New Vanderbilt Rehabilitation And Care Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Staten Island, New York.
- Location
- 135 Vanderbilt Ave, Staten Island, New York 10304
- CMS Provider Number
- 335372
- Inspections on file
- 19
- Latest survey
- July 16, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at New Vanderbilt Rehabilitation And Care Center, Inc during CMS and state inspections, most recent first.
The facility failed to maintain food safety standards, with undated and unlabeled items in the refrigerator, improper temperature control in the dry storage room, and cold food items not held at proper temperatures during tray line service. The Dietary Chef and Food Service Director acknowledged lapses in labeling and equipment functionality.
The facility failed to maintain proper infection control practices during wound care and medication administration. A nurse did not perform hand hygiene or change gloves appropriately while providing wound care to a resident with a Stage 4 pressure ulcer. Another nurse demonstrated inadequate infection control during wound care for a resident with an unstageable pressure ulcer, failing to sanitize the bedside table and not performing hand hygiene after cleaning the wound. Additionally, a nurse did not perform hand hygiene between glove changes while administering medications via a gastrostomy tube and instilling eye drops for a resident.
The facility did not honor the shower preferences of three residents, impacting their self-determination. A resident with cognitive impairment was not showered as scheduled, while two cognitively intact residents were unable to receive showers as frequently as desired due to scheduling and staffing constraints. Staff interviews revealed a lack of awareness and flexibility in accommodating these preferences.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as broken furniture, mismatched paint, and an unresolved ceiling leak affecting multiple units. Staff interviews revealed that maintenance issues were reported but not promptly addressed, and the maintenance team was understaffed, impacting repair times.
The facility did not accommodate residents' dietary preferences, failing to meet nutritional, religious, cultural, and ethnic needs. A resident was denied ice cream due to kosher restrictions, another did not receive their chosen meal, and a third expressed dissatisfaction with limited non-kosher options. The facility's adherence to kosher laws restricted menu choices, causing resident dissatisfaction.
The facility's QAPI program failed to effectively identify and prioritize problems, resulting in repeated deficiencies from a previous survey. Issues included resident rights, advance directives, and professional standards. Despite having a QAPI plan and reporting system, the facility struggled with compliance, partly due to a new Director of Nursing.
A resident with cognitive impairments was sprayed with hand sanitizer by a Dayroom Attendant in an attempt to stop the resident's behavior, leading to a physical altercation with another resident. The incident, captured on video but not retained, showed the Attendant's inappropriate action, which violated the facility's abuse prevention policy. Staff interviews confirmed the events, and the Attendant was terminated following the investigation.
A resident-to-resident altercation was not reported to the NY State Department of Health within the required 2-hour timeframe. The incident involved two residents with cognitive impairments, where one resident flipped the other from their wheelchair. The delay in reporting was attributed to the incident occurring on a Sunday when the DON was not present, resulting in a deficiency.
A facility failed to thoroughly investigate an alleged staff-to-resident abuse incident involving a Dayroom Attendant and a cognitively impaired resident. The Dayroom Attendant was seen on video spraying the resident with hand sanitizer, but the facility did not conduct a comprehensive investigation, lacking interviews or witness statements. The Director of Nursing and Administrator reviewed the footage but did not preserve it or complete a separate investigation, resulting in a deficiency.
A facility failed to revise a resident's Comprehensive Care Plan for Activities of Daily Living quarterly, despite completed assessments. The resident, diagnosed with Cerebrovascular Accident, Hypertension, and Hyperlipidemia, had their care plan last revised several months prior. Staff interviews confirmed that the responsibility for updating care plans lies with the nurse supervisor, but the necessary updates were not made.
A resident with Major Depressive Disorder and Alzheimer's disease exhibited worsening behavioral symptoms, leading to an increase in psychotropic medication without assessing for underlying medical causes. Despite severe cognitive impairment and routine antipsychotic medication, there was no documented medical workup before the dosage increase. Interviews with staff revealed fluctuating behavior over two months, with the psychiatrist adjusting medication without confirming an assessment for potential infections.
A facility failed to accurately document a resident's participation in a floor ambulation program. Despite records indicating the resident was engaged in the program, interviews revealed the resident was not receiving the care. The resident, with a history of cerebrovascular accident and hypertension, expressed a desire for increased mobility. Staff were unaware of the program, and the Director of Nursing acknowledged the discrepancy between documented and actual care.
