Nathan Littauer Hospital Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Gloversville, New York.
- Location
- 99 East State Street, Gloversville, New York 12078
- CMS Provider Number
- 335351
- Inspections on file
- 12
- Latest survey
- March 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Nathan Littauer Hospital Nursing Home during CMS and state inspections, most recent first.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with cognitive impairment did not have a documented fall prevention plan involving mattresses. Another resident with edema lacked a care plan for physician-ordered ACE bandage use. A third resident with vision issues had no care plan for vision needs or specialist follow-up.
The facility failed to maintain food service safety and cleanliness standards in the main kitchen and resident unit nutrition areas. Observations included debris on kitchen equipment, missing temperature logs, and dirt accumulation on various surfaces. Interviews revealed staff negligence in cleaning duties, with plans to develop a duty list for daily responsibilities.
A facility exceeded the acceptable medication error rate, with errors involving two residents. One resident received insulin late, after eating, without a follow-up glucose check or notification to a nurse or physician. Another resident self-administered a nebulizer treatment left at the bedside, contrary to facility policy. The DON confirmed no residents were authorized to self-administer medications.
The facility was cited for not designating a specific individual as the Infection Preventionist, with the DON performing dual roles due to staffing issues. The Administrator was unaware of the requirement for a distinct Infection Preventionist role, leading to a citation under regulatory standards.
A survey found that a medication cart in the facility's West Unit Team 1 contained opened medications without proper labeling, including insulin vials and eye drops lacking open or expiration dates. Interviews revealed that staff did not consistently follow procedures for labeling medications, despite receiving training on this practice.
The facility failed to properly constitute its Quality Assessment and Assurance Committee, as the Director of Nursing was also serving as the Infection Preventionist, contrary to regulations. The Administrator was unaware of the requirement for these to be separate roles, leading to a deficiency that could impact all residents.
The facility failed to maintain residents' dignity as staff wore gloves while feeding them, contrary to the facility's policy on dignity and respect. Observations showed staff consistently using gloves for infection control, despite some recognizing it could be perceived as undignified. The DON acknowledged no written policy required glove use during feeding, highlighting inconsistency in practice and understanding among staff.
The facility was cited for failing to maintain a clean and safe environment, with surveyors observing soiled floors, disrepair in door frames and walls, and unfinished repairs in resident rooms. Staff interviews revealed ongoing issues with cleanliness and maintenance, despite previous efforts to address these concerns.
A facility failed to provide meaningful activities for a resident, leading to a deficiency in supporting their well-being. The resident, who was unable to complete a mental status interview, was observed over several days in bed, non-verbal, and not participating in activities. The Activities Director admitted that one-on-one visits were not documented, contrary to facility policy, and the DON confirmed this lack of documentation.
Two residents experienced neglect due to miscommunication and inadequate care. One resident was not monitored or cared for during a night shift, while another rolled out of bed and hit their head due to improper assistance. Both incidents highlight failures in communication and adherence to care protocols.
A facility failed to provide a written notice of its bed hold policy to a resident and/or their representative upon transfer to the hospital. The resident, who had severe cognitive impairment, was transferred due to a fall and possible fracture. The facility's policy requires such notification, but it was not documented. The Director of Nursing acknowledged the inconsistency in completing the notice of discharge, which includes the bed hold policy notification.
A resident with mild cognitive impairment and a history of shortness of breath fell in their room and was assisted by CNAs into a wheelchair without notifying a nurse or reporting the incident. The resident's shortness of breath was attributed to anxiety by an LPN, and the fall was only discovered after the resident was hospitalized post-discharge.
A resident with severe cognitive impairment had an injury of unknown origin that was not reported within the required timeframe. An LPN discovered a discolored area on the resident's foot but failed to report it to an RN, delaying the investigation. The injury, later identified as a fracture, was reported to the Department of Health two days late, resulting in a deficiency citation.
The facility breached confidentiality by including social security numbers on the Criminal History Record Check form, which was not requested. The New Employee Director admitted to inadvertently distributing these documents with private information, despite securing them in a locked cabinet. This mistake was recognized and acknowledged during a recertification survey.
A facility failed to involve a resident's family member in quarterly care plan meetings, despite the resident being cognitively intact and the family visiting daily. The facility's policy required family participation in care planning, but the family was only involved in the initial and discharge planning meetings, not the quarterly ones.
