New Paltz Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in New Paltz, New York.
- Location
- 1 Jansen Road, New Paltz, New York 12561
- CMS Provider Number
- 335188
- Inspections on file
- 25
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at New Paltz Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors found that two residents with orders for as-needed oxycodone did not have consistent documentation of pain assessments or medication administration. Pain levels were not always assessed or recorded before and after medication was given, and staff interviews confirmed that documentation was often incomplete. The DON acknowledged that pain assessments were not consistently documented when pain medication was administered.
The facility did not ensure accurate documentation and oversight of controlled substance administration, as oxycodone was signed out for two residents without corresponding entries in the MAR. Some LPNs admitted to not always documenting as-needed pain medication due to being busy, and the pharmacy consultant only reviewed the MAR remotely without auditing narcotic control sheets. The DON confirmed there was no formal process to reconcile these records, resulting in discrepancies in controlled substance documentation.
The facility did not maintain adequate nursing staff and supervision, resulting in multiple shifts where only one aide or nurse was present for over 30 residents, frequent lack of nurse supervisors, and staff not completing full shifts. This led to delayed care, unaddressed call bells, incomplete resident care, and incidents such as a resident fall and a dislodged catheter not being promptly managed. Staff and residents reported ongoing issues with low staffing, missed care, and unmanageable workloads.
A cognitively impaired resident with a history of wandering was able to enter another resident's room and bed, where inappropriate physical contact occurred at the request of the impaired resident. Despite care plans identifying risks and interventions for abuse prevention, staff did not effectively prevent the incident, and the impaired resident was unable to recall the event.
The facility failed to ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, as required. On specific dates, the facility lacked RN coverage, relying instead on LPNs and on-call RNs. Staffing challenges and recruitment efforts were noted, but the deficiency remained.
The facility did not complete Annual Performance Reviews for three staff members as required by their policy. The Assistant Director of Nursing/Nurse Educator, new to the facility, acknowledged the absence of these reviews, which was confirmed by the DON during a survey.
The facility did not ensure food and drink were served at safe and appetizing temperatures. Two residents reported their food was consistently cold. A test tray showed food temperatures below acceptable levels, with the Dietary Technician unable to explain the discrepancy, despite stating that food left the kitchen at proper temperatures.
The facility failed to maintain proper infection control practices, including not updating the Water Management Plan and Environmental Risk Assessment annually. A resident's urine collection bag was improperly maintained, and another resident did not receive a consented vaccine in a timely manner. Four staff members were not screened or offered pneumococcal vaccination, and staff failed to use proper PPE with residents on Enhanced Barrier Precautions.
The facility failed to provide the required 12 hours of annual in-service training for three CNAs, as mandated by federal and state regulations. Documentation showed that the CNAs received only partial training hours, with CNA #10 receiving 6.5 hours, CNA #14 receiving 3.5 hours, and CNA #15 receiving 3.0 hours. The Assistant Director of Nursing, employed since September 2024, was unable to provide additional documentation, and the Director of Nursing confirmed this deficiency.
A resident with severe cognitive impairment was found with bruises, and their family reported alleged abuse. Despite overhearing the resident's claims of being hurt, an LPN and a CNA did not report the incident immediately. The facility's Administrator misunderstood reporting requirements, leading to a delay in notifying the State Agency. The facility's failure to report the alleged abuse promptly resulted in a deficiency.
A facility failed to thoroughly investigate abuse allegations involving a resident with severe cognitive impairment. The resident's family reported bruises inconsistent with documented falls, but the investigation was incomplete, lacking input from key staff and the Medical Director. The facility's policy required thorough investigations, but staff statements indicating potential abuse were not adequately considered, leading to a deficiency citation.
A resident was transferred to the hospital for a possible gastrointestinal bleed without receiving written notification in a language they understood. The family was informed by phone but did not receive written notice, and the Ombudsman was not notified. The facility's process for handling such notifications was not followed, leading to a deficiency.