A resident with intact cognition and multiple diagnoses, including Diabetes Mellitus, was subjected to a blood glucose monitoring procedure in a public dining area, violating their right to privacy and dignity. The LPN involved was instructed to perform the procedure whenever they encountered the resident, but typically in private areas. Both the RN Supervisor and the DON confirmed that the procedure should have been conducted in the resident's room to maintain privacy.
The facility failed to ensure that two residents were provided the option to formulate and document advance directives. One resident, who was moderately cognitively intact, had no orders for advance directives in their medical records, and another resident had no advance directive options selected in their care plan. Interviews with staff revealed inconsistencies in the process of documenting advance directives, with unclear responsibilities among staff members.
A resident with diabetes had a blood sugar level below the required threshold, but the physician was not notified as per the facility's policy. The LPN claimed to have sent a text to the physician, but the physician did not receive it. The DON confirmed that the LPN should have followed the physician's orders and notified the physician and their supervisor.
A resident with a feeding tube received medications improperly when an LPN used a pistol syringe to force medications through the tube, contrary to the facility's policy of administering by gravity flow. This inconsistency in procedure understanding among staff led to a deficiency in professional standards.
Two residents with indwelling catheters were observed with their catheter bags improperly positioned above bladder level, compromising drainage and increasing the risk of urinary tract infections. Despite having care plans and physician orders, staff failed to adhere to facility policies, and interviews revealed inadequate monitoring and supervision by nursing staff.
A facility failed to ensure timely action on a pharmacist's drug regimen review for a resident with Alzheimer's and Anxiety Disorder. Despite the attending physician's agreement to check Depakote levels, no lab tests were ordered or conducted. Interviews revealed a lack of follow-through, with the attending physician deferring responsibility to a psychiatrist and the Medical Director emphasizing the attending physician's responsibility.
A resident with a history of cerebrovascular accident and other conditions was not provided with a prescribed Floor Ambulation Program to maintain mobility. Despite a physician's order and discharge recommendations from physical therapy, the program was not implemented due to a lack of communication and awareness among nursing staff. The resident expressed a desire for more activity, but the facility failed to execute the necessary care plan.
The facility failed to submit MDS 3.0 assessments within the required timeframe, affecting all residents reviewed. Delays ranged from 38 to 63 days due to late documentation by interdisciplinary team members and staffing issues. The MDS/Rehabilitation Department head and Secretary acknowledged the delays, and the Administrator was aware but uncertain about the responsible parties.
The facility did not ensure proper disposal of garbage, as the compactor door was left ajar, attracting flies. During a kitchen inspection, a Dietary Worker was observed bringing garbage to the disposal area, where the compactor door was open. Staff interviews confirmed that the compactor is used by housekeeping and food service staff, who are expected to keep the door closed. The facility's policy requires all kitchen waste to be properly disposed of in the compactor.
A resident at the facility was involved in an altercation with a staff member, leading to the use of excessive force. The incident was deemed to be abusive, and the staff member was terminated as a result. The incident was reported to the facility's administration, and an investigation was conducted, revealing that the staff member had used excessive force against the resident.
A resident with severe cognitive impairment and aggressive behavior was physically restrained and slapped by a CNA during an altercation. The facility's surveillance footage confirmed the abuse, which violated the facility's policy against physical restraint. Staff interviews supported the findings, highlighting inappropriate actions taken by the CNA.
A resident with severe cognitive impairment and multiple diagnoses, including Disorganized Schizophrenia, exhibited aggressive behavior towards staff and other residents. The facility's Comprehensive Care Plan lacked individualized interventions and was not updated or evaluated after incidents of aggression. Staff interviews revealed a lack of documented instructions for monitoring the resident's behavior or guidance on handling aggression, highlighting a failure to provide necessary behavioral health care and services.
