessible for the resident who was paralyzed on the right side. Staff interviews revealed that the resident was recently moved to a new room where they could not use the cold water in the bathroom sink. Both the LPN and CNA confirmed the resident's difficulty in using the bathroom due to the sink's placement and the resident's paralysis. The Unit Manager and the Director of Nursing acknowledged the issue, stating that all residents should have access to both hot and cold water for activities of daily living. An occupational therapist also confirmed the resident's inability to use the right side and the need for accommodations to use the sink effectively.
Failure to Provide Portable Oxygen Leads to Resident Isolation
Penalty
Summary
The facility did not ensure that Resident #429 was free from involuntary seclusion, as the resident reported feelings of social isolation due to not being allowed to leave their room to attend activities, have meals in the dining room, or socialize with peers and family. This was because their portable oxygen tank was empty and was not refilled. The facility's policy on Resident Abuse Reporting prohibited mistreatment, neglect, or abuse, including involuntary seclusion of residents. The policy on Portable Liquid Oxygen System required certified nurse aides to monitor the delivery of oxygen therapy and fill portable cylinders from the base unit when empty. However, this was not consistently done for Resident #429, leading to their isolation in the room. Resident #429, who was admitted with chronic obstructive pulmonary disease and respiratory failure with hypoxia, required oxygen at 4-6 liters via nasal cannula to maintain oxygen levels of 90% or greater. The resident's care plan included the use of a concentrator out of the room and participation in therapeutic activities. Despite this, observations revealed that the resident often had an empty portable oxygen tank and had to stay hooked to the wall oxygen, preventing them from attending morning activities and other engagements. The resident expressed frustration and upset over missing activities and appointments due to the lack of filled portable oxygen tanks. Interviews with staff confirmed that the responsibility of filling portable oxygen tanks was assigned to certified nurse aides on every shift, but this task was not always completed due to short staffing and other reasons. Staff acknowledged that when portable tanks were empty, residents like Resident #429 were confined to their rooms and missed out on activities and appointments. The Director of Nursing stated that all staff were trained on filling portable tanks and expected this to be done every shift, but acknowledged that residents being unable to leave their rooms due to lack of portable oxygen constituted isolation.
Failure to Conduct Annual Performance Reviews for Certified Nurse Aides
Penalty
Summary
The facility failed to ensure that certified nurse aides had their performance reviews completed once every 12 months, as required. Specifically, certified nurse aides #20 and #21, who had been employed for more than 12 months, did not have documented evidence of annual performance evaluations. The facility's policy required supervisors and managers to monitor personnel compliance and conduct annual performance evaluations, but this was not adhered to in these cases. The Administrator confirmed that the evaluations were not completed, and the Unit Managers and Assistant Director of Nursing were identified as responsible for these evaluations. Interviews with various staff members, including the Unit Manager, Assistant Director of Nursing, Director of Nursing, and Chief People Officer, revealed inconsistencies and a lack of clarity regarding the evaluation process. The Unit Manager could not recall the date of the last evaluation for certified nurse aide #20 and had no access to previous evaluations for comparison. Certified nurse aide #20 confirmed they had never received an annual evaluation. The Director of Nursing and Chief People Officer provided conflicting information about the evaluation process and responsibilities, further highlighting the facility's failure to ensure proper performance reviews were conducted and documented as required by regulations.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, Resident #158, who had severe cognitive impairment and behavioral symptoms due to Alzheimer's disease, was not provided with preferred person-centered activities. The resident's care plan included interventions such as listening to specific types of music, engaging in one-to-one activities, and participating in group activities when possible. However, these interventions were not consistently implemented, as evidenced by multiple observations of the resident being left alone in their room with inappropriate music playing or no stimulation at all. The resident's activity records showed minimal engagement in both group and individual activities, despite the care plan's emphasis on these interventions. The resident's family and staff interviews revealed that the resident enjoyed specific types of music and activities, such as blues and jazz music, playing the