Maria Regina Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Brentwood, New York.
- Location
- 1725 Brentwood Road, Brentwood, New York 11717
- CMS Provider Number
- 335837
- Inspections on file
- 15
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maria Regina Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility did not update its Emergency Preparedness Plan annually as required. The last update was in October 2022, and the plan still listed former personnel as the Administrator and Director of Building Services. The current Administrator, who started in 2024, confirmed the plan had not been updated since their tenure began.
The facility did not provide complete records of fire alarm system inspections and smoke detector sensitivity tests during a Life Safety Code recertification survey. The only document available was a vendor invoice, lacking the detailed inspection report required by NFPA 72. The Director of Building Services acknowledged the recent inspection but failed to produce the necessary documentation.
The facility did not conduct or document a formal risk assessment for building system categories as required by the 2012 NFPA 99 Health Care Facilities Code. During a survey, it was found that the necessary documentation was missing, and the Administrator and Director of Building Services acknowledged this deficiency. The facility failed to provide the required documentation by the end of the survey.
The facility failed to develop timely and complete care plans for residents, including a resident with a PICC line, another requiring assistance with ADLs, and a third with severe cognitive impairment needing oxygen therapy. Care plans lacked necessary goals and interventions, contrary to facility policy.
The facility failed to ensure the emergency generator was tested according to NFPA standards, as logs did not include transfer time, preventing verification of compliance with the 10-second service requirement. Staff acknowledged the omission and stated future tests would include this data.
The facility failed to document specific emergency scenarios during fire drills, as required by NFPA 101. Six out of twelve drills lacked details on the simulated conditions, making it unclear if drills were conducted under varying conditions. The Director of Building Services acknowledged the oversight.
A resident was found with expired eye medications on their bedside table, which they self-administered without a physician's order or assessment. Facility staff were unaware of the medications in the resident's room, and the facility's policy required medications to be stored securely and not used past expiration.
A resident with a history of pressure ulcers and falls was found to have a bruise of unknown origin on the left forearm, which was not reported by the CNA who discovered it. The facility's policy requires immediate reporting of such injuries, but the CNA assumed it had already been reported. The bruise was not documented until surveyors observed it, and staff interviews revealed a lack of awareness about the injury.
A resident was inaccurately documented as comatose in the Quarterly MDS assessment, despite being interactive and having a care plan indicating cognitive abilities. The error was made by a social worker responsible for the MDS section, and the MDS Coordinator did not verify the accuracy of individual sections.
A resident with severe cognitive impairment and a physician's order for daily use of bilateral hearing aids frequently removed them, but the care plan was not updated to reflect this behavior. Observations showed the resident without hearing aids, and staff interviews confirmed the oversight. The facility's policy required care plan updates for significant changes, which was not followed.
A resident experienced an 8.48% significant weight loss over 90 days, which was not addressed by the Clinical Dietitian as required by facility policy. The dietitian focused on month-to-month weight changes and did not inform nursing staff of the significant loss, preventing timely intervention. The resident, with Type 2 Diabetes Mellitus and Hypertension, did not receive necessary nutritional support due to this oversight.
A resident experienced an 8.48% significant weight loss over 90 days, which was not addressed by their Primary Physician. The facility's policy required significant weight changes to be identified and referred to the attending Physician by the Clinical Dietitian. However, the Clinical Dietitian did not identify the weight loss in a timely manner, and the Primary Physician did not document the resident's weight during their monthly review. The Charge Nurse was not informed, and thus the Primary Physician was not notified of the significant weight loss.
The facility failed to provide sufficient nursing staff on Unit 2 East, as required by their policy and Facility Assessment. During March 2024, staffing levels were below the necessary numbers, with instances of only two LPNs and three CNAs scheduled when more were needed. A grievance report and staff interviews confirmed the impact of these shortages, leading to delays in resident care. The facility was aware of the issue and had been recruiting new staff to address the understaffing.
A resident with Dry Eye Syndrome and Cataract was found with expired eye drops on their bedside table, which they self-administered without a physician's order. Facility staff were unaware of the medications in the resident's room, and the Director of Nursing confirmed that medications should not be accessible without proper evaluation and orders.
A survey found that a facility's Type 2 Essential Electrical System did not comply with NFPA standards, as Emergency and Critical Branch circuits were not separated in panels on both floors. This was acknowledged by the Administrator and Director of Building Services.
The facility was found non-compliant with NFPA codes due to improper storage near electrical panels and a disrepair of an emergency receptacle. Items were stored less than 3 feet from electrical panels on two floors, and a receptacle in the nurse station was in disrepair.
During a survey, it was found that fire/smoke doors on the first floor did not close properly, and the facility's inspection documentation lacked required verification items per NFPA standards. The Director of Building Services acknowledged the oversight.
During a Life Safety Code recertification survey, deficiencies were observed in the facility's maintenance. A leaking pipe in the phone data room and broken glass on exit door #201 were noted, indicating a failure to maintain a safe and functional environment. The Director of Building Services acknowledged these issues.
The facility failed to maintain and test its sprinkler systems according to NFPA standards. Sprinkler heads were obstructed by light fixtures, and some showed dust and corrosion. Inspection records lacked evidence of required check valve inspections and did not document water pressure values during tests.
A resident with dementia ingested hair dye left unattended at the nursing station, resulting in hospital transfer for swelling of the lips and tongue. The incident revealed a lapse in the facility's policy on securing hazardous substances.