Food Safety and Storage 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 a kitchen observation, it was noted that the dairy walk-in refrigerator contained undated and unlabeled food items, specifically leftover scrambled eggs and boiled eggs covered with aluminum foil. Additionally, the dry storage room was found to be humid, lacking ventilation, and excessively hot, with a temperature of 87.7 degrees Fahrenheit. This room contained expired items, including bottles of sweet chili sauce past their best-by date and salsa bottles that required cool storage. The Dietary Chef acknowledged responsibility for labeling and dating prepared foods but admitted that this was missed for the leftover breakfast items. Further observations during a tray line service revealed that cold food items were not held at the proper temperatures. A cheese sandwich, a plate of lettuce and tomato, and a tuna fish sandwich were all found to be above the required temperature, registering at 59, 64, and 63.5 degrees Fahrenheit, respectively. The Food Service Director confirmed that sandwiches are typically made and stored in the freezer before being placed on ice for lunch service, but the freezer was not functioning properly on the day of the observation. The Director of Maintenance also noted the lack of ventilation in the dry storage room, attributing the high temperature to the hot summer weather, which should ideally be below 75 degrees Fahrenheit.
Infection Control Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care and medication administration, as observed during the recertification survey. Registered Nurse Supervisor #8 did not perform hand hygiene or change gloves appropriately while providing wound care to a resident with a Stage 4 pressure ulcer. The nurse removed the soiled dressing and proceeded to clean the wound and apply treatment without washing hands or changing gloves, contrary to the facility's infection control policy. Licensed Practical Nurse #4 also demonstrated inadequate infection control during wound care for a resident with an unstageable pressure ulcer. The nurse failed to sanitize the bedside table, did not clean the wound from inner to outer aspects, and did not perform hand hygiene after cleaning the wound. Additionally, the nurse returned an opened multipack of gauze to the medication cart, further compromising infection control standards. Licensed Practical Nurse #5 did not perform hand hygiene between glove changes while administering medications via a gastrostomy tube and instilling eye drops for a resident. Despite being taught to wash hands between glove changes, the nurse admitted to forgetting this step during the procedure. The Director of Nursing confirmed that staff are instructed to perform hand hygiene after every glove change, highlighting a lapse in adherence to infection control protocols.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not adhering to the residents' preferences for the number of showers per week. Resident #143, who has a diagnosis of cerebrovascular accident and hypertension, expressed a desire to be showered twice a week as per their schedule. However, documentation revealed that the resident was only showered on three occasions in June and twice in early July, with no evidence of refusal on other scheduled days. Interviews with staff indicated a lack of awareness and documentation regarding the resident's shower schedule and preferences. Resident #63, who is cognitively intact and requires moderate assistance with bathing, expressed a desire to shower more frequently than the scheduled twice a week. Despite this, the resident was told to wait until their designated shower days. The staff confirmed that the resident had not requested additional showers during the day shift but had requested bed baths, which were accommodated. The facility's policy did not appear to support flexibility in accommodating the resident's preferences for more frequent showers. Resident #39, who is cognitively intact and requires dependent-level assistance for bathing, was unable to shower on Wednesdays due to dialysis appointments, leaving only Saturdays for showers. The resident expressed dissatisfaction with the thoroughness of the staff's cleaning and the inability to have their hair washed due to time constraints. Staff interviews revealed that the shower schedule was rigid, with changes requiring approval from the social worker and Director of Nursing, and that additional shower requests were only accommodated if staffing allowed.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the recertification survey. On Unit 5, a wooden closet was found with scuff marks and scratches, and the lock was broken. Unit 6 had several issues, including missing name plaques, mismatched and scuffed paint, cracked armrests on wheelchairs, rusted lockers, and a black substance on the shower room floor grout. Unit 7 exhibited mismatched paint, scuff marks, and scratched furniture, while Unit 2 had an active ceiling leak in a resident's room. Unit 8 had mismatched paint, stained walls, a chipped radiator, a broken nightstand, dusty furniture, and improperly hung privacy curtains. Interviews with staff revealed that maintenance issues were reported in a maintenance book at the nurse's station, and broken furniture was either fixed or discarded. The Director of Nursing mentioned that weekly rounds were conducted with the Administrator, Maintenance, and Housekeeping Director to address maintenance and housekeeping issues. However, the ongoing ceiling leak in a resident's room on Unit 2 was not resolved despite maintenance examining it, and the resident reported that the leak had been an ongoing issue. Further interviews indicated that maintenance requests were managed via a computer ticketing system, and housekeepers were not responsible for identifying when curtains needed cleaning or fixing. The Director of Housekeeping stated that daily rounds were made to identify concerns, but specific issues were communicated by nurses. The Director of Maintenance acknowledged the leak in the resident's room and mentioned that the maintenance team was limited in number, which affected the speed of repairs. These deficiencies were documented in the New York State Department of Health Complaint Intake, which noted the facility's uncleanliness and broken furniture.