harmonica, and participating in spiritual programs. However, the resident was often found in their room with new age rap music playing, which they did not like, or with no music or TV on at all. This lack of appropriate stimulation likely contributed to the resident's episodes of yelling and anxious restlessness. Staff interviews indicated a lack of consistent understanding and implementation of the resident's care plan. Certified nurse aides and licensed practical nurses acknowledged that the resident did better in group settings and enjoyed specific types of music, yet the resident was frequently left alone in their room. The social worker and unit manager also noted that the resident should be engaged in activities as much as their behavior allowed, but this was not consistently practiced. The facility's failure to provide appropriate person-centered activities and stimulation for Resident #158 resulted in unmet needs and behavioral symptoms that were not adequately addressed.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility did not ensure each resident was treated with respect and dignity in a manner that promoted maintenance or enhancement of their quality of life for two residents. Resident #384, who was admitted with diagnoses including hemiplegia, obesity, and diabetes, was found in bed with soiled sheets and vomit on their tee shirt. Despite the resident's call bell being activated at 7:30 AM, it was not answered until 8:22 AM. The LPN who responded cleaned the floor but did not clean the resident or change the soiled bed sheets. The resident remained in the soiled bed until 3:13 PM when the sheets were finally changed, but the resident was still not washed up and expressed a desire for a shower. Interviews with staff confirmed that the call bells were often not answered timely and that it was undignified to leave a resident in such a condition. Resident #414, admitted with diagnoses including heart disease and central retinal vein occlusion, was observed multiple times with unshaven stubble, greasy hair, and wearing the same clothes for consecutive days. The resident's room was consistently found with an overflowing bag of dirty clothes, a sticky floor, and a smell of urine. The resident expressed a desire for a shower and clean clothes, stating that their shower day was often moved for staff convenience. Interviews with staff revealed that laundry was picked up only twice a week, leading to a backlog of dirty clothes in the resident's room. The CNA assigned to the resident confirmed that the resident did not refuse care and that the laundry backlog and lack of personal hygiene were undignified. The Director of Nursing stated that call bells should be answered within five minutes and that it was unacceptable for residents to remain in soiled conditions. They also confirmed that laundry backlogs could lead to odors and were not dignified. The facility's failure to promptly address the residents' personal hygiene and environmental cleanliness needs resulted in a lack of dignity and respect for the residents involved.
Failure to Develop and Implement Discharge Plan
Penalty
Summary
The facility failed to ensure the discharge needs of Resident #429 were identified and resulted in the development of a discharge plan. Resident #429, who was admitted with chronic obstructive pulmonary disease, respiratory failure with hypoxia, and diabetes, did not have an active discharge plan despite expressing interest in a lateral transfer to local nursing facilities. The resident was not updated on the status of the lateral transfer request and was not invited to participate in the development of a person-centered care plan. The facility's policies on discharge planning and comprehensive care planning were not followed, as the resident and their family were not included in care plan meetings, and there was no documented evidence of an active discharge plan from August 2023 through February 2024. The social worker's progress notes indicated that a referral for a lateral transfer was made in June 2023, and the resident was placed on a waiting list, but there was no follow-up on the status of the waiting list. The resident's quarterly care conferences did not include the resident or their family, and there was no documentation of a discharge plan. The social worker assigned to the resident was new and unaware of the discharge plan, which contributed to the lack of follow-up and communication with the resident regarding their discharge status. Interviews with the resident and facility staff revealed that the resident had been in the facility for one year and had never been invited to a care plan meeting to discuss their discharge. The resident expressed frustration about not being informed about the status of their lateral transfer request and not being included in care plan meetings. The Director of Social Work acknowledged that follow-up on the discharge plan should have occurred but did not due to the social worker being new. The resident also mentioned that they were told by the facility that they were no longer eligible for a transfer due to insurance reasons, further complicating their discharge planning process.