Failure to Update Emergency Preparedness Plan Annually
Penalty
Summary
The facility failed to ensure that its Emergency Preparedness Plan was reviewed and updated at least annually, as required by 42 CFR 483.73(a). During a document review on the 22nd of the month, it was discovered that the last update to the Emergency Preparedness Plan was conducted on October 18, 2022. Additionally, the approval and implementation sheet listed former personnel as the Administrator and Director of Building Services, rather than the current individuals in these roles. On the 24th of the month, the Administrator confirmed that the plan had not been updated since they assumed their role in 2024, acknowledging the oversight and indicating an intention to review and update the plan.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 I. Immediate corrective action. On 01/24/2025, a review and update was conducted for the Emergency Management Plan. Upon inspection of the facility's Emergency Preparedness Binder, the Emergency Management Plan was found to be current with all regulatory requirements. The reviewed by sheet was signed and dated and put in the front of the binder for compliance. II. Identification of Others. To further ensure compliance and safety, all sections of the binder were reviewed in its entirety to ensure it had retained inspection sheets and their label/tab; this audit did not yield any insufficiencies or concerns for compliance and safety. III. Systemic Changes 1. The Administrator and Maintenance Director have been provided a comprehensive and detailed in-service regarding 'E-004', inclusive of but not limited to: the deficiencies observed during the environmental survey led by the NYS DOH, staff responsibility in continuous auditing, and the immediate reporting of findings to the Director of Maintenance or Administrator as applicable, so corrective action or repair may immediately ensue. All binders, and their respective sections, will be appropriately labeled as we proceed. The Emergency Manual will be inspected annually and signed on the reviewed by sheet and dated. 2. An audit tool has been created and implemented by the Director of Maintenance to identify any/all potential deficiencies of 'E-004'. This audit will occur monthly for the first three months of its implementation, then after, quarterly three times. IV. Quality assurance All audits of 'E-004' and any subsequent findings will be presented with the Administrator and interdisciplinary team at quality assurance and performance improvement (QAPI) meetings, held on a monthly basis. V. Individual Responsible for Correction. The Director of Maintenance is responsible for the completion of this correction.
Failure to Provide Fire Alarm System Inspection Records
Penalty
Summary
The facility failed to ensure that records of all inspections, testing, and maintenance of the fire alarm system were provided upon request, as required by NFPA 72: National Fire Alarm and Signaling Code. During a Life Safety Code recertification survey, it was observed that the records provided for review only included a fire alarm vendor invoice dated November 1, 2024, which described services for a period from November 1, 2024, to April 30, 2025. However, a complete fire alarm system inspection report, as specified in NFPA 72: 14.6.2.4, and the last smoke detectors' sensitivity test were not available for review. The Director of Building Services stated that the fire alarm inspection and smoke detector sensitivity test had been performed the previous week and that they would request the report from the company. Despite this, no additional documentation evidencing the fire alarm system inspection was provided by the end of the survey. This lack of documentation indicates non-compliance with the requirements for maintaining and providing records of fire alarm system inspections and testing.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. Fire alarm company was called to set up sensitivity testing on (MONTH) 24th. Sensitivity testing is scheduled for (MONTH) 14th. A binder was immediately created by the Director of Maintenance to ensure proper documentation of all fire alarm systems/ smoke detectors inspections including sensitivity testing on all required equipment. The fire inspection company was called on (MONTH) 24th to forward all proof of previous inspection going back 12 months. II. Anyone has the potential to be affected. III. The maintenance department has been educated by Director of Maintenance on 2/12/25 regarding 2010 NFPA 72 14.5.3.1.2.3. IV. Facility has developed an audit tool to monitor complaint record keeping for smoke detectors and fire alarm system inspections including sensitivity testing. Audits shall be conducted after annual inspection has been completed and copy of report will be sent to Administrator by the Director of Maintenance on all system inspections. All findings will be reported to QAPI committee. V. Responsible party: Director of Maintenance/Designee.
Failure to Document Risk Assessment for Building Systems
Penalty
Summary
The facility failed to conduct and document a formal risk assessment for building system categories as required by the 2012 NFPA 99 Health Care Facilities Code. This deficiency was identified during a survey conducted on the 24th of the month in 2025. The surveyors reviewed the documentation provided by the facility and found that it did not include a risk assessment for building system categories, which is necessary to determine the appropriate category for each system based on the potential impact of system failure on patient care. During the exit interview, both the Administrator and the Director of Building Services acknowledged the absence of the required documentation. The facility was unable to provide the necessary risk assessment documentation by the end of the survey, which is a violation of the NFPA 99 code and the New York Codes, Rules, and Regulations (10 NYCRR 711.2 (a)). This oversight indicates a failure to comply with the standards set for ensuring the safety and well-being of patients and caregivers in the event of a building system failure.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility immediately began to create a risk assessment document. Risk assessment is completed and went into effect on 2/12/25. II. Anyone has the potential to be affected. III. The maintenance department was educated on NFPA 101 fundamentals – building system categories on 2/12/25 by Director of Maintenance. IV. The facility created an audit tool to ensure the risk assessments include all required sections and are completed. Audit will be conducted upon creation to risk assessments and assessed quarterly. V. Responsible party: Director of Maintenance/ Designee.