A resident with a history of falls did not have their care plan revised after multiple incidents, despite being cognitively intact and requiring assistance with transfers. The facility's policy on falls management was not followed, as there was no documented evidence of care plan updates. Staff interviews indicated the resident's preference for independence contributed to the falls, but the care plan remained unchanged.
Two residents in an LTC facility did not receive care according to professional standards and care plans. One resident with a Life Vest had improper intervention by an LPN, and documentation omissions were noted. Another resident with Type 1 Diabetes had multiple omissions in insulin administration and blood sugar monitoring. Staff interviews revealed non-compliance with policies and procedures.
A resident with multiple diagnoses, including anxiety and right hemiplegia, experienced several unwitnessed falls without proper follow-up actions in an LTC facility. Despite policies requiring fall risk assessments and neurological checks, these were not consistently completed. Staff admitted to documentation and supervision failures, citing staffing issues as a barrier to one-to-one supervision. The resident was often found on the floor, and environmental hazards were not addressed, leading to a deficiency in providing a safe environment and adequate care.
The facility failed to maintain adequate staffing levels, resulting in insufficient care for residents. Over a 43-day period, the facility was understaffed on 35 days, leading to long wait times for call bell responses and hurried care. Residents and their representatives reported inattentive and rude staff, particularly during night shifts. The facility struggled with local recruitment and relied on travel agencies, causing high turnover and inadequate training for temporary staff.
A facility failed to ensure the attending physician documented the review and response to drug regimen review recommendations for a resident. The Medical Director did not sign or date the June 2024 Drug Regimen Reviews, which included a discrepancy in Sertraline dosage and a recommendation for a lipid profile. Interviews revealed the Medical Director did not receive the forms for review, leading to the deficiency.
A resident admitted with various medical conditions did not receive timely dental services as required by the facility's policy. Despite having intact cognition and expressing a need for dentures to assist with eating, there was no documented dental consult since admission. The DON acknowledged the oversight and mentioned the facility's process for addressing dental concerns.
The facility failed to adhere to professional standards for food service safety, with undated and unlabeled food items found in freezers, expired macaroni noodles in the emergency food supply, and a dietary aide without a beard covering. Additionally, the emergency food supply room had a peeling and stained ceiling due to a water leak, which the maintenance director was unaware of due to lack of reporting and absence of work orders.
Multiple deficiencies were identified, including a resident being transferred into a wheelchair with a broken brake, persistent uncleanliness in hallways and resident rooms, and the absence of a privacy curtain for a resident's toilet area. Staff interviews revealed inconsistent communication and awareness regarding these issues, and cleaning practices were found to be inadequate.
A resident with a fracture and diabetes was admitted with a deep tissue injury, but the facility failed to implement a skin integrity care plan and follow physician orders for skin checks and CAM boot use. The resident developed a new pressure ulcer on the heel, and treatments were inconsistently documented. Staff interviews revealed lapses in documentation and adherence to treatment protocols, and the administration acknowledged the lack of a care plan and documentation for interventions.
A resident left the facility without staff noticing until the next day, leading to a Code Gray being called. The facility's policies for reporting missing residents and documenting leave of absence were not followed, resulting in a lack of communication and documentation. Staff interviews revealed that the resident's absence was not communicated to the night shift, and the facility's computer system did not reflect the resident's leave of absence.
