Northeast Ctr For Rehabilitation And Brain Injury
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Katrine, New York.
- Location
- 300 Grant Avenue, Lake Katrine, New York 12449
- CMS Provider Number
- 335845
- Inspections on file
- 28
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Northeast Ctr For Rehabilitation And Brain Injury during CMS and state inspections, most recent first.
The facility did not maintain adequate staffing levels of CNAs and LPNs as determined by its own Facility Assessment, resulting in frequent understaffing across various shifts. Staff reported difficulty providing care due to high resident assignments, and a resident described long wait times for assistance. Administrative staff acknowledged ongoing staffing shortages and ineffective recruitment efforts.
The facility's assessment lacked required details on CNA and LPN staffing for weekends and emergencies, as well as behavioral health staffing, and was neither dated nor signed by QAPI or involved staff. Interviews revealed that staff often worked short-handed, and a resident reported long wait times for assistance and inconsistent care depending on staff present. The administrator confirmed the assessment's deficiencies and lack of awareness of updated staffing regulations.
A resident with diabetes was observed self-injecting insulin in a hallway, in view of staff, surveyors, and other residents, after being handed a syringe by an RN. The resident did not have a current order to self-administer insulin at the time, and the administration occurred without privacy, contrary to facility policy on resident dignity and rights.
A facility failed to train agency staff in behavioral health care, resulting in an agency CNA improperly restraining a resident with behavioral issues. The resident, who had a history of physical and verbal behaviors, was restrained by the CNA, who was not trained in the facility's behavioral management protocols. The facility's policy excluded agency staff from mandatory training, leading to this deficiency.
A resident in a LTC facility was subjected to abuse by a CNA who restrained them inappropriately, preventing them from leaving their room. The resident, who had cognitive impairments and behavioral issues, was not protected due to the CNA's lack of training in behavior management, as agency staff did not receive the same training as regular staff. This incident highlights a deficiency in the facility's implementation of its abuse prevention policy.
A facility failed to train an agency CNA in behavior management, resulting in improper handling of a resident with behavioral issues. The CNA, lacking Mandt training, held the resident's arms and prevented them from leaving their room, contrary to the care plan. Facility policy excluded agency staff from necessary training, contributing to the deficiency.
A resident with severe cognitive deficits and a requirement for a two-person assist for transfers fell and sustained a head injury when a CNA attempted to transfer them alone. The CNA was aware of the care plan but proceeded without assistance, resulting in the resident rolling off a shower trolley and hitting the floor, necessitating hospital treatment for a laceration.
The facility failed to notify residents and the Ombudsman of hospital transfers as required. Two residents were transferred without receiving written notices in a language they understood, and the Ombudsman was not informed of any transfers for eight residents. Staff interviews confirmed the lack of documentation and notification.
The facility failed to maintain adequate staffing levels, resulting in unmet resident needs and complaints. A resident did not receive documented showers for nearly a month, and family members reported residents were asked to hold their urine due to insufficient staffing. Staffing records showed consistent understaffing compared to projected needs, particularly on the Vent and NRP5 units. Staff interviews confirmed the challenges in maintaining adequate staffing, affecting their ability to provide timely care.
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of symptom tracking prior to antibiotic initiation for two residents. Antibiotics were started without documented symptom tracking on the Line List for Antibiotic Use. The Assistant Director of Nursing confirmed that symptom tracking is not integrated into the facility-wide document, highlighting a gap in infection control practices.
The facility failed to maintain a clean and comfortable environment, with rooms in disrepair and feeding tube pumps containing dried formula. Despite daily cleaning schedules, rooms had soiled walls, stained curtains, and odors of urine. Housekeeping and maintenance staff were unaware of these issues, indicating a lapse in service provision.
The facility failed to resolve and document grievances for two residents. One resident's family was unaware of grievance procedures, and their complaints were not logged or communicated. Another resident's friend attempted to file a complaint about taking the resident out, but it was not documented, and no complaint form was provided. The Grievance Officer was on leave, and the Liaison was unavailable, leading to unresolved grievances.
A facility failed to protect two residents from abuse due to inadequate supervision. A resident with a history of aggression was not monitored according to their care plan, leading to a physical altercation with another resident. The staff member responsible did not maintain required supervision or report escalating behaviors, resulting in a violation of facility policies.
The facility did not develop baseline care plans within 48 hours for three residents admitted with various medical conditions, including ALS, respiratory failure, bipolar disorder, and cerebral infarction. Interviews revealed that the baseline care plan form does not automatically populate in the electronic medical record, requiring manual input by the admitting nurse. The DON and Assistant DON were unaware of these issues, indicating a lack of oversight.
Two residents requiring assistance with activities of daily living did not receive scheduled showers, leading to a deficiency. One resident, with a spinal cord injury, reported missed showers despite being scheduled twice weekly. Another resident, with severe cognitive impairment, had significant gaps in shower documentation. Staff interviews revealed issues with communication, documentation, and low staffing levels, contributing to the deficiency.