Deficiencies in Timely and Complete Care Planning
Penalty
Summary
The facility failed to ensure timely development of person-centered care plans for residents, as evidenced by deficiencies identified during a recertification survey. Resident #272 was readmitted with a Peripherally Inserted Central Catheter (PICC) line, but a care plan for its use and care was not developed until seven days after admission. This delay occurred despite the facility's policy requiring care plans to be initiated within 48 hours for residents with a PICC line. The Registered Nurse responsible for the admission assessment acknowledged the oversight, and the Director of Nursing Services confirmed the expectation for timely care plan initiation. Resident #3's care plans for Activities of Daily Living (ADLs) were incomplete, lacking goals and interventions. The resident required maximum assistance for dressing and was dependent on staff for transfers. Despite a quarterly care plan meeting, the interdisciplinary team failed to identify and address the incomplete care plans. The Minimum Data Set Coordinator and the Director of Social Work both acknowledged the oversight, with the latter stating that the care plans should have been reviewed and completed during the quarterly meeting. Resident #19, who had severe cognitive impairment and received oxygen therapy, had a care plan for noncompliance that was incomplete, lacking goals and interventions. The resident was observed not receiving oxygen therapy as prescribed. The Director of Social Work, responsible for initiating the care plan, admitted to the error of not including necessary goals and interventions. The Director of Nursing Services confirmed that the care plan should have been complete, indicating a lapse in the facility's adherence to its policy on comprehensive care planning.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A. Immediate Corrective Action: 1. Resident #272 who still resides in facility was affected by this deficient practice. 2. The CCP for resident #272 titled PICC/Central Line Care/Management of CVP Line was initiated on 1/24/25 to ensure the proper management of the PICC line. 3. RN #2 was counseled and re-educated regarding the initiation of resident centered plan of care. 4. Resident #3 who still resides in the facility was affected by this deficient practice. 5. The CCP for resident #3 was modified on 1/24/25 to reflect resident centered goals and interventions. 6. The Director of Social Work was counseled and re-educated to ensure resident centered goals and interventions are reflected on care plans and reviewed quarterly. 7. Resident #19 who still resides in the facility was affected by this deficient practice. 8. The CCP for resident #19 was modified on 1/24/25 to reflect resident centered goals and interventions. 9. The Director of Social Work was counseled and re-educated to ensure that the resident centered goals and interventions are reflected when the care plan is initiated. B. Identification of Others: 1. All residents that reside in the facility have been identified at risk for failure to develop and implement a comprehensive care plan. 2. The facility initiated an audit of all residents’ comprehensive care plans to ensure development and implementation. The residents discovered to be at risk of failure to develop and implement a comprehensive resident centered comprehensive care plans were identified and modified immediately. C. Systematic Review to Prevent Re-Occurrence: 1. The Interdisciplinary Care Plan Team reviewed the Care Plan Policy and Procedure and no changes were necessary. 2. All clinical staff responsible for care planning have been re-educated by the RN Educator to ensure development and implementation of a comprehensive care plan for all residents. 3. The DNS developed an audit tool to be utilized at initial, quarterly and annual care plan meetings to ensure that care plans are reviewed. 4. The DNS developed an audit tool to ensure development and implementation of all residents. Ten residents’ comprehensive care plans will be audited weekly for three months then quarterly thereafter for one year. D. Quality Assurance: 1. The DNS/Designee will report on the findings of the audit quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice.
Generator Testing Deficiency
Penalty
Summary
The facility failed to ensure that the emergency generator was inspected and tested in accordance with the NFPA 99 Health Care Facilities Code and NFPA 110, Standard for Emergency and Standby Power Systems. Specifically, there was no evidence that the generator was capable of supplying service within the required 10-second interval after a loss of normal power. This deficiency was identified during a document review and staff interviews, where it was noted that the monthly full load test logs did not include the transfer time, making it impossible to verify compliance with the 10-second requirement. During the survey, the Director of Building Services acknowledged the omission and stated that the transfer time would be added to the monthly load test moving forward. Additionally, maintenance staff, who had been working at the facility for several years, confirmed that they had never been asked to record the transfer time, although they believed the generator started within 5 seconds. This oversight in documentation and testing procedures led to the deficiency being cited.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. Generator log sheets were immediately updated to include transfer times for each test. II. Anyone has the potential to be affected. III. The maintenance department was educated on NFPA 101 Electrical System Maintenance and testing by Director of Maintenance on 2/12/25. IV. Audit tool was created to ensure generator logs included transfer time sections going forward. Audits will be conducted by the director of maintenance monthly for 12 months. V. Responsible party: Director of Maintenance/ Designee
Fire Drill Documentation Deficiency
Penalty
Summary
The facility failed to ensure that fire drill written records included the specific emergency fire conditions simulated during each drill, as required by NFPA 101: Life Safety Code. This deficiency was identified during a review of fire drill records from August 17, 2024, to January 15, 2025, where it was noted that six out of twelve fire drills did not document the scenario that caused the simulated fire drill and fire alarm activation. The reports merely noted that a 'Code red' was called, all rooms were closed, and there was a good response from staff, without detailing the specific scenario played. This omission made it impossible to verify that the drills were conducted under varying conditions, as required by the code. The Director of Building Services acknowledged this oversight and indicated that scenarios would be added to future fire drills.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility immediately added the scenario simulated to the Fire Drill Report for all fire drills going forward. II. Anyone has the potential to be affected. III. The maintenance director was educated on 2012 NFPA 101:4.7.4 on 2/12/25 by the Corporate Director of Maintenance. IV. The facility created an audit tool to ensure fire drills include a simulated scenario when conducted. Audits will be conducted by the Director of Maintenance monthly for 12 months. All findings will be reported on QAPI. V. Responsible party: Director of Maintenance/ Designee.