Failure to Consistently Document Pain Assessments and Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to ensure consistent pain management and documentation for two of three residents reviewed for pain medication. Both residents had physician orders for as-needed oxycodone, with specific instructions to assess and document pain levels prior to and after administration. However, review of narcotic control sheets and medication administration records over several months revealed numerous instances where pain assessments were not documented as required, and administration of pain medication was not consistently recorded. For one resident with a history of bipolar disorder and multiple fractures, narcotic control sheets showed oxycodone was signed out frequently, but pain assessments and documentation in the medication administration record were missing for a significant number of administrations. The resident reported not receiving pain medication as needed, particularly during overnight shifts, and stated that their concerns were not addressed. Interviews with nursing staff confirmed that pain assessments were not always performed or documented, and that the narcotic book was sometimes used to track administration times instead of the medication administration record. Another resident with a femur fracture, pain, and a hip wound also had incomplete documentation of pain assessments and medication administration. Staff interviews revealed that documentation was often incomplete, leading to missed pain assessments before and after medication administration. The DON acknowledged that pain assessments would only be triggered in the medication administration record if the medication was documented as given, and confirmed that there was no consistent documentation of pain assessments for these residents.
Failure to Ensure Accurate Documentation and Oversight of Controlled Substance Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents by not ensuring accurate dispensing and administration of controlled substances, specifically oxycodone, for two out of three residents reviewed. For one resident with diagnoses including bipolar disorder and multiple fractures, the narcotic control sheets indicated that oxycodone was signed out numerous times over several months, but there was no corresponding documentation in the Medication Administration Record (MAR) for a significant number of those instances. The resident reported not receiving pain medication as ordered, particularly during overnight shifts, and expressed concerns about possible drug diversion, which they stated were not taken seriously by staff. Interviews with nursing staff confirmed that pain medications administered were not always documented in the MAR, citing being busy as a reason for incomplete records. For another resident admitted with a femur fracture and pain, the narcotic control sheets also showed oxycodone was signed out multiple times, but half of those administrations were not documented in the MAR. This resident, however, reported receiving pain medication consistently and denied any issues with administration. Observations confirmed that narcotics were physically accounted for, and security protocols for medication storage were followed. Despite this, staff interviews revealed a pattern of incomplete documentation, with some nurses relying on narcotic control sheets rather than the MAR to track administration times. The facility's policy required staff to document medication administration in the MAR immediately after giving each dose, but this was not consistently followed. The pharmacy consultant, who worked offsite, only reviewed the MAR and did not audit narcotic control sheets or pain assessments, as per the contract with the facility. The Director of Nursing acknowledged that there was no formal process to reconcile narcotic control sheets with the MAR, and the pharmacist did not conduct onsite reviews. This lack of oversight and incomplete documentation led to discrepancies in the administration records of controlled substances.
Failure to Maintain Adequate Nursing Staff and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple days where staffing levels fell below the facility's own staffing plan and regulatory requirements. On several occasions, there was only one certified nurse aide assigned to units with over 30 residents during the night shift, and nurse supervisors were frequently not present during evening and night shifts. Staffing records showed inconsistencies, with staff not completing full shifts, coming in late, or leaving early, and callouts were often not replaced. These staffing shortages led to delays in care, such as long wait times for call bell responses, incomplete turning and repositioning, and residents not being assisted out of bed or returned to bed as needed. Specific incidents highlighted the impact of inadequate staffing on resident care and safety. On one night shift, a resident sustained a fall when only one LPN was present on the unit due to a callout that was not covered, and no nurse supervisor was in the building. Another resident dislodged their urinary catheter and did not receive timely assistance, with a fellow resident having to stay with them for two hours until the morning shift arrived. Staff interviews confirmed that when only one aide was present on a unit, essential cares were not completed, residents were left wet, and medication administration was delayed. Staff also reported that they were often required to work double shifts, skip breaks, and manage unmanageable workloads due to chronic understaffing and unreliable scheduling. Residents and their representatives expressed concerns during council meetings about the lack of responsiveness to call bells, missed or rushed care, and the particular challenges during overnight shifts. The facility's Director of Nursing and Administrator acknowledged ongoing recruitment challenges, frequent callouts, and the difficulty in maintaining adequate staffing, especially for night shifts. Despite being aware of these issues, the facility did not adjust staffing based on resident acuity or ensure that callouts and shift changes were effectively managed, resulting in repeated instances where resident care and safety were compromised.