Failure to Accommodate Dietary Preferences
Penalty
Summary
The facility failed to ensure that menus met the nutritional, religious, cultural, and ethnic needs of residents, as evidenced by several incidents during the survey. Resident #37, who has intact cognition and does not follow a kosher diet, was denied ice cream during a lunch service because dairy was not allowed to be served with meat at a special barbecue event. This denial visibly upset the resident, highlighting a failure to accommodate individual dietary preferences. Additionally, Resident #143, who has severely impaired cognition, did not receive their chosen alternative menu item, a cheeseburger, as it was served without cheese, contrary to their request. Resident #58, with intact cognition and a member of the Resident Council, expressed dissatisfaction with the facility's strict adherence to kosher dietary laws, which limited their food choices. The resident reported that the regular menu did not accommodate their cultural preferences, and they were forced to order from a limited alternative menu daily. During a pre-planned Super Bowl event, some menu items were not initially ordered due to lack of approval from the Rabbi, causing dissatisfaction among residents. The Food Service Director confirmed that the kitchen follows kosher dietary laws, which restricts the preparation of certain foods, and stated that alternative menu options are available but must adhere to these laws.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems and opportunities for improvement, as evidenced by seven repeated deficiencies from the previous survey. These deficiencies included issues related to resident rights, advance directives, notification, environment, investigation of allegations, professional standards, activities of daily living, communication, catheter care, drug regimen review, food and nutrition services, garbage disposal, resident records, and QAPI itself. The facility's QAPI plan, dated January 1, 2024, outlined a system for monitoring care and services, incorporating feedback from various stakeholders, and using performance indicators to identify opportunities for improvement. However, the facility did not adequately address these areas, leading to repeated deficiencies. During the survey, it was observed that the facility's QAPI program did not effectively track and monitor adverse events or implement action plans to prevent recurrence. The Administrator acknowledged that when deviations from expected performance or negative trends occur, they are brought to the attention of the Quality Assurance committee. Despite having a system in place for reporting quality concerns and conducting weekly rounds with department heads, the facility continued to struggle with compliance in several areas. The Administrator also noted that the Director of Nursing was new to the facility, which may have contributed to the ongoing challenges in addressing the deficiencies.
Resident Abuse by Dayroom Attendant
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Dayroom Attendant and a resident with moderately impaired cognition. The resident, who had diagnoses including Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus, was sprayed with hand sanitizer by the Dayroom Attendant while attempting to exit the dayroom. This action was captured on video surveillance during an investigation of a separate resident-to-resident altercation. The facility's policy on abuse prevention mandates protection from abuse, mistreatment, and exploitation, which was not adhered to in this instance. The incident occurred when the Dayroom Attendant, who was the only staff present in the dayroom with about ten residents, used hand sanitizer on the resident to stop them from hitting and kicking. Following this, another resident flipped the resident's wheelchair, causing them to fall. The Dayroom Attendant claimed the use of hand sanitizer was a method of redirection. However, the video footage, which was not retained, showed the Dayroom Attendant flicking hand sanitizer at the resident, contradicting the facility's abuse prevention policy. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse Supervisor, confirmed the sequence of events and the lack of injuries to the resident. The Director of Nursing and the Administrator reviewed the video footage and confirmed the abuse, leading to the termination of the Dayroom Attendant. Despite the facility's policy and procedures, the incident was not documented in the resident's medical record, highlighting a lapse in adherence to regulatory requirements.
Delayed Reporting of Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the New York State Department of Health within the required 2-hour timeframe. This incident involved two residents, one with moderately impaired cognition due to Bipolar disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus, and the other with severely impaired cognition due to Major Depressive Disorder, Alzheimer's disease, and Diabetes Mellitus. The altercation occurred when one resident flipped the other from their wheelchair, as documented in an Accident/Incident Report. The Director of Nursing was informed of the incident on the same day it occurred, but the report to the Department of Health was delayed until the following day. The Director of Nursing stated that the delay was due to the incident occurring on a Sunday when they were not present at the facility. The Administrator believed the incident was reported within the required timeframe, but the documentation showed otherwise, leading to a deficiency under 10 NYCRR 415.4(b)(2).