Inadequate Supervision and Accident Hazards
Penalty
Summary
The facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible for two residents. Specifically, one resident was found on the floor between their bed and the wall due to the bed brakes not being locked. The resident had severe cognitive impairment, was totally dependent for bed mobility, and had a history of falls. The incident report and staff statements indicated that the bed was in the lowest position but not locked, leading to the resident falling out of bed. The care plan did not specify the position of the bed or the placement of the fall mat, and there was no documentation to ensure the bed was locked when the resident was in it. The staff involved were re-educated, but the incident was deemed avoidable due to a care plan violation and policy violation regarding the bed brakes not being locked. Another resident with severe dementia and a history of sexually inappropriate behaviors was allowed to propel their wheelchair independently throughout the facility without an adequate supervision plan. The resident had multiple documented incidents of inappropriate touching of other residents and frequently left their unit without notifying staff. The care plan included interventions to not seat the resident near female residents during meals or activities, but these interventions were not consistently followed. Staff interviews revealed that the resident was often off the unit and difficult to track, and there was a lack of communication and monitoring of the resident's behaviors across different units. The resident's care plan interventions were not enforced throughout the facility, leading to inadequate supervision and potential safety risks for other residents. The facility's policies on resident abuse reporting, adverse incident management, and fall risk evaluation were not effectively implemented. The lack of consistent documentation, communication, and adherence to care plan interventions contributed to the deficiencies observed. The facility failed to provide a safe environment and adequate supervision for the residents, resulting in preventable incidents and potential harm.
Inadequate Pain Management for Resident Following Fall
Penalty
Summary
The facility failed to provide adequate pain management for Resident #168 following a fall that resulted in a hip fracture. Despite the resident's complaints of pain in the left hip and knee, there was no documented evidence that the resident's level of pain was evaluated or that pain management was provided from the time of the fall on 12/23/2023 until the resident was sent to the hospital on 12/25/2023. The facility's policy required ongoing pain assessments and management, but this was not adhered to in the case of Resident #168, who had diagnoses including Alzheimer's disease, weakness, and osteoarthritis. Interviews with staff and the resident's family revealed that the resident's pain was not adequately addressed. The family was not properly informed about the resident's condition, and the nurses did not contact the provider for pain medication orders despite the resident's complaints of pain. The Director of Nursing confirmed that the nurses should have called the medical provider to obtain orders for pain medication, but this was not done. The physician also stated that there was no note from a provider that pain medication was requested by nursing.
Deficiency in Nurse Competency and Training
Penalty
Summary
The facility did not ensure that licensed nurses had the specific competencies and skills necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. Specifically, three licensed practical nurses (LPNs) did not have timely online training, annual competencies, or documented orientation competencies completed. LPN Unit Manager #4 had several online trainings completed after their due dates, and both LPN Unit Managers #4 and #33, as well as LPN #34, did not attend the competency/skills fair in 2023. Additionally, LPN Unit Managers #4 and #33 did not have documented competencies from orientation. This lack of training and competency documentation was confirmed through interviews with staff and review of facility records. A resident expressed concerns that nurses did not know how to change their ostomy appliances properly, often using multiple appliances per change, which could lead to wastage. An LPN also stated they had never received education for ostomy or wound care in the facility. Another LPN mentioned that they only signed a paper monthly with in-service topics but did not receive ongoing skill competencies after their initial hire. The Director of Nursing (DON) and other staff confirmed that annual competencies were mandatory and tracked by the education department. The DON stated that nursing staff should be pulled off the schedule if they had not completed their annual competencies. However, the DON was unaware that the three LPNs in question had not completed their required competencies. The facility's policy required all certified nurse aides and licensed nurses to be competency tested annually, but this was not adhered to in these cases.
Failure to Promptly Notify Medical Provider of X-ray Results
Penalty
Summary
The facility did not ensure the medical provider was promptly notified of radiology results for a resident who had fallen and required x-rays. Specifically, the resident had an x-ray ordered for their left knee and hip after a fall, which was completed on the same day. However, the results indicating a minimally displaced fracture of the left femoral neck were not communicated to the medical provider in a timely manner. The results were available in the electronic medical record but were not followed up on by the nursing staff until two days later when the resident's family inquired about the x-ray results. The resident, who had diagnoses including Alzheimer's disease, weakness, and osteoarthritis, experienced a fall after being pushed by another resident. Despite the x-ray being completed and the results being available, the nursing staff did not notify the medical provider or follow up on the results promptly. The delay in communication resulted in the resident experiencing pain and the family being unaware of the severity of the injury until they visited the resident and inquired about the x-ray results. Interviews with the nursing staff and the Director of Nursing revealed that there was an expectation for nurses to follow up on x-ray results within 30 to 45 minutes after the x-ray was completed. However, there was no specific policy in place to ensure this follow-up occurred. The failure to promptly notify the medical provider of the x-ray results led to a delay in the resident receiving appropriate medical attention for their hip fracture.
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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