Failure to Protect Cognitively Impaired Resident from Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering was found in another resident's bed. The cognitively impaired resident had diagnoses including unspecified dementia, cerebral infarction, and unspecified psychosis, and was known to wander into other residents' rooms. The care plan for this resident identified risks for abuse, neglect, and exploitation, and included interventions such as assessment for signs of abuse and prompt investigation of any allegations. Despite these interventions, the resident was able to enter another resident's room and bed without effective prevention. The other resident involved was cognitively intact and admitted to touching the impaired resident's breasts at the request of the impaired resident. There was no prior documentation or care plan indicating that this resident exhibited any sexually inappropriate behavior. Staff interviews confirmed that the cognitively impaired resident was known to wander and had previously entered other residents' rooms and beds. At the time of the incident, the impaired resident was found partially undressed in the other resident's bed, and was unable to recall the event or appear distressed during subsequent interviews. The facility's investigation concluded that no abuse had occurred, citing a lack of malicious intent. However, the impaired resident's inability to make sound decisions and the failure to prevent the incident despite known risks and existing care plans led to the deficiency. The facility's policy required processes to prevent and report suspected or alleged abuse, neglect, or exploitation, but these processes were not effectively implemented to protect the resident from abuse in this instance.
Deficiency in RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required by regulations. Specifically, the facility was unable to provide documented evidence of an RN working on certain dates, including 10/20/24, 11/2/24, 11/3/24, 11/16/24, and 11/17/24. The Facility Wide Assessment did not include a plan for RN coverage for the required hours, and the Daily Nurse Staffing Roster confirmed the absence of an RN on the specified dates. Interviews with the Staffing Coordinator, Director of Nursing, and an LPN revealed that the facility relied on Licensed Practical Nurses (LPNs) and on-call RNs to cover shifts when an RN was not present, particularly on weekends. The Director of Nursing and other RNs were on-call and available to present to the facility if needed, and a telehealth line was available for mid-level coverage by a Physician Assistant or Nurse Practitioner. However, the facility acknowledged challenges in staffing and was actively recruiting additional RNs. The Administrator also noted difficulties in hiring locally, contributing to the staffing challenges. Despite these efforts, the facility did not meet the regulatory requirement for RN coverage, resulting in a deficiency.
Failure to Conduct Annual Staff Performance Reviews
Penalty
Summary
The facility failed to ensure that Annual Performance Reviews were completed for its staff members at least once every 12 months, as required by their policy. During a recertification survey, it was found that the facility could not provide documentation of Annual Performance Reviews for three out of five staff members reviewed. The facility's policy, dated September 29, 2019, mandates that a performance evaluation be completed annually for each employee. However, during interviews and record reviews, both the Assistant Director of Nursing/Nurse Educator and the Director of Nursing acknowledged the absence of these reviews for the specified staff members. The Assistant Director of Nursing/Nurse Educator, who is new to the facility, admitted to not having completed the annual performance reviews yet.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food and drink were provided to residents at palatable, attractive, and safe temperatures. During the recertification survey, it was observed that food was not served at appropriate temperatures for two residents. Resident #17 and Resident #23 both reported that their food was consistently served cold. A test tray checked by the Dietary Technician revealed that the temperatures of the food items were below the acceptable range, with pork gravy at 103.3 degrees Fahrenheit, mashed potatoes at 123.4 degrees Fahrenheit, cooked carrots at 102.6 degrees Fahrenheit, and cranberry juice at 62 degrees Fahrenheit. The Dietary Technician was unable to explain why the food temperatures were low, despite stating that the food and beverages were at acceptable temperatures when they left the kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by several deficiencies identified during a recertification survey. The Water Management Plan was not updated annually, and the Environmental Risk Assessment had not been performed annually to identify areas where Legionella could spread. The Director of Maintenance was unaware of the requirement for annual reviews and assessments, indicating a lack of awareness and adherence to infection control protocols. Resident #13's urine collection bag was not maintained in a manner to prevent infection. Observations revealed that the urine collection bag and drainage port were in