A resident with a history of [REDACTED] did not receive necessary vision care, including an eye exam and new glasses, since admission to the facility. Despite the resident's cognitive ability to communicate their vision difficulties, the facility failed to arrange a follow-up ophthalmology appointment as recommended in a previous consult. The resident's care plan lacked provisions for vision care, and staff interviews revealed a lack of awareness and coordination in addressing the resident's needs.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #3, who had severe cognitive impairment and a history of falls, did not have a care plan that included the use of multiple mattresses in their room as a fall prevention measure. Despite the presence of these mattresses being a daily safety precaution, it was not documented in the care plan, and staff were unaware of its inclusion. Resident #9, who had intact cognition and chronic bilateral lower extremity edema, did not have a care plan that included the physician-ordered intervention of wrapping their legs with ACE bandages. Although the resident and staff confirmed the daily application and removal of the bandages, this intervention was not documented in the care plan, leading to a lack of formalized care planning for this medical condition. Resident #19, who was cognitively intact and had vision problems, did not have a care plan addressing their vision needs or the use of glasses. The resident reported difficulty with vision and the need for an ophthalmology appointment, which had not been scheduled since their admission. The facility's failure to coordinate follow-up specialist visits and update the care plan to include vision care needs contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Resident #3- Identified and implemented a care plan for Falls was identified and implemented. Interventions have been initiated to reflect current approaches in plan to ensure safety. Resident #9- Reviewed and updated care plan for [MEDICAL CONDITION]. Interventions have been added to care plan to reflect approaches currently in place to ensure patient centered care and current needs. Resident #19- Identified and implemented a care plan for Vision. Interventions have been added to reflect current needs. Identification of other residents and corrective action: Every resident has potential to be affected by this deficient practice. All care plans for each resident will be audited for accuracy, correct those needed and to ensure all needs are addressed. Measures and Systemic Changes: The Interdisciplinary Care Plan Committee Policy was reviewed and updated appropriately. Education will be provided to staff regarding the changes in policy and for the process of completion of the care plan for each resident to ensure the care plan is person centered for each individual. Monitoring: All care plans will be audited weekly following the care plan meeting schedule. All care plans will be reviewed at least once within a 90 day period. This will be audited weekly for 3 months consecutively. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Ann(NAME) Mogensen, Director of Nursing by 3/31/25
Deficiencies in Food Service Safety and Cleanliness
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in both the main kitchen and resident unit nutrition areas. During the initial inspection, surveyors observed a build-up of debris on the manual can opener and mixer, dust and dirt on fire extinguishers, and a large pool of free-standing water on the floor of the walk-in refrigerator. Additionally, the storage area for clean pots, pans, and food containers had items that were not fully dried, and the rolling toaster had a significant amount of debris underneath. The final rinse pressure on the dishwasher was below the recommended level due to a malfunctioning gauge. In the East nutrition area, temperature logs for the refrigerator and freezer were missing for several dates, and there was a noticeable accumulation of dirt, grime, and food particles on various surfaces, including the refrigerator/freezer unit, microwave, and drawers. Interviews with the Director of Food Services and the Environmental Services Director revealed that staff were not diligent in cleaning and maintaining the equipment and kitchen areas. The Environmental Services Director acknowledged the lack of cleanliness and mentioned the development of a duty list to ensure daily responsibilities are completed.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: Manual can opener was found to have build-up of debris in the cutting area of the device. Mixer had dirt and debris on and under the device. Dust and dirt were on top of two fire extinguishers in the main kitchen. All three of these items were addressed immediately and cleaned during/after the initial walk through. Staff were reminded during a daily kitchen huddle on (MONTH) 6th that the areas need to be cleaned daily. East Nutrition Area: Temperature logs for the refrigerator/freezer in the East Nutrition area were missing dates from (MONTH) 6, 8, 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. West Nutrition Area: Temperature logs for the refrigerator and freezer were found to be missing dates for (MONTH) 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. Walk-in freezer was found to have a large puddle of free-standing water on the floor. Eastern Refrigeration was called to come address the puddle. A small water leak was found around the walk-in cooler and fixed. The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. Shortly after inspection, all pots and pans were pulled and inspected to ensure there was no wet nesting. The staff members responsible for cleaning and putting away dishes were reminded that all pots, pans, and containers need to be fully dried and contain no moisture before they are put away. The rolling toaster contained a large amount of debris under and behind the