Medication Storage and Self-Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as evidenced by the case of a resident who was observed to have multiple bottles of eye medications on their bedside table. The resident, who had diagnoses including Dry Eye Syndrome and Cataract, was seen self-administering expired Refresh Liquigel eye drops without a physician's order or an assessment to self-administer medications. The facility's policy required that medications be stored in an orderly manner and locked when not in use, and prohibited the use of expired medications. Interviews with facility staff, including Licensed Practical Nurses and the Director of Nursing Services, revealed that the resident did not have a physician's order to self-administer medications and should not have had access to any medications, especially expired ones, in their room. The pharmacist confirmed that expired medications should not be used as they may become less effective. The deficiency was identified during a recertification survey, highlighting a lapse in the facility's adherence to its medication storage policy.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Immediate Corrective Action: 1. On 1/22/25, the two Refresh Liquid Eye Drops and the two [MEDICATION NAME] Eye Lubricant were removed from resident #31 room with explanation provided to resident. The expired Refresh Liquid Eye Drops were discarded. 2. Resident #31 was assessed for self-administration as per request. The resident’s wishes for self-administration were assessed by the Interdisciplinary Care Plan Team and was deemed to be capable of self-administration. The attending physician was made aware and orders received for self-administration of Refresh Eye Drops. A locked box and key were issued to resident. The plan of care was updated to include self-administration. 3. The Licensed Practical Nurse #5 was counseled and re-educated to ensure that medications are stored properly, residents are promptly evaluated for potential for self-administration, a physician order [REDACTED]. B. Identification of Others: 1. All residents’ rooms were surveyed for risk of same. Individual request for self-administration and proper storage of medications were assessed by the Interdisciplinary Care Plan Team. Orders were received from the attending physician and orders updated as necessary to include self-administration. 2. All storage areas were inspected for expired medications. No expired medications were identified. C. Systematic Review to Prevent Re-Occurrence: 1. The facility Self-Administration Policy and Procedure was reviewed by the Interdisciplinary Care Plan Team. 2. The Director of Nursing developed an audit tool to audit 10 residents for expired medications, safe storage of medications, evaluation of residents to self-administer medications, and physician orders [REDACTED]. The audit tool will be completed weekly for 3 months and then quarterly for one year thereafter. 3. The DNS/Designee will be responsible for completion of audit. 4. All nursing staff were re-educated regarding expired medications, safe storage of medications, evaluation for self-administration, and physician orders [REDACTED]. D. Quality Assurance: 1. The DNS/Designee will report on the findings quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that injuries of unknown origin were reported within 24 hours, as required by their Abuse Prevention policy. This deficiency was identified for a resident who had a bruise of unknown origin on the left forearm, which was not reported by the Certified Nursing Assistant (CNA) who discovered it. The CNA, who worked the night shift, observed the bruise during their shift but did not report it, assuming someone else had already done so. This lack of reporting was contrary to the facility's policy, which mandates immediate reporting of any changes in skin integrity to the nurse in charge. The resident involved had a history of a Stage III Pressure Ulcer and repeated falls, with intact cognition and no behavioral symptoms. The resident required assistance with daily activities and had no functional limitations in the upper and lower extremities. Despite regular skin assessments and care plans in place, the bruise was not documented until observed by surveyors. Interviews with various staff members, including the LPN and Wound Care RN, revealed that they were unaware of the bruise until it was pointed out during the survey. The Director of Nursing Services confirmed that the CNA should have reported the bruise, and an investigation was initiated once the issue was brought to their attention.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 A: Immediate Correction Action 1. Resident #273 who still resides at the facility was affected by this deficient practice. 2. An Accident and Incident report was initiated. 3. Nursing Assistant #6 was counseled and re-educated on 1/30/25 Abuse Prevention and Reporting. B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The facility conducted a skin assessment on 20 random residents to see if there were any changes in skin condition that were not reported. There were no findings noted. C: Systematic Review to prevent re-occurrence 1. The DNS devised an audit tool to ensure that all skin changes are reported and documented in a timely manner with the proper notifications to MD, family and governmental agencies if applicable. 2. The facilities policy titled Abuse Prevention dated 10/22 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 3. The facilities policy titled Potential for Risk in Skin Integrity Prevention and Treatment dated 5/2011 was reviewed by the Administrator, Medical Director, and DNS and no changes were made. 4. The RN Nurse Educator will re-educate all nurses, CNA's, housekeeping, maintenance, recreation, dietary, pastoral care, and ancillary staff on Abuse Prevention and Reporting. 5. The RN Nurse Educator will re-educate all CNA’s on monitoring the resident’s skin during ADL’s and reporting any skin changes to the nurse. D: Quality Assurance 1. The DNS and or designee will audit 10 residents weekly x 3 months and thereafter monthly for 1 year until 100% compliance is obtained to ensure that there have been no undocumented skin changes. 2. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 3. The DNS will report the findings of this audit quarterly at the QAPI meeting. 4. The DNS/ designee is responsible for ensuring the correction of this deficient practice.
Inaccurate Resident Assessment in MDS
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status during a recertification survey. Specifically, the Quarterly Minimum Data Set (MDS) assessment for a resident inaccurately documented the resident as comatose, despite evidence to the contrary. The resident, who was diagnosed with Dementia and Depression, was observed to be interactive and responsive, as evidenced by their ability to smile and wave at a surveyor. Additionally, a Comprehensive Care Plan indicated the resident could make themselves understood, and a physician's order included a floor ambulation program, further contradicting the comatose status recorded in the MDS. The error was attributed to Social Worker #1, who was responsible for completing the MDS Section B (Hearing, Speech, and Vision) and admitted to mistakenly documenting the resident's status as comatose. The Minimum Data Set Assessment Coordinator acknowledged the error, stating that they do not review individual sections of the MDS for accuracy, only for completion. This oversight led to the inaccurate assessment being recorded, which was not aligned with the resident's actual condition and capabilities.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A: Immediate Correction Action 1. Resident #128 who still resides at the facility was not affected by this deficient practice. 2. The MDS for resident #128 was corrected to reflect “0” on 1/24/2025. 3. Social Worker #1 was re-educated on MDS accuracy by the RN Nurse Educator. B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The facility ran a report on Section B, question B0100 to see if any other residents were coded incorrectly and there was no inaccurate finding. C: Systematic Review to prevent re-occurrence 1. The facilities policy titled Minimum Data Set Completion Assignment dated 10/18/2023 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 2. The RN Nurse Educator will re-educate all staff that are assigned to complete the MDS assessment on MDS Assessment Accuracy. D: Quality Assurance 1. The DNS devised an audit tool to ensure that all MDS Assessments are accurate. 2. The DNS and or designee will audit 10 MDS assessments section B question B0100 weekly x 3 months and monthly thereafter for 1 year until 100% compliance is obtained to ensure that the MDS accuracy. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting. 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice.