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged staff-to-resident abuse incident involving a Dayroom Attendant and a resident with moderately impaired cognition due to Bipolar Disorder, Alzheimer's disease, and Type 2 Diabetes Mellitus. The incident was captured on video surveillance during an investigation of a separate resident-to-resident altercation, where the Dayroom Attendant was seen spraying the resident with hand sanitizer. Despite the immediate suspension and subsequent termination of the Dayroom Attendant, the facility did not conduct a comprehensive investigation as required by their policy. There was no documented evidence of interviews or witness statements from staff or residents present at the time of the incident. The Director of Nursing and the Administrator both reviewed the video footage, which was not preserved, and acknowledged the Dayroom Attendant's actions. However, the Director of Nursing included the staff-to-resident abuse summary in the resident-to-resident altercation report and did not complete a separate investigation. The Administrator could not explain the lack of staff statements and indicated that the Director of Nursing was responsible for the investigation. This oversight resulted in a deficiency as the facility did not adhere to its policy of thoroughly investigating all allegations of abuse.
Failure to Revise Comprehensive Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment, specifically for a resident with a diagnosis of Cerebrovascular Accident, Hypertension, and Hyperlipidemia. The care plan related to Activities of Daily Living was not revised quarterly as required. The Quarterly Minimum Data Set assessments were completed on two occasions, but there was no documented evidence that the Comprehensive Care Plan had been reviewed and revised after these assessments. Interviews with facility staff revealed that the responsibility for updating care plans lies with the nurse supervisor. However, the care plan for the resident's Activities of Daily Living had not been updated after the care plan meetings, as confirmed by the Registered Nurse Supervisor. This oversight was evident for one resident out of the five reviewed for Activities of Daily Living, indicating a lapse in the facility's adherence to its policy and procedure for maintaining individualized interdisciplinary plans of care.
Failure to Assess Underlying Causes Before Increasing Psychotropic Medication
Penalty
Summary
The facility failed to ensure that psychotropic drugs were administered to residents only when necessary to treat a specific condition, as diagnosed and documented in the clinical record. This deficiency was identified during a survey conducted from July 9, 2024, to July 16, 2024, involving Resident #102, who exhibited worsening behavioral symptoms. Despite these changes, the resident was not assessed for possible underlying medical causes before an increase in psychotropic medication was prescribed. Resident #102, diagnosed with Major Depressive Disorder, Alzheimer's disease, and Diabetes Mellitus, displayed severe cognitive impairment and received antipsychotic medications routinely. The resident's behavior included yelling profanity, crying out for their child, and exhibiting paranoia and confusion. Despite these symptoms, there was no documented evidence of a medical workup to rule out underlying medical conditions before increasing the resident's antipsychotic medication dosage. Interviews with facility staff, including the psychiatrist and the Director of Nursing, revealed that the resident's behavior had been fluctuating for two months. The psychiatrist adjusted the medication dosage due to increased behaviors without confirming whether the attending physician had assessed the resident for potential infections. The Director of Nursing emphasized the importance of ruling out medical conditions when residents exhibit increased behaviors, but acknowledged that such behavior was not new for Resident #102.