The facility failed to provide appropriate follow-up care for three residents, leading to deficiencies in their treatment. A resident with a suprapubic catheter did not receive a follow-up urology appointment, resulting in an emergency situation. Another resident did not receive a neurology consultation as recommended, and a third resident was observed with poor positioning due to inadequate care. Transportation issues and communication lapses contributed to these deficiencies.
A resident with amyotrophic lateral sclerosis and respiratory failure developed a stage 3 pressure ulcer due to inadequate skin assessments and preventive care. Despite being at risk, the resident did not receive timely skin evaluations or treatment for initial redness on the buttocks. The facility's documentation and staffing issues contributed to the deficiency, as the new skin assessment software did not integrate with the electronic medical record, leading to communication gaps among staff.
A resident's medication orders were incorrectly transcribed upon admission, leading to the administration of medications at incorrect times. The error was discovered when a family member alerted the NP, who admitted to focusing on dosage rather than timing when verifying orders.
The facility did not complete annual performance reviews for two CNAs, as required. The Director of Human Resources noted the absence of these reviews and attributed the responsibility to the unit manager, who reported not being trained or informed about the reviews. The DON was unaware of the oversight, highlighting a lapse in management communication.
A resident with bipolar disorder did not receive a required psychiatric consultation due to a transition in the facility's psychiatric services, leading to a backlog in evaluations. The resident, who was on antipsychotic medication, was not evaluated as per the physician's order, highlighting a deficiency in meeting behavioral health care needs.
A CNA was observed standing while feeding two residents, failing to provide a dignified dining experience. The CNA mentioned back pain and height as reasons for standing, and later admitted to forgetting the requirement to sit while feeding.
The facility failed to provide timely Notice of Medicare Non-Coverage to two residents' representatives, as required by policy. In one case, attempts to contact the family were not documented, and in the other, no contact was made due to family disinterest. The Administrator signed the notices without ensuring representatives were informed.
A facility failed to monitor a resident's weight timely, despite significant weight loss and physician orders for weekly weights. The resident, with severe cognitive impairment and multiple diagnoses, experienced a 9.29% weight loss. A 'weigh now' order was not executed, and staff interviews revealed lapses in communication and adherence to orders.
The facility failed to ensure proper medication storage and expiration management, with expired medications found in storage areas and a Lantus Insulin Pen not discarded after 28 days. A refrigerator containing Lorazepam was not secured to a permanent fixture. Staff interviews revealed lapses in checking for expired medications, and the Director of Nursing acknowledged that unit refrigerators are not bolted to a permanent fixture.
A resident with dementia and behavioral issues was hit by a Community Support Specialist (CSS) after throwing food at them. The CSS, not assigned to assist with meals, reacted inappropriately by striking the resident. Witnesses confirmed the incident, and the facility's investigation noted the CSS's response was inappropriate, though abuse was not substantiated due to lack of intent. The CSS was removed from the unit, and the incident was reported to the administration.
A facility failed to report the results of an abuse investigation to the NY State Department of Health within the required timeframe. A resident with severe cognitive impairment was allegedly hit by a staff member after throwing food. The incident was witnessed by an LPN and a CNA, and the investigation found the abuse unsubstantiated. However, the facility submitted the report 2 days late, with initial errors in case numbers and dates.
A resident with severe cognitive impairment and behavioral issues did not have a comprehensive care plan to prevent abuse until after an incident occurred. Despite multiple instances of aggression documented in the behavior care plan, the facility failed to initiate a care plan addressing the potential for abuse in a timely manner. Interviews revealed inconsistencies in the process of initiating and updating care plans, contributing to this deficiency.
The facility failed to ensure timely medication administration for two residents, resulting in missed doses of prescribed medications. One resident missed 46 doses of Dronabinol, and another missed 8 doses of Bupropion. There was a lack of proper documentation and follow-up actions by the facility.
The facility failed to ensure residents were free from significant medication errors, resulting in multiple missed doses for two residents due to unavailability and lack of proper documentation and communication.
A resident with specific dietary needs, including double portions, did not receive the prescribed amount of food during meal observations on two occasions. Despite clear documentation and physician orders, the resident received only one sandwich instead of two. Staff interviews confirmed the oversight.
The facility failed to ensure proper storage of refrigerated food, as observed during a kitchen tour where a pan with marinated meat and a container with green paste were found unlabeled and undated, contrary to the facility's policy.
The facility failed to prevent a physical altercation between two residents, resulting in one resident being punched in the face and sustaining a bleeding lip. Despite documented behavior care plans and known risks, the facility did not provide adequate supervision or separation to prevent the incident.
The facility failed to report an incident of resident-to-resident abuse within the required 24-hour timeframe. A resident with multiple diagnoses was found bleeding from the mouth after an unwitnessed altercation, but the incident was not reported to the New York State Department of Health due to perceived inconsistencies in the resident's account and lack of direct observation.
The facility failed to ensure necessary monitoring of a resident's weight, despite physician orders for monthly weights. The resident had a history of weight fluctuations and no documented refusals, but weights were missing for several months. Staff were aware of the issue, but no action was taken to address it.