Failure to Update Care Plan for Hearing Aid Compliance
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This deficiency was identified for a resident who had a physician's order to use bilateral hearing aids daily. Despite the resident's noncompliance and frequent removal of the hearing aids, the comprehensive care plan for the hearing deficit was not updated to indicate the resident's behavior. The facility's policy required care plans to be reviewed quarterly, annually, or when there was a significant change in the resident's condition, but this was not adhered to in this case. The resident in question was admitted with diagnoses including Dementia with severe agitation, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease, and had severely impaired cognition. Observations during the survey revealed that the resident was not wearing hearing aids and was unable to hear or respond to greetings. Interviews with staff, including an LPN and the Director of Nursing Services, confirmed that the resident often refused to wear the hearing aids and that the care plan should have been updated to reflect this behavior. The failure to update the care plan was a violation of the facility's policy and regulatory requirements.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A: Immediate Correction Action 1. Resident #102 who still resides at the facility was affected by this deficient practice. 2. The CCP for resident #102 titled Hearing Deficit was updated to reflect the residents non-compliance with hearing aid usage on 1/24/2025. 3. Charge Nurse #2 was counseled and re-educated on Care Plan timing and revision by the RN Nurse Educator on 2/5/25. B: Identification of Others 1. All residents that reside in the facility with hearing aids have the potential to be affected by this deficient practice. 2. The facility audited all residents that have the potential of same deficient practice and there were no negative findings. C: Systematic Review to prevent re-occurrence 1. The facilities policy titled Care Plan dated 8/2022 was reviewed by the Administrator, Medical Director and DNS and no changes were made. 2. The RN Nurse Educator will re-educate all nurses on Care Plan Timing and Revision. D: Quality Assurance 1. The DNS devised an audit tool to ensure that all care plans are timely and revised according to the facilities policy and procedure. 2. The DNS and or designee will audit the care plans of 10 residents weekly x 3 months and thereafter monthly for 1 year or until 100% compliance is achieved. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting. 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that Resident #5 maintained acceptable nutritional and hydration status, as evidenced by an 8.48% significant weight loss over 90 days, which was not addressed by the Clinical Dietitian. The facility's policy requires the Clinical Dietitian to review residents' weight status and refer any significant weight changes to the attending Physician for further review and interventions. However, the Clinical Dietitian did not identify or address the significant weight loss of Resident #5, who has Type 2 Diabetes Mellitus and Hypertension, and a BIMS score indicating moderately impaired cognitive skills. The Clinical Dietitian was responsible for entering residents' weights into the Electronic Medical Record (EMR) and generating a report of significant weight losses. Despite the policy, the Clinical Dietitian focused primarily on month-to-month weight changes rather than cumulative weight loss over three months. Consequently, the significant weight loss of Resident #5 was not addressed in a timely manner, as the Clinical Dietitian had not yet completed the necessary documentation for January 2025. Interviews with facility staff revealed that the Clinical Dietitian did not inform the nursing staff of Resident #5's significant weight loss, which would have prompted the nursing staff to notify the resident's Primary Physician. The Director of Nursing Services confirmed that Clinical Dietitians are responsible for reporting significant weight losses to the Interdisciplinary Team and ensuring that the Primary Physician is informed to obtain new orders to address the weight loss. This oversight resulted in a failure to implement timely interventions for Resident #5's nutritional needs.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 A: Immediate Correction Action 1. Resident #5 who still resides at the facility was affected by this deficient practice. 2. The clinical dietician for resident #5 reviewed the chart, initiated weekly weights, and added supplements. 3. Clinical Dietician #1 was educated on the facility policy on weight loss and weight monitoring on 1/24/25. B: Identification of Others 1. All residents that reside in the facility have the potential to be affected by this deficient practice. 2. The Chief Clinical Dietician ran the weight loss report for the month of (MONTH) on all residents to see if there were any residents with unidentified significant weight loss. There were no negative findings. C: Systematic Review to prevent re-occurrence 1. The facilities policy titled Weight Loss dated 2/2019 was reviewed by the Administrator, Medical Director and DNS and no changes were made to the policy. 2. The facilities policy titled Weight Monitoring was reviewed by the Administrator, Medical Director and DNS and no changes were made to the body of the policy, an effective date of 1/25/25 was given. 3. The RN Nurse Educator will re-educate all Clinical Dieticians on Weight Loss and Weight Monitoring policies and procedures. D: Quality Assurance 1. The DNS devised an audit tool to ensure that all residents experiencing weight loss are captured and documented according to the facilities policy and procedure. 2. The DNS and or designee will audit the weights of 10 residents weekly x 3 months and thereafter monthly for 1 year or until 100% compliance is achieved. 3. Any negative audit findings will immediately be addressed by the DNS/ designee with an onsite teaching/in-service, and disciplinary action as needed. 4. The DNS will report the findings of this audit quarterly at the QAPI meeting. 5. The DNS/ designee is responsible for ensuring the correction of this deficient practice.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that the medical care of Resident #5 was adequately supervised by their Primary Physician, particularly in monitoring changes in the resident's medical status. Resident #5 experienced an 8.48% significant weight loss over a 90-day period, from October 2024 to January 2025, which was not addressed by their Primary Physician. The facility's policy required that significant weight changes be identified and referred to the attending Physician by the Clinical Dietitian for further review and interventions. However, the Clinical Dietitian did not identify the significant weight loss in a timely manner, and the Primary Physician did not document the resident's weight during their monthly review, leaving the weight change portion of the visit blank. Interviews revealed that the Clinical Dietitian focused primarily on month-to-month weight changes and did not have time to document significant weight loss notes for January 2025. The Charge Nurse was not informed of the significant weight loss, and thus did not notify the Primary Physician. The Primary Physician admitted to not realizing the omission in their documentation and stated they were not informed of the significant weight loss. The Medical Director emphasized that the Primary Physician should have documented the resident's weight and addressed any significant weight loss with appropriate interventions.