Inaccurate Documentation of Resident Ambulation Program
Penalty
Summary
The facility failed to maintain accurate and complete medical records for Resident #143, as required by professional standards. Despite documentation indicating that Resident #143 was participating in a floor ambulation program, interviews and observations revealed that the resident was not receiving such care. The resident, who had a history of cerebrovascular accident and hypertension, expressed a desire to be more mobile to prevent further decline. However, the resident reported not engaging in any walking or ambulation activities with staff, contrary to the documented records. The facility's records inaccurately reflected that Resident #143 was participating in a floor ambulation program, with tasks documented as completed despite staff being unaware of such a program. Certified Nursing Assistants interviewed stated they were not informed of any ambulation program for the resident and could not explain why the tasks were recorded as completed. The Director of Nursing acknowledged that care should be accurately documented and that staff should only document tasks that have been performed, highlighting a discrepancy between documented care and actual care provided.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that each resident was treated with respect and dignity, specifically in the case of a resident with intact cognition and diagnoses including Schizophrenia, Depression, and Diabetes Mellitus. During a recertification survey, it was observed that a Licensed Practical Nurse (LPN) performed a blood glucose monitoring procedure on the resident in the Unit 3 Dining Room, in front of other staff and residents who were eating lunch. This action was contrary to the facility's policy, which emphasizes the importance of privacy and dignity in resident care. Interviews conducted during the survey revealed that the LPN was instructed to collect the fingerstick from the resident whenever they encountered them, but typically in areas where privacy could be maintained. Both the Registered Nurse Supervisor and the Director of Nursing acknowledged that the procedure should have been conducted in the resident's room to ensure privacy and maintain dignity. The facility's policy on resident rights, dated April 2023, clearly states the importance of promoting resident independence and a positive quality of life, which was not adhered to in this instance.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents were provided the option to formulate an advance directive and that these directives were documented for each resident. This deficiency was identified during a recertification survey, where it was found that two residents, out of six reviewed for advance directives, did not have documented evidence of discussions or decisions regarding their advance directives. Specifically, Resident #502, who was moderately cognitively intact, had no orders for advance directives in their medical records, and there was no documentation in the social service notes indicating that advance directives had been reviewed with them. Similarly, Resident #233, who was cognitively intact, had no advance directive options selected in their care plan, and there was no evidence of discussions with the resident or their representative. Interviews with facility staff revealed a lack of clarity and consistency in the process of documenting advance directives. Registered Nurse Supervisor #9 was unsure of the responsibility for placing Medical Orders for Life-Sustaining Treatment forms in the chart, while Registered Nurse #3 indicated that the social worker was responsible for discussing and documenting advance directives upon admission. The Director of Social Work confirmed that discussions should occur on admission, but acknowledged the absence of documentation for the two residents in question. The Director of Nursing stated that admission nurses should verify and document advance directive preferences, but this process was not followed for the residents identified in the report.
Failure to Notify Physician of Low Blood Sugar
Penalty
Summary
The facility failed to immediately inform the physician when a resident's blood sugar level was below the specified parameter. This deficiency was identified during a recertification survey, where it was found that a resident with diagnoses including Schizophrenia, Depression, and Diabetes Mellitus had a physician's order to notify the physician if their blood sugar was below 70 mg/dL. On a specific date, the resident's blood sugar was recorded at 64 mg/dL, but there was no documented evidence that the physician was notified as required. The facility's policy on diabetic management required notifying the primary medical doctor of any signs of hypoglycemia. Despite this, the LPN responsible for the resident's care claimed to have texted the physician with the low blood sugar result, but the physician stated they did not receive any notification. The Director of Nursing confirmed that the LPN should have followed the physician's orders and notified both the physician and their supervisor about the low blood sugar reading.
Improper Medication Administration via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that services provided met professional standards, as evidenced by the improper administration of medications via a gastrostomy tube for one resident. The facility's policy required medications to be administered separately and by gravity flow, but a Licensed Practical Nurse (LPN) was observed using a pistol syringe to force medications through the tube. This method of administration was contrary to the facility's policy, which specified that medications should be delivered slowly by gravity. The resident involved had a feeding tube and was receiving medications such as Acidophilus, multivitamins, and Vitamin C through this route. During the observation, the LPN crushed the medications, diluted them, and used a pistol syringe to push them through the tube, rather than allowing them to flow by gravity. Interviews with the LPN and a Registered Nurse Supervisor revealed a lack of clarity and consistency in the understanding of the correct procedure for administering medications via a gastrostomy tube, contributing to the deficiency.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper catheter care for two residents, leading to a deficiency in preventing urinary tract infections. Resident #20, who has a neurogenic bladder and an indwelling catheter, was observed multiple times with the Foley catheter bag improperly positioned above the bladder level, compromising the drainage system. Despite having a comprehensive care plan and physician's orders for catheter care, the staff did not adhere to the facility's policy of keeping the drainage bag below the bladder to prevent urine reflux. Similarly, Resident #160, who also has a neurogenic bladder and a history of urinary tract infections, was observed with their catheter bag improperly positioned above the bladder level. The resident, dependent on staff for toileting hygiene, had their catheter bag hanging loosely from their wheelchair and placed on the upper side rail of the bed. The staff, including Certified Nursing Assistants and a Registered Nurse Supervisor, failed to ensure the catheter bag was positioned correctly, despite being trained on proper catheter care. Interviews with staff revealed a lack of consistent monitoring and supervision to ensure catheter bags were positioned correctly. The Director of Nursing acknowledged that staff were trained on catheter care but expressed surprise at the lack of proper monitoring by unit nurses and supervisors. This deficiency highlights a failure in staff adherence to established protocols and inadequate supervision, leading to improper catheter care for the residents.