contact with the floor, and the leg bag was hanging over the toilet handrail without a cap cover. Certified Nurse Aide #1 used improper techniques when handling the urine collection bag, which could potentially spread infections. The Infection Preventionist acknowledged the need for constant education and reminders for staff to perform tasks correctly. Additionally, Resident #51 consented to receive the Respiratory Syncytial Virus vaccine but did not receive it until almost two months later, despite the vaccine being available. Furthermore, four staff members were not screened, offered, or given the opportunity to accept or decline pneumococcal vaccination. Staff also failed to apply proper Personal Protective Equipment while assisting residents on Enhanced Barrier Precautions, as observed with Resident #23 and Resident #26. These lapses in infection control practices highlight significant deficiencies in the facility's infection prevention and control program.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service training, as mandated by federal and state regulations. Specifically, the facility could not provide documentation that three CNAs, identified as #10, #14, and #15, received the necessary training hours. The facility's policy on Staff Development and In-service Programming, revised in January 2023, requires personnel to participate in in-service training to remain current in knowledge affecting service delivery. However, the documentation showed that CNA #10 received only 6.5 hours, CNA #14 received 3.5 hours, and CNA #15 received 3.0 hours of training. During interviews, the Assistant Director of Nursing admitted the inability to provide the required 12 hours of training for the CNAs in question. The Assistant Director, who had been employed since September 2024, attempted to contact the previous Assistant Director of Nursing but was unable to obtain additional training documentation. The Director of Nursing confirmed the Assistant Director's statement regarding the lack of sufficient training hours for the CNAs. This deficiency was identified during a recertification survey conducted from November 14 to November 22, 2024, and is in violation of 10 NYCRR 415.26 (c)(1)(iv).
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, identified as Resident #176, to the State Agency within the required timeframe. The incident came to light when the resident's family reported bruises on the resident's forehead after a hospital transfer for altered mental status. Despite the facility's policy requiring immediate notification to the State Agency within two hours of identifying an alleged incident, the facility did not comply. The resident had a history of severe cognitive impairment and was dependent on others for care, making them vulnerable to abuse. The investigation revealed that a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA) overheard the resident yelling about being hurt and beaten, but they did not report these statements to the administration immediately. The facility's Accident and Incident Report initially documented the bruises as resulting from previous falls, but the Registered Nurse Unit Manager later initiated an investigation due to inconsistencies with the fall history. The facility's Administrator admitted to labeling the incident as alleged abuse to appease the family and avoid a report to the Department of Health, misunderstanding the reporting requirements. Interviews with staff and the resident's Health Care Proxy indicated that the resident had previously verbalized abuse allegations, which were not adequately addressed by the facility. The Medical Director was not informed of the alleged abuse, and the facility's Director of Nursing emphasized the importance of reporting all allegations to the State Agency, regardless of the facility's internal findings. The failure to report the alleged abuse promptly and the mishandling of the situation led to the deficiency noted in the survey.
Failure to Investigate Abuse Allegations Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident with severe cognitive impairment. The resident, who had a history of anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis, was reported by their family to have multiple bruises on their forehead upon transfer to the hospital. Despite the facility's policy requiring prompt and thorough investigations of such allegations, there was no documented evidence of a complete investigation. Staff statements indicated that the bruising was attributed to falls, but inconsistencies were noted, as the bruises were not consistent with the falls documented in the facility's records. Interviews with staff revealed that the investigation was not comprehensive, as key statements from staff members who heard the resident's claims of being hurt were not adequately considered. The Medical Director was not informed of the abuse allegations, and the investigation was deemed incomplete without their assessment. The facility's Administrator and Director of Nursing acknowledged that the investigation was not thorough and that the statements from staff who heard the resident's cries for help should have been taken seriously. The failure to properly investigate the allegations of abuse and neglect resulted in a deficiency citation.