Plan Of Correction
Plan of Correction: Approved February 12, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A: Immediate Correction Action 1. Resident #5 who still resides at the facility was affected by this deficient practice. 2. Resident #5 was immediately placed on weekly weights. 3. Laboratory values ordered on [DATE] to identify any contributing factors. Values were in normal limits. 4. Physician #1 addressed weight loss in his monthly note. 5. Clinical Dietician #1 was counseled and re-educated to identify weight loss and follow facility Weight Monitoring Policy and Procedure. B: Identification of Others 1. All residents’ weights were reviewed and assessed for weight loss as outlined in the Weight Monitoring Policy and Procedure. No resident was identified as potential for this deficient practice. 2. The RN Educator re-educated the Physician, Dieticians, and Nursing staff to identify residents with weight loss as outlined in the Weight Monitoring Policy and Procedure. Upon identification of residents with weight loss, proper notification and documentation of weight loss is mandated. C: Systematic Review to prevent re-occurrence 1. The facility Weight Monitoring Policy and Procedure was reviewed by the Interdisciplinary Care Planning Team and no changes were made. 2. The DNS developed a Weight Monitoring Audit tool to identify residents with weight loss identified by this deficient practice to ensure communication and documentation. Ten residents will be audited weekly and thereafter ten residents will be audited quarterly for one year or until 100% compliance. D: Quality Assurance 1. The DNS/Designee will review the findings of the Weight Monitoring Audit. Negative findings will be immediately addressed by the DNS/Designee with onsite in-service and disciplinary action as needed. 2. The DNS/Designee will report the findings of this Weight Monitoring Audit quarterly at the QAPI meeting. 3. The DNS/Designee is responsible for ensuring the correction of this deficient practice.
Staffing Deficiency on Unit 2 East
Penalty
Summary
The facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident. This deficiency was identified for Unit 2 East during the Sufficient Staffing Task. The facility's policy required a sufficient number of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants to meet the healthcare needs of all residents. However, during March 2024, the staffing levels on Unit 2 East were below the required numbers as documented in the Facility Assessment. Specifically, the daily staffing sheets revealed that on several occasions, the unit was understaffed. For instance, on 3/3/2024, there were only two Licensed Practical Nurses and three Certified Nursing Assistants scheduled, whereas the Facility Assessment required four Certified Nursing Assistants. On 3/24/2024, only one Licensed Practical Nurse and three Certified Nursing Assistants were scheduled, despite the need for two Licensed Nurses and four Certified Nursing Assistants. Similar staffing shortages were noted on 3/10/2024, 3/17/2024, and 3/31/2024. A grievance report filed by a family member highlighted the impact of these staffing shortages, noting that on 3/10/2024 and 3/17/2024, only two Certified Nursing Assistants were available to assist residents during the 7:00 AM to 3:00 PM shift. Interviews with staff confirmed the understaffing issues, with Certified Nursing Assistants and Licensed Practical Nurses acknowledging that the unit was often short-staffed, leading to delays in resident care. The Staffing Coordinator and Director of Nursing Services were aware of the understaffing, and the facility had been actively recruiting new staff to address the issue.
Improper Storage and Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by their policy. This deficiency was identified during a recertification survey for a resident with Dry Eye Syndrome and Cataract, who was observed to have a plastic cup containing two bottles of Refresh Liquigel eye drops and two bottles of Systane Lubricant eye ointment on their bedside table. The resident self-administered the expired Refresh Liquigel eye drops, which were not stored in a locked compartment, and there was no documentation of an assessment or comprehensive care plan allowing the resident to self-administer medications. Interviews with facility staff, including LPNs and the Director of Nursing Services, revealed that the resident did not have a physician's order to self-administer medications, and the presence of expired medications in the resident's room was against facility policy. The pharmacist confirmed that expired medications should not be used as they may become less effective. The Director of Nursing Services acknowledged that the resident should not have had access to any medications without proper evaluation and orders.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Immediate Corrective Action: 1. Resident #31 who still resides in the facility was affected by this deficient practice. 2. On 1/22/25, two Refresh Liquid Eye Drops and the two [MEDICATION NAME] Eye Lubricant were in the resident’s room and were not secured. The medications were removed from resident #31 room immediately with explanation provided to resident. 3. The Licensed Practical Nurse #5 was counseled and re-educated to ensure that medications are stored properly. B. Identification of Others: 1. All residents’ rooms were surveyed for risk of same. No resident was identified at risk of this deficient practice. 2. The Policy and Procedure titled Storage of Medications was reviewed by the Interdisciplinary Care Planning Team and no changes were made. C. Systematic Review to Prevent Re-Occurrence: 1. The Director of Nursing developed an audit tool to audit 10 residents to ensure safe storage of medications for residents who are care planned for self-administration and all areas where medications are stored. The audit tool will be completed weekly for 3 months and then quarterly for one year thereafter or until 100% compliance. 2. The DNS/Designee will be responsible for completion of audit. 3. All nursing staff were re-educated regarding safe storage of medications. E. Quality Assurance: 1. The DNS/Designee will report on the findings quarterly at the QAPI meeting. 2. Negative findings will be immediately addressed by the DNS/Designee with onsite teaching/in-service, and disciplinary action as necessary. 3. The DNS/Designee is responsible to ensure correction of this deficient practice.