Failure to Act on Pharmacist's Drug Regimen Review
Penalty
Summary
The facility failed to ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This deficiency was identified during a recertification survey, specifically affecting one resident who was reviewed for unnecessary medications. The resident, diagnosed with Alzheimer's Disease and Anxiety Disorder, was receiving antipsychotics and Divalproex (Valproic acid) as part of their treatment. The Consultant Pharmacist recommended checking the serum level of Depakote, but there was no evidence that this laboratory test was ordered or conducted, despite the attending physician's agreement to do so. Interviews with facility staff revealed a lack of follow-through on the pharmacist's recommendations. The Registered Nurse Supervisor could not find documentation of the lab order or any refusal by the resident to have the test done. The attending physician deferred responsibility to the psychiatrist, who did not receive a copy of the drug regimen review. The Medical Director emphasized that the attending physician is responsible for ordering labs if they agree with the pharmacist's recommendations. The Director of Nursing stated that the process involves the attending physician reviewing and agreeing to the pharmacist's recommendations, after which the nurses are expected to carry out the orders. However, this process was not followed, leading to the deficiency.
Failure to Implement Ambulation Program for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the ambulation ability of a resident, identified as Resident #143. The resident, who was admitted with diagnoses including Cerebrovascular Accident, Hypertension, and Hyperlipidemia, had intact cognition and required supervision for walking. Despite a physician's order for a Floor Ambulation Program, which included ambulating 100 feet using a rolling walker with supervision, the program was not implemented. The resident expressed a desire to be more active to prevent further decline in mobility, but reported not engaging in any walking or ambulation activities with staff. The facility's policy on Restorative Nursing Services indicated that residents should receive care to promote safety and independence. However, the Comprehensive Care Plan for Resident #143 lacked documentation of a floor ambulation program. The Certified Nursing Assistant (CNA) documentation showed that the resident's ambulation tasks were infrequently completed, with no evidence of refusal from the resident. Interviews with CNAs and a Licensed Practical Nurse (LPN) revealed a lack of awareness about the resident's ambulation program, indicating a communication breakdown between the rehabilitation and nursing staff. The Director of Rehabilitation confirmed that Resident #143 was discharged from physical therapy with a recommendation to continue a Floor Ambulation Program to maintain functional ability. The responsibility for implementing this program was assigned to the nursing staff, but it was not executed. The Registered Nurse Supervisor acknowledged the existence of the order for the ambulation program but could not explain why it was not carried out. This oversight resulted in the resident not receiving the necessary care to maintain their mobility, as required by the facility's policies and physician's orders.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System Assessment Submission and Processing system in a timely manner. Specifically, admission, annual, and quarterly assessments were not submitted and transmitted within the required 14 calendar days after completion. This deficiency was identified during a recertification survey conducted from July 9, 2024, to July 16, 2024, and affected all 53 residents reviewed for the Resident Assessment facility task. The report highlights several instances of late submissions, including a resident whose quarterly assessment was completed and signed on May 18, 2024, but not transmitted until July 8, 2024, resulting in a 51-day delay. Another resident's assessment was completed on May 7, 2024, but transmitted 48 days late. Similar delays were noted for other residents, with transmission delays ranging from 38 to 63 days. These delays were attributed to the late completion of documentation by some interdisciplinary team members involved in the assessments. Interviews with facility staff revealed systemic issues contributing to the delays. The Minimum Data Set/Rehabilitation Department head acknowledged that some team members completed their documentation late, affecting the timely submission of assessments. The Minimum Data Set Secretary indicated that assessments were submitted late because they were not marked as ready to submit by the department head. Additionally, the Director of Social Work cited staffing issues as a factor in the late submissions. The Administrator was aware of the issue but uncertain about who was responsible for signing the assessment books.