apparatus. The rolling toaster was moved and the counter was thoroughly cleaned. The issue was addressed with staff at a daily kitchen staff huddle on (MONTH) 6th, 2025. Responsible staff were reminded that this area needs to be cleaned after each use. Dirt and grime were found on the shelving unit above the grill cooking area. The shelving unit was wiped down and properly cleaned shortly after inspection. Discussion with the cooks took place on (MONTH) 6th, 2025 at daily staff huddle reminding the responsible staff members that the kitchen shelving unit needs to be cleaned each day. Final rinse pressure on the dishwasher was 13psi. The signage on the device had a recommendation of 20psi (+ or - 5psi). At the time of inspection, management was aware that the psi was not correct and a call had been made to Action Service, our repair company. (NAME), the Tech from Action Service, had come out and determined the machine was functioning as it should but there was a problem with the PSI Gauge and sensor. The part was immediately ordered and replaced/fixed on Tuesday (MONTH) 4th. Identification of other residents and corrective action: All above listed items will be audited at a frequency of twice per week. The Nutrition Management team already conducts a monthly food safety/sanitation audit. The audit frequency will change from monthly to twice per week for a period of 3 months or 90 days. Measures and Systemic Changes: Education and In-Servicing will take place with Nutritional Services staff to ensure compliance. Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Monitoring: Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation, or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Joe Clemens, Manager of Nutrition Services, by 3/31/25.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 8% during a recertification survey, exceeding the acceptable threshold of 5%. This was observed in two residents out of 16 during a medication pass. The facility's policy requires that medications be administered in accordance with specific guidelines, including timely administration and proper documentation in the electronic Medication Administration Record (eMAR). One resident, who had moderate cognitive impairment, was supposed to receive insulin before meals as per physician orders. However, the insulin was administered 90 minutes after a blood glucose reading of 347 mg/dL and after the resident had already consumed lunch. The LPN responsible for administering the insulin acknowledged the delay and did not take another blood glucose reading or report the late administration to a registered nurse or physician. Another resident, also with moderate cognitive impairment, was observed self-administering a nebulizer treatment that had been left at their bedside by an LPN. The LPN had signed off on the administration of the nebulizer treatment without ensuring the medication was consumed or that the resident rinsed their mouth afterward. The facility's Director of Nursing confirmed that no residents were authorized to self-administer medications, and medications should not be left at the bedside.
Infection Preventionist Role Not Designated
Penalty
Summary
The facility was cited for not designating an individual as the Infection Preventionist responsible for the facility's Infection Prevention Control Practices. Instead, the Director of Nursing (DON) had been performing a dual role as both the Infection Preventionist and Nurse Educator since May 10, 2023. This dual role was due to staffing issues, as stated by the DON during an entrance interview. The facility's policy and procedure on Infection Prevention and Control, revised in 2024, indicated that inquiries concerning infection control should be referred to the Infection Preventionist or DON. However, the facility failed to have a specified individual solely responsible for infection prevention, which is a requirement under the regulations. During the survey, it was revealed that the Administrator was unaware that the Infection Control Preventionist should not have a dual role with the DON. The review of key personnel documentation from 2023 confirmed that the DON was listed as the designated Infection Preventionist. The deficiency was identified under the 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c), which mandates that the Infection Preventionist should have a specific role without dual responsibilities. This oversight in staffing and role designation led to the citation during the recertification survey.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The Infection Control Committee policy was reviewed and revised to correctly identify the Infection Preventionist. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: An annual audit will be conducted to ensure that the IP continues to meet the requirements as set forth in F882. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Director of Nursing by 3/31/25
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice, as observed during a recertification survey. Specifically, the West Unit Team 1 medication cart contained opened medications, including vials of insulin and other medications, without open or expiration dates. Additionally, several bottles of eye drops lacked labels identifying the resident and did not have open or expiration dates. This deficiency was identified through observation, record review, and interviews with facility staff. Interviews with staff revealed a lack of adherence to the facility's policy regarding medication labeling. A Licensed Practical Nurse (LPN) stated that medications were labeled by the pharmacy, but acknowledged that labels on eye drops had fallen off, and they did not write expiration dates on the bottles. The Assistant Director of Nursing confirmed that it was the nurse's responsibility to label medications with open and expiration dates upon opening. The Director of Nursing reiterated that nurses were trained to label medications and check expiration dates before administration. Despite this training, the deficiency was noted, indicating a lapse in following established procedures.