Failure to Provide Written Transfer Notification and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding the reason for a transfer to the hospital, as well as failing to notify the Office of the State Long-Term Care Ombudsman. The resident, who had diagnoses including Acute Kidney Failure, Neuromuscular Dysfunction of Bladder, and Encephalopathy, was transferred to the hospital for further evaluation due to blood in stool and a possible gastrointestinal bleed. Although the family was notified by telephone and agreed with the transfer, they did not receive a written notification in a language they understood, as required. The Director of Nursing confirmed that the facility could not locate a copy of the written transfer notification. The process for notifying the Ombudsman was also not followed, as the facility was unable to provide evidence of such notification. The responsibility for notifying the Ombudsman and the resident's family was assigned to the Social Worker, who had left the facility in September 2024 and had not been replaced. This lack of documentation and communication led to the deficiency identified during the recertification survey.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was revised for a resident who experienced multiple falls. The resident, who was admitted with diagnoses including a hip fracture and muscle weakness, had falls on three separate occasions. Despite these incidents, there was no documented evidence that the care plan interventions were reviewed or revised to address the falls, as required by the facility's policy on Falls Management and Prevention. The resident was cognitively intact and required partial assistance with certain transfers but was independent with wheelchair locomotion. The falls occurred on different dates, with the first being an unwitnessed fall while transferring from the bed to a wheelchair, the second being a fall from the edge of the bed, and the third being a witnessed fall where the resident lost balance. Each incident was documented, but the care plan was not updated to reflect new interventions or strategies to prevent further falls. Interviews with staff, including a CNA and an LPN, revealed that the resident often attempted to be independent and did not always call for assistance, which contributed to the falls. The Director of Nursing confirmed that the care plans are supposed to be updated by RNs and that the interdisciplinary team should implement appropriate interventions. However, there was no documented evidence that the care plan was revised after the falls, highlighting a deficiency in the facility's care planning process.
Deficiencies in Care for Residents with Life Vest and Diabetes
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for two residents. One resident, who was admitted with a wearable defibrillator (Life Vest) due to a history of Sudden Cardiac Arrest, became unresponsive. The nurse attending to the resident improperly pressed the response button on the Life Vest, contrary to the facility's policy that only the resident should press the button. Additionally, there were multiple omissions in the March Medication Record regarding the monitoring and maintenance of the Life Vest, including ensuring correct placement, battery changes, and documentation of these actions. Another resident with Type 1 Diabetes Mellitus and a history of Diabetic Ketoacidosis experienced multiple omissions in the Medication Administration Record for insulin administration and blood sugar monitoring over several months. The facility's policy required documentation of blood sugar levels and insulin administration, but there were numerous instances where this was not done. The Medical Director emphasized the importance of notifying them if blood sugar levels were critically high or low and ensuring that insulin was administered as ordered. Interviews with staff revealed a lack of adherence to policies and procedures, with nurses failing to document medication administration and blood sugar monitoring accurately. The Director of Nursing and other staff acknowledged the importance of following physician orders and documenting all actions in the Medication Administration Record to ensure proper management of residents' medical conditions.
Inadequate Supervision and Fall Prevention for Resident
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident, leading to multiple unwitnessed falls and a lack of appropriate follow-up actions. The resident, who had diagnoses including anxiety, cerebral infarction, right hemiplegia, and unspecified psychosis, experienced several falls between January and March 2024. Despite the facility's policy requiring fall risk assessments and neurological checks after falls, these were not consistently completed or documented for the resident. The resident's care plan was not reviewed or revised in a timely manner, and there was no evidence of enhanced monitoring or one-to-one supervision after the resident verbalized suicidal ideation. The facility's staff, including the Registered Nurse Unit Manager and the Director of Nursing, acknowledged the lack of documentation and supervision. They admitted that neurological checks were not consistently performed or uploaded into the system, and that the facility did not have a reliable method for tracking one-to-one supervision. The staff also noted that the facility was reluctant to place residents on one-to-one supervision due to staffing issues, which contributed to the resident's repeated falls and lack of supervision. Interviews with staff and a complainant revealed that the resident was frequently found on the floor, sometimes with their head against the wall, and that requests to address environmental hazards, such as the placement of a radiator, were not acted upon. The facility's failure to implement and document necessary safety measures and supervision for the resident, despite their high fall risk and suicidal ideation, resulted in a deficiency in providing a safe environment and adequate care.