Improper Garbage Disposal in Facility
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during the Recertification survey. Specifically, the garbage compactor door was found ajar, allowing multiple flies to gather on top of the garbage inside the compactor. This observation was made during a kitchen inspection when a Dietary Worker was seen bringing garbage to the disposal area outside the building. The facility's policy, dated 1/8/2024, mandates that all kitchen waste be properly disposed of in the compactor, with the door kept closed. Interviews with staff revealed that the compactor is used by both housekeeping and food service staff, and all are expected to keep the door closed after use. The Dietary Worker acknowledged that the door should have been closed, and both the Food Service Director and the Director of Housekeeping confirmed that staff are required to adhere to this procedure. The Director of Housekeeping also mentioned collaborating with the Food Service Director to educate staff on the proper garbage disposal process.
Resident Abuse Incident
Penalty
Summary
A resident at the facility was involved in an altercation with a staff member, leading to a series of events that were deemed abusive. The incident began when the resident, who was in a wheelchair, attempted to remove items from the wall. The staff member, in an attempt to prevent the resident from doing so, engaged in a physical altercation. The situation escalated, resulting in the resident being restrained on the floor by the staff member. This was considered an inappropriate use of force and restraint, leading to the classification of the incident as abuse. The staff member involved in the incident was observed to have used physical force against the resident, which was deemed excessive and inappropriate. The use of force was not in accordance with the facility's policies and procedures, and the staff member's actions were considered to be abusive. The incident was further exacerbated by the fact that the resident was restrained on the floor, which was deemed to be an inappropriate use of force. The incident was reported to the facility's administration, and an investigation was conducted. The investigation revealed that the staff member had used excessive force against the resident, and that the use of force was not in accordance with the facility's policies and procedures. The incident was classified as abuse, and the staff member was terminated as a result of their actions.
Resident Restraint and Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint, as observed during an abbreviated survey. The incident involved a resident with diagnoses of Intellectual Disability, Disorganized Schizophrenia, and Depression, who exhibited severe cognitive impairment and aggressive behavior. On the night of the incident, the resident became agitated and physically aggressive, attempting to throw objects and strike a CNA. The CNA, in an attempt to control the situation, engaged in physical restraint by holding the resident's arms and using their knee to prevent the resident from getting up after a fall. The facility's surveillance footage revealed that the CNA slapped the resident during the altercation, which was confirmed by the facility's internal investigation. The CNA's actions were deemed abusive and constituted the use of physical restraint, which is against the facility's policy. The Director of Nursing and the Administrator both reviewed the footage and concluded that the CNA's actions were inappropriate and abusive. Interviews with staff members present during the incident corroborated the findings from the surveillance footage. The CNA involved stated that their intention was to prevent the resident from injuring themselves, but the actions taken were not in line with the facility's policies on handling aggressive behavior. The facility's policy emphasizes that staff should not restrain residents and should instead call for help when a resident becomes aggressive.
Failure to Provide Adequate Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident received the necessary behavioral health care and services to maintain their highest practicable well-being. The resident, diagnosed with Intellectual Disability due to [NAME]-Will Syndrome, Disorganized Schizophrenia, and Depression, exhibited several incidents of aggressive behavior towards staff and other residents. Despite having a Comprehensive Care Plan (CCP) in place, the facility did not evaluate the effectiveness of the interventions to address the resident's aggression. The CCP lacked individualized interventions related to the resident's behavior, and there was no documented evidence that the interventions were reviewed and evaluated after each incident of physical aggression. The facility's policy required that each resident receive necessary behavioral health care and services, but the interventions documented in the CCP were not updated or evaluated after incidents of aggression. Interviews with staff revealed that there were no documented instructions for monitoring the resident's behavior or guidance on what to do if the resident became physically aggressive. The Director of Nursing and other staff members acknowledged that the CNA Accountability should specify actions to take when a resident becomes aggressive, and it is the unit manager's responsibility to update the care plan with new interventions after each episode of aggressive behavior.
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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