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: Immediate inspection of the West Unit Team 1 medication cart was performed and any medications found without label or date were appropriately disposed of and new ones were supplied by pharmacy and appropriately stored, labeled and dated per policy. Identification of other residents and corrective action: All residents are at risk for this deficient practice. All medication cart drawers were checked and any medications found without label or dated will be appropriately discarded and new ones will be supplied by pharmacy that are appropriately stored, labeled and dated per policy. Measures and Systemic Changes: Medication Administration Policy reviewed no changes. All nurses will be educated on policy regarding proper labeling and storage of medication. Monitoring: Auditing will be done twice a week for one month, then weekly for one month, then biweekly for one month. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: 3/31/25 Lynne Kaiser ADON
Improper Constitution of Quality Assurance Committee
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance Committee was properly constituted, as required by regulations. Specifically, the Director of Nursing was also serving as the Infection Preventionist, which is not permissible. The facility's Quality Assurance and Performance Improvement Plan outlined that the committee should include the Administrator, Medical Director, Director of Nursing, and Infection Preventionist, among others. However, due to staffing issues, the Director of Nursing was fulfilling multiple roles, including that of the Infection Preventionist and Nurse Educator. This dual role was not recognized by the Administrator, who was unaware that the Infection Preventionist should be a separate position. The facility's policy and procedure for Infection Prevention and Control, last revised in 2024, stated that the Infection Prevention and Control Committee should oversee the implementation of infection control policies and practices. During interviews, it was revealed that the facility held monthly meetings, but the responsibility for signing in was left to the staff. The Administrator admitted to being unaware of the requirement for the Infection Preventionist to be a distinct role, which contributed to the deficiency. This oversight had the potential to affect all residents of the facility, as the committee's role is crucial in coordinating and evaluating performance improvement projects.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The QAPI policy was reviewed with no changes. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: Audits of QAPI attendance will be completed to ensure the IP is present. This will be completed x 90 days. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Administrator by 3/31/25.
Dignity Concerns with Glove Use During Feeding
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by staff wearing gloves while feeding residents in the West dining room and by the East nurses station. Observations were made on multiple occasions where staff members wore gloves during feeding, which was not aligned with the facility's policy on promoting dignity and respect. The policy, effective since May 2020, emphasized that residents should be cared for in a manner that enhances their quality of life and individuality. Despite this, staff members, including Certified Nurse Aides and Licensed Practical Nurses, were observed wearing gloves while feeding residents, citing infection control as the reason. Interviews with staff revealed a lack of consensus on the dignity implications of wearing gloves during feeding. Some staff members believed it was necessary for infection control, while others recognized it could be perceived as undignified by residents. The Director of Nursing acknowledged that there was no written policy mandating glove use during feeding and suggested that concerns about dignity could be addressed in individual care plans. However, the inconsistency in practice and understanding among staff members contributed to the deficiency in maintaining residents' dignity during feeding.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and home-like environment, as evidenced by multiple deficiencies observed during a recertification survey. The surveyors noted that the floors in the corridors of both the East and West Units were soiled with dirt, particularly next to walls, in corners, and along door thresholds. Additionally, door frames and doors in several resident rooms were in disrepair, with scrapes, chips, and gouges. The walls in these units were also found to be in poor condition, with scrapes, chips, and unpainted areas. In one specific resident room, the wall was unfinished due to a previous water pipe break, and the ceiling tiles in the television rooms had visible water stains. Furthermore, the shower rooms were soiled with dirt and a dark black substance on the walls, and the handrails throughout the units were scuffed and scraped, exposing the underlying wood. Interviews with facility staff revealed that the Environmental Services Director acknowledged the lack of cleanliness and was in the process of developing a duty list for daily responsibilities. The Engineering Supervisor stated that their team was responsible for the facility's overall appearance and received multiple work orders daily for maintenance issues. They also mentioned a previous attempt to address the facility's appearance with a full touch-up on walls and door frames about a year ago. However, ongoing issues persisted, and a 3-month renovation plan was in place to address these concerns, including fixing resident room doors and improving the general appearance of the facility.