Staffing Deficiency Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by the staffing schedule from October 10, 2024, through November 21, 2024, which showed understaffing on 35 out of 43 days reviewed. The facility's staffing plan required a specific number of nurses and certified nurse aides per shift, but these numbers were not consistently met. Residents and their representatives reported long wait times for call bell responses, especially during the night shift, and noted that staff were often inattentive or rude. The shortage of certified nurse aides was particularly problematic, leading to hurried care and extended wait times for services such as medication administration and feeding. Interviews with staff and management revealed that the facility struggled with local recruitment and relied heavily on travel agencies to fill staffing gaps, which contributed to high turnover and inadequate training for temporary staff. The Director of Nursing acknowledged ongoing staffing challenges since July 2024, despite recent efforts to hire additional registered nurses. The staffing coordinator confirmed that call-outs were managed by offering overtime and shift coverage incentives, but these measures were not always sufficient to maintain adequate staffing levels. The use of travel certified nurse aides was noted to cause dissatisfaction among residents due to the constant turnover and lack of familiarity with state regulations.
Failure to Document Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented the review and response to drug regimen review recommendations for a resident. Specifically, the Medical Director did not sign or date the Drug Regimen Reviews for June 2024 for a resident with diagnoses including Diabetes Mellitus II with Hyperglycemia, Cardiac Arrhythmia, and Depression. The Drug Regimen Review noted a discrepancy between the psychiatry recommendation to increase Sertraline to 100 mg daily and the actual prescription of 75 mg daily. Additionally, the review recommended a lipid profile to monitor Atorvastatin, but there was no documented evidence of the Medical Director's review or response to these recommendations in the resident's electronic medical record. Interviews revealed that the facility's process involves printing Drug Regimen Reviews and placing them in folders for the Medical Director's review. However, the Medical Director stated that they did not receive the forms for review, as indicated by the absence of their signature and date on the documents. The Director of Nursing confirmed that the June 2024 Drug Regimen Reviews were not signed and dated by the physician, and there was no documented reply to the recommendations. This lack of documentation and follow-up on the Drug Regimen Reviews led to the deficiency identified during the recertification survey.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services in a timely manner for a resident who was admitted on 2/29/24. The resident, who has diagnoses including Peripheral Vascular Disease, Major Depressive Disorder, and an Acquired Absence of the Left Leg above the knee, had intact cognition as per the Quarterly Minimum Data Set dated 11/3/24. Despite the facility's policy stating that routine and emergency dental services should be available based on resident assessment and care plans, there was no documented evidence of a dental consult for this resident since their admission. During an interview and observation on 11/19/24, the resident reported not receiving a routine dental consultation since admission and expressed a desire for dentures to assist with eating, as they were edentulous and had previously used dentures that required adjustment. The Director of Nursing confirmed that the facility has a dental consultant who visits monthly and as needed, but was unsure of the exact visit cycle. They stated that any nursing team member could report concerns to the unit manager or Assistant Director of Nursing, and they would discuss the resident's concern with the physician to potentially place an order for a dental consult.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, several deficiencies were observed, including undated ice cream in the meat and vegetable freezers, unlabeled and undated food items such as burgers, steak sandwiches, cheese pizza, chicken breast, hot dogs, lasagna sheets, strawberries, French toast, garlic toast, and diced carrots. Additionally, there were expired boxes of deluxe original cheddar macaroni noodles in the emergency food supply room. A dietary aide was observed in the kitchen without a beard covering, which is against the facility's policy. The facility's emergency food supply room had a ceiling that was peeling and stained with a black/brown substance, which the Director of Maintenance attributed to a water leak. The Director of Maintenance was unaware of the ceiling's condition as they do not enter the room unless issues are reported by staff. The facility does not use work orders, relying instead on verbal communication for maintenance needs. The Food Service Director acknowledged the need for staff to label and date food items and for dietary workers to wear appropriate coverings, but these practices were not consistently followed, leading to the observed deficiencies.