Penalty
Summary
Citation DetailsDetails not available.
Non-compliance with Essential Electrical System Requirements
Penalty
Summary
During a Life Safety Code recertification survey conducted on the 23rd of the month in 2025, it was observed that the facility did not maintain its Type 2 Essential Electrical System in accordance with NFPA 99 and NFPA 70 standards. Specifically, the surveyors noted that the Emergency (Life Safety) Branch wiring was not separated from the Critical Branch wiring. This issue was identified in the Emergency Power panels labeled as LPEDD and LPEHH, located on the first and second floors of the facility, respectively. The panel labeled LPEHH, situated in the soiled room on the second floor, contained circuits from both the Emergency and Critical Branches. Emergency circuits such as circuit#20 F/A Door Holder and circuit#22 F/A Control Panel were found alongside Critical Branch circuits, including Nurse Station Receptacles, Room Receptacles, and Nurse Station Refrigerator. Similarly, the panel labeled LPEDD on the first floor also mixed Emergency circuits like circuit#20 F/A Mag Door Holder and circuit#22 F/A Control Panel with Critical Branch circuits such as Nurse Station Receptacles, Room Receptacles, and Kitchen AC. These findings were acknowledged by the facility's Administrator and the Director of Building Services during the exit interview on the 24th of the month in 2025. The lack of separation between the Emergency and Critical Branch circuits in the electrical panels represents a failure to comply with the specified electrical system requirements, potentially impacting the facility's ability to maintain essential services during power interruptions.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility contacted electrical company on 2/12/25 to separate the branch circuits; completion date of 3/17/25. II. Anyone has the potential to be affected. III. The maintenance department were educated on NFPA 101 Electrical System – Essential Electrical systems on 2/12/25 by the Director of Maintenance. IV. The maintenance director will monitor the work to ensure successful relocation of the branch circuits to the proper panels. Any findings will be reported to QAPI. V. Responsible party: Director of Maintenance/ Designee.
Deficiencies in Electrical System Compliance
Penalty
Summary
The facility failed to maintain compliance with NFPA 70: National Electrical Code and NFPA 99: Health Care Facilities Code, as observed during a Life Safety Code recertification survey. Specifically, the surveyors noted that the minimum clear spaces required for electrical equipment were not maintained. Assorted items were stored less than 3 feet away from electrical panels in various locations, including the clean holding rooms on the first and second floors. This improper storage was observed on two of the three floors within the facility, indicating a systemic issue with maintaining clear spaces around electrical equipment. Additionally, a receptacle identified as EHH-CKT#9 in the nurse station on the second floor was found to be in disrepair. The Director of Building Services was present during the observations and acknowledged the issues. The failure to maintain clear spaces around electrical panels and the disrepair of an emergency receptacle represent deficiencies in the facility's adherence to safety codes, potentially impacting the safe operation and maintenance of electrical systems.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Items have been removed from 3ft around the electrical panel. Clean holding rooms 229, 268 on the second floor and first floor clean holding room [ROOM NUMBER] were removed and replaced. Nurse station receptacle EHH-CKT#9 was repaired 02/28/2025. II. Anyone has the potential to be affected. III. The maintenance department were educated on NFPA 101 Electrical System û other on 2/12/25 by Director of Maintenance. IV. The facility created an audit tool to ensure there are no items stored within 3ft of electrical panels and that all receptacles are in working condition. Audits will be conducted weekly for 1 month and monthly for 3 months. V. Responsible party: Director of Maintenance/ Designee.
Fire/Smoke Door Maintenance Deficiency
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility did not maintain and inspect fire/smoke doors in accordance with NFPA 101 and NFPA 80 standards. Specifically, on the first floor, fire doors #8 and #4 failed to close properly when tested. This deficiency was noted in the presence of the Director of Building Services, indicating a failure to ensure that these critical safety features were functioning as required. Additionally, a review of the facility's documentation revealed that the Monthly Smoke, Fire Door Operation Check, and Smoke Barrier Penetration Inspection, as well as the Monthly Fire Door Barrier Check, did not include verification of the 11 items specified by NFPA 80:5.2.4.2. This omission was acknowledged by the Director of Building Services, who stated that the facility would update their inspection checklist to include these items. However, at the time of the survey, the deficiency remained unaddressed.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. All fire doors were immediately inspected and adjusted by Director of Maintenance. Door 4 and 8 are now in compliance. No other issues were found. II. The monthly fire door barrier checklist has been updated to reflect the 11 items specified and required by NFPA 80:5.2.4.2. III. Anyone has the potential to be affected. IV. The maintenance of Director was educated on 2012 NFPA 101: Maintenance, Inspection and testing- doors on 2/12/25 by Corporate Director of Maintenance. V. An audit tool created to ensure fire doors all close properly and that the 11 specified items from NFPA 80:5.2.4.2 are included in all inspections. Audits to be conducted by the director of maintenance monthly for 12 months. All findings reported to QAPI. VI. Responsible party: Director of Maintenance/ Designee.