Failure to Provide Meaningful Activities for a Resident
Penalty
Summary
The facility failed to ensure the provision of meaningful activities for a resident, leading to a deficiency in supporting the resident's physical, mental, and psychosocial well-being. The facility's policy required the Department of Recreational Therapy to provide leisure programs for all residents, including those unable to attend group activities, on a seven-day-per-week basis. However, Resident #10, who was admitted with a diagnosis that included an inability to complete a mental status interview, was observed over several days in bed, non-verbal, and not participating in any activities. The resident was noted to be in the same position with the lights and television off, indicating a lack of engagement in meaningful activities. Interviews with the Activities Director revealed that although the resident was assessed for activity preferences upon admission, there was no documentation of one-on-one activity visits for the resident. The Activities Director acknowledged that one-on-one visits were not documented, which was a deviation from the facility's policy. The Director of Nursing confirmed the lack of documentation for one-on-one activities, which contributed to the deficiency in providing adequate support for the resident's quality of life.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: A progress note regarding the programming offered/implemented was completed on 2/13/25. The resident #10 passed away prior to receiving the statement of deficiencies. Identification of other residents and corrective action: All residents have the potential to be affected by the deficient practice. An audit of all recreation care plans for appropriate goals/interventions and appropriate documentation will be completed and any gaps identified will be addressed. Measures and Systemic Changes: Implemented policy “Recreation Program Development” 3/10/2025. Updated the Recreation Attendance sheet to include the time of a 1 on 1 visit. Education of the Recreation staff related to the new policy and documentation will be completed by 3/31/25. Monitoring: A weekly review of residents with a change in condition/status will be completed x30 days and as changes occur. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Erin Fazzio, Supervisor of Recreation, by 3/31.
Neglect of Residents Due to Miscommunication and Inadequate Care
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by two incidents involving Resident #10 and Resident #19. Resident #10, who was admitted with a diagnosis of [REDACTED], did not receive care during the night shift from 11:00 PM to 7:00 AM on January 29-30, 2025. The resident was found soaked and unchanged, indicating a lack of personal care and monitoring. This incident was attributed to a miscommunication regarding the assignment of caregivers, as the resident required no male caregivers, and the assigned Certified Nurse Aide was male. Resident #19, who was cognitively intact and required substantial assistance for mobility and personal care, experienced an incident on January 21, 2024, when they rolled out of bed and hit their head on furniture. This occurred while receiving care from a Certified Nurse Aide, who failed to use a second person for assistance as required. The resident was using a soft mattress pad overlay, which moved and caused them to slide to the floor. The resident sustained a bump on the forehead and was sent to the emergency department for evaluation. Both incidents highlight a failure in communication and adherence to care protocols, resulting in neglect of the residents' needs. The facility's policy on resident abuse and neglect was not followed, leading to these deficiencies in care. The incidents were investigated, and it was determined that staff did not provide the necessary care and supervision to prevent harm to the residents.
Failure to Provide Bed Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to a resident and/or the resident's representative upon transfer to the hospital. This deficiency was identified during a recertification survey, where it was found that the facility did not ensure the required notification was given to a resident who was transferred to the hospital due to a fall and possible fracture. The facility's policy, effective since October 2022, mandates that residents and their representatives be informed in writing about the bed hold policy in a language and manner they understand prior to any facility-initiated transfer or discharge. Resident #12, who had severe cognitive impairment and was responsible for making decisions regarding daily life tasks, was transferred to the emergency department. However, there was no documented evidence that the bed hold policy notice was provided at the time of transfer. Interviews with the Director of Nursing revealed that the responsibility for ensuring the bed hold policy notification was completed fell on nursing, social work, and the business office. The Director acknowledged that the notice of discharge, which includes the bed hold policy notification, had not been consistently completed.
Unreported Fall and Lack of Assessment for Resident
Penalty
Summary
Resident #62, who had mild cognitive impairment and a history of shortness of breath, experienced a fall in their room prior to being discharged from the facility. The incident was not reported to a nurse, and no assessment or interventions were conducted following the fall. The resident was found on the floor by three Certified Nurse Aides (CNAs), who assisted the resident into a wheelchair without notifying a nurse or reporting the incident. The CNAs involved, including CNA #8 who led the response, did not follow protocol by failing to report the fall to a nurse. CNA #8 informed a Licensed Practical Nurse (LPN) that the resident was short of breath but did not mention the fall. The LPN, unaware of the fall, attributed the shortness of breath to the resident's anxiety and administered a nebulizer treatment. The resident was discharged the following morning without any documentation or intervention related to the fall. The incident came to light when the resident's family informed the facility's Social Worker that the resident had fallen and was subsequently hospitalized due to persistent shortness of breath. The facility's Director of Nursing initiated an investigation after being notified by the Social Worker. The investigation revealed that the CNAs involved did not follow the proper procedure of reporting the fall and ensuring a nurse assessed the resident before moving them.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the required timeframe, leading to a deficiency. On January 23, 2025, a Licensed Practical Nurse (LPN) discovered a purple/blue area on the right foot of a resident during a routine skin check. However, the LPN did not report this finding to a Registered Nurse (RN) for further assessment, which delayed the investigation and reporting process. The injury was not reported to the State Survey Agency until January 25, 2025, which was beyond the mandated two-hour reporting window for such incidents. The resident involved had severe cognitive impairment and was unable to recall any incident that could have caused the injury. The resident was later assessed by a provider who ordered an x-ray to rule out a fracture. The x-ray revealed a displaced fracture of the 4th and 5th metatarsal necks, likely due to minimal impact, as the resident had significant osteopenia. Despite the injury being discovered on January 23, 2025, it was not until January 25, 2025, that the Director of Nursing (DON) reported the incident to the Department of Health, following the discovery of the injury by a Certified Nurse Aide during morning care. The facility's policy required immediate reporting of suspected abuse, neglect, or injuries of unknown origin, but this protocol was not followed. The DON acknowledged that the LPN should have notified an RN immediately after the initial discovery on January 23, 2025, to ensure timely assessment and reporting. The delay in reporting the injury to the Department of Health constituted a failure to comply with regulatory requirements, resulting in a deficiency citation.