Failure to Maintain Safe, Clean, and Private Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed and reported across three units. One resident, admitted with heart failure, obstructive uropathy, and diabetes mellitus, was cognitively intact and required substantial assistance for transfers. Despite this, the resident's wheelchair had a broken left brake for at least a week, and staff continued to transfer the resident without locking the brake. Certified Nurse Assistants, the Occupational Therapist, and the Therapy Director had inconsistent awareness and communication regarding the broken brake, and the Director of Maintenance was only notified about the issue the day before the interview, despite prior notifications to other staff members. Additional deficiencies included uncleanliness and lack of privacy in resident areas. Observations revealed dirt, dust, and food debris in hallways and outside resident rooms, as well as a dirty over-bed table with dried coffee stains and caked food. One resident's room lacked a privacy curtain for the toilet area, resulting in embarrassment for the resident and a lack of privacy during toileting. Staff interviews confirmed the absence of the curtain for an extended period and inconsistent cleaning practices for resident areas. The Director of Maintenance and the Director of Housekeeping were not fully aware of these ongoing issues, and cleaning equipment was reported as inadequate for maintaining cleanliness.
Failure to Prevent Pressure Ulcers and Incomplete Documentation
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development of new pressure ulcers for a resident who was admitted with a deep tissue injury. The resident, who had a fracture of the left fibula, Type 2 Diabetes, and Depression, was admitted with an unstageable pressure injury on the left dorsal foot. Despite physician orders for skin checks every shift and the use of a CAM boot when out of bed, these orders were not consistently followed. The resident developed a new pressure ulcer on the left heel, and treatments were not completed as ordered. The facility's documentation was inconsistent and incomplete. The November 2023 Treatment Administration Record showed multiple instances where skin inspections and Skin Prep treatments were not documented as completed. Weekly skin evaluations were also not documented as completed for the month of November. Interviews with staff revealed a lack of consistent documentation and adherence to treatment protocols, with some staff unable to recall whether the CAM boot was worn properly or removed as needed. The facility's administration acknowledged the lack of a skin integrity care plan upon admission and the absence of documentation for interventions or physician notifications regarding the pressure injury present on admission. They also noted the resident's non-compliance with the CAM boot, which was not documented. The facility was unable to provide documentation of care plan interventions for skin integrity prior to the development of the heel pressure injury, indicating a failure in the implementation and monitoring of necessary care protocols.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to maintain adequate supervision to prevent an elopement incident involving a resident. The resident left the building on January 22, 2024, without staff noticing their absence until the following day when the nurse could not find the resident for morning medications. A Code Gray was called, and the resident was located at a friend's house and returned to the facility later that day. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but this was not followed in this case. The facility's Out on Pass/Leave of Absence policy was not properly executed. Although an Out-on-Pass Agreement form was signed by the resident, their representative, and a registered nurse, it was incomplete and lacked the date or time of the resident's return. Additionally, the receptionist and unit clerk were unaware of the resident's departure, and there was no documentation at the front desk. The resident's absence was not communicated to the night shift staff, leading to a delay in recognizing the resident's absence. Interviews with staff revealed a lack of communication and documentation regarding the resident's leave of absence. The Director of Nursing did not classify the event as an elopement, as they believed the resident was out on pass. However, the absence of proper documentation and communication led to the resident being considered missing. The facility's computer system also lacked documentation of the resident's leave of absence, indicating a failure in the facility's procedures to track and monitor residents' whereabouts effectively.
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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