Deficiencies in Facility Maintenance and Safety
Penalty
Summary
The facility was found to have deficiencies in maintaining the physical environment during a Life Safety Code recertification survey. Observations made in the basement revealed that the phone data room had a pipe leaking from the ceiling into a plastic bucket, indicating a failure to maintain the building in good repair. Additionally, the exit door #201 leading to the courtyard was observed with broken glass, further demonstrating the facility's inability to ensure a safe, healthy, functional, sanitary, and comfortable environment for residents, personnel, and the public. These issues were noted during the survey, and the Director of Building Services acknowledged the need to address them.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. The facility immediately contacted a plumber to address the leaking pipe; the leak was repaired on 2/05/25. The Facility immediately covered the broken glass on the door leading to the courtyard, and the broken glass has since been replaced on 2/21/25. II. Anyone has the potential to be affected. To further ensure compliance and safety, all other applicable areas have been audited for leaking pipes in the ceiling and broken glass in all windows and doors. III. The maintenance department in-serviced on I310 – 415.29 physical environment on 2/12/25 by Director of Maintenance. IV. The facility created environmental audit tools to ensure a safe, healthy, functional, sanitary, and comfortable environment. Audits on the environment will be conducted biweekly for 3 months and then monthly for 3 months. V. Responsible party: Director of Maintenance/ Designee
Sprinkler System Maintenance and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that its sprinkler systems were maintained and tested in accordance with NFPA 13 and NFPA 25 standards. During a Life Safety Code recertification survey, it was observed that sprinkler heads were improperly positioned in close proximity to light fixtures, which could obstruct the discharge and distribution of water. Specifically, a light fixture was installed approximately 2 inches from a sprinkler head in the residents' donation clothes storage room, and another was 1 inch from a sprinkler head in the dietary office closet, both on the second floor. Additionally, the survey revealed maintenance issues with the sprinkler heads themselves. The sprinkler head inside the walk-in refrigerator in the kitchen was found to have heavy dust accumulation, and another sprinkler head in the walk-in refrigerator by the mechanical room in the basement showed signs of corrosion. These conditions indicate a lack of proper maintenance and inspection, which are required to ensure the effective operation of the sprinkler system. Furthermore, a review of the facility's sprinkler system inspection records showed deficiencies in documentation. The records did not include evidence of a check valve inspection, which is required every five years. A vendor invoice from October 2023 mentioned an internal inspection of piping but did not specify if the check valve inspection was performed. Additionally, a report from October 2024 failed to record the supply and residual water pressure values during a drain test. The Director of Building Services acknowledged these documentation gaps and stated that they would contact the inspection company for clarification, but no further documentation was provided by the end of the survey.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 I. All sprinklers were audited to ensure proper location and free of dust to ensure proper distribution of water from the sprinkler head; no other issues were found. The light fixtures identified during the survey for being too close to the sprinkler heads have been relocated, allowing for proper distribution of water. Sprinkler company was called on (MONTH) 24th to schedule onsite tech to relocate the sprinkler head in the donation storage room, the dietary office. Sprinkler heads for the walk-in refrigerator have been ordered and will be replaced by 3/7/25. II. Sprinkler company was called on (MONTH) 24th to review and update the most recent 5-year sprinkler system inspection to ensure completed information, including the check valves and all boxes are checked off properly. Documents were received on 2/28/25. Sprinkler company has also supplied paperwork showing that the supply and residual water pressure was completed. III. Anyone has the potential to be affected. IV. The maintenance department has been educated on LSC K-353 NFPA 101 Sprinkler System Maintenance and Testing by the Director of Maintenance. V. Facility has developed an audit tool to ensure sprinkler inspections are properly documented and complete. Facility has developed an audit tool to ensure sprinkler heads are clear of fixtures that would impede the proper distribution of water, dusted, and corrosion-free. Audits will be completed by the Director of Maintenance after each inspection. Audits will be conducted on sprinkler heads monthly for 3 months. All findings to be reported to QAPI. VI. Responsible party: Director of Maintenance/Designee.
Resident Ingests Hazardous Substance Due to Inadequate Supervision
Penalty
Summary
The facility did not ensure that each resident received adequate supervision to prevent accidents, resulting in harm to a resident with dementia. Specifically, a resident with severe cognitive impairment was observed drinking from a bottle of Wella Color Charm hair dye that had been left unattended at the nursing station. The resident was subsequently transferred to the hospital for swelling of the lips and tongue, indicating actual harm but not immediate jeopardy. The resident, who had diagnoses including anemia, dementia, and high blood pressure, was seated in a reclining wheelchair near the nursing station when the incident occurred. The hair dye bottle had been left at the nursing station after a volunteer failed to deliver it to the beauty parlor. A Certified Nurse's Aide observed the resident drinking from the bottle and immediately reported it to the Charge Nurse, who then called the Nursing Supervisor. The resident was assessed and transported to the hospital for treatment. Interviews with staff and review of facility policies revealed that hazardous substances like hair dye should have been stored in a locked, secure location. The incident was deemed an isolated event, but it highlighted a lapse in following the facility's hazard communication policy. The staff involved were retrained, and the Charge Nurse responsible was disciplined and is no longer employed at the facility.
Removal Plan
- Policies for storage of hair care items for residents and securing hazardous items were reviewed and revised.
- Staff was retrained on the revised policies.
- Charge Nurse #2 was disciplined and is no longer employed at the facility.
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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