Confidentiality Breach in Employee Records
Penalty
Summary
The facility failed to maintain the confidentiality of Criminal History Record Check (CHRC) records by including social security numbers on the employee information document, which was not requested. This deficiency was identified during a recertification survey through record review and interviews. The New York State Department of Health Criminal History Record Check Form 103 contained employees' social security numbers and other confidential personal information. During an interview, the New Employee Director acknowledged receiving this form during the onboarding process and confirmed that the information was secured in a locked cabinet, with only the director having access. However, the director admitted to inadvertently providing the documents containing private information to the administrator for distribution, recognizing this as a mistake that would not be repeated.
Failure to Involve Family in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their representative were given the opportunity to participate in the development and implementation of the resident's person-centered care plan. Specifically, the family member of a resident, who was cognitively intact and able to make decisions, was not invited to participate in quarterly care plan meetings. The facility's policy required that residents and their designated representatives be encouraged to participate in care plan development, including initial, significant changes, and annual care plans. However, the family member was only involved in the initial care plan meeting and a follow-up meeting related to discharge planning, but not in the quarterly meetings. Interviews revealed that the Director of Social Work acknowledged that family members were not notified of quarterly care plan meetings unless there was a significant change or a specific request from the family. The family member of the resident, who visited daily, expressed that they were not made aware of or invited to these meetings. The facility's practice of not notifying family members of quarterly care plan meetings was inconsistent with their policy, leading to the deficiency cited in the survey.
Failure to Provide Vision Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities, as required by regulation 483.25(a). The resident, who was admitted with a diagnosis of [REDACTED], was cognitively intact and able to communicate effectively. Despite expressing difficulty with vision and the ineffectiveness of their old glasses, the resident had not been provided with an eye exam, new glasses, or a follow-up ophthalmology appointment since their admission. The last ophthalmology consult was dated July 2020, prior to the resident's admission, and recommended a follow-up in three months, which was not arranged by the facility. The resident's Comprehensive Care Plan, dated December 2024, did not include any plan for vision care or glasses. Interviews with the Director of Nursing and a Registered Nurse revealed that the resident had not been seen by an ophthalmologist since admission, and it was the unit manager's responsibility to coordinate such follow-up visits. The Registered Nurse was unaware that the resident wore glasses and acknowledged the omission in the care plan, indicating a lack of awareness and coordination in addressing the resident's vision needs.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Corrective Action for those identified: Resident #19 has an ophthalmology appointment scheduled for 3/14/25 at 1500. The care plan for Resident #19 was updated to include vision concerns and use of eye glasses on 2/14/25. Identification of other residents and corrective action: All residents are at risk for the deficient practice. An audit of all residents for indication for follow up vision assessments and/or use of eyeglasses will be completed to ensure care planning (inclusive of scheduling of necessary follow up appointment) is completed appropriately. Measures and Systemic Changes: A new policy “Care of Visually Impaired Residents” was initiated on 3/11/2025. Education of pertinent staff related to the new policy will be completed by 3/31/25. Monitoring: An audit of all new admissions will be conducted to ensure vision treatment and assistive devices are appropriately addressed. This will occur weekly x 4 weeks and then monthly x 3 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Annmarie Mogensen, Director of Nursing, by 3/31/25.
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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