Failure to Maintain Adequate Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to consistently meet the needs of all residents, as evidenced by a review of staffing schedules and interviews with staff and residents. The facility's own Facility Assessment established required staffing levels for Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) for each shift, but actual staffing frequently fell below these levels across multiple days and shifts. For example, on several occasions, the number of CNAs and LPNs scheduled was less than what was determined necessary by the facility's assessment, particularly on evening and night shifts. Staff interviews confirmed ongoing staffing shortages. CNAs reported that staffing was inadequate, making it difficult to complete necessary care tasks such as showers and timely response to resident needs. They described working short-staffed, lacking help, and being unable to provide good care due to the high number of residents assigned to them. A resident reported waiting up to 2.5 hours for call bell responses and stated that delays in care depended on which staff were working. The resident also described being told by administration that there were many other residents to care for, indicating that staff were overwhelmed by their assignments. Administrative staff, including the Staffing Coordinator, DON, and Administrator, acknowledged the staffing issues. The Staffing Coordinator stated that staffing often fell below the minimum required, especially on weekends, and that incentives such as gift cards and bonuses were not always effective in attracting staff. The DON was aware of the inadequate staffing but was unable to specify the required staffing numbers for all units. The Administrator noted that the facility was in a staffing crisis, that the Facility Assessment did not reflect weekend or low census needs, and that efforts to address staffing shortages had not been successful. The deficiency was cited under 10NYCRR 415.13(a)(1)(i-iii).
Incomplete Facility Assessment Omits Staffing and Behavioral Health Needs
Penalty
Summary
The facility failed to ensure its facility-wide assessment included all necessary resources to competently care for residents during both routine operations and emergencies. The assessment provided was undated and unsigned, lacking documentation of review or approval by the Quality Assurance and Performance Improvement (QAPI) committee. It did not specify minimum staffing requirements for Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) on weekends, nor did it address the number of staff needed for behavioral healthcare services. The assessment also omitted information on staffing for emergencies and did not include signatures from staff involved in its creation or review. Observations and interviews revealed that staff and residents experienced the effects of inadequate staffing. A CNA reported frequent short staffing, making it difficult to provide adequate care to all residents. A resident described extended wait times for call bell responses, sometimes up to 2.5 hours, and noted that responses varied depending on which staff were on duty. The resident also reported being told they had behavioral issues when voicing concerns and that administration became upset when calls were escalated. The administrator acknowledged that the facility assessment did not reflect weekend staffing needs or behavioral health services and was unaware of recent changes in staffing regulations.
Resident Self-Administers Insulin Without Privacy or Proper Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Type 2 diabetes mellitus, hypertension, and unspecified visual disturbance was observed self-administering insulin in a public area of the facility. The resident, who was cognitively intact and had no physical impairments, was handed a syringe with insulin by a registered nurse at the nurse's station and proceeded to inject the insulin into their abdomen in the presence of staff, surveyors, and other residents. This action was observed by surveyors during an abbreviated survey. Review of the facility's policies indicated a commitment to protecting residents' rights to privacy and dignity. However, the nurse allowed the resident to self-administer insulin in a public setting without ensuring privacy. Interviews revealed that, at the time of the incident, there was no physician order permitting the resident to self-administer insulin, although there was an order for self-administration of eye drops. The order for insulin self-administration was only added after the incident.
Inadequate Training for Agency Staff Leads to Resident Restraint
Penalty
Summary
The facility failed to include all staff, particularly agency staff, in their behavioral health care training program, which led to an incident involving a resident with behavioral issues. The facility's policy required training for all employees, including full-time, part-time, and per-diem staff, but explicitly excluded agency staff from this requirement. This lack of training was evident when an agency Certified Nurse Aide (CNA) was not equipped to handle a resident's behaviors appropriately. The CNA restrained the resident by holding their arms and preventing them from leaving their room, which was against the facility's behavioral management protocols. The resident involved had a history of physical and verbal behaviors, rejection of care, and wandering, as documented in their care plan. The care plan included interventions such as observing for signs of agitation, redirecting the resident, and consulting psychiatry or psychology as needed. However, the agency CNA was not trained in these interventions or the facility's specific behavioral crisis intervention training, known as Mandt training. This training was provided to regular staff but not to agency staff, as confirmed by interviews with the facility's staff educator and nursing leadership. The incident was reported when other CNAs heard the resident yelling for help and observed the agency CNA physically restraining the resident. Despite being instructed to release the resident, the CNA initially did not comply. Interviews with facility staff revealed that agency staff were not given the same training as regular employees due to time and resource constraints. The Director of Nursing and the Administrator acknowledged that agency staff were not included in the Mandt training, which is crucial for managing residents with behavioral issues. This oversight in training contributed to the inappropriate handling of the resident by the agency CNA.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. Certified Nursing Assistant # 1 was immediately terminated on 01/12/2025. 2. All behavioral residents have the potential to be affected by this deficient act. The Director of Nursing will audit all agency staff who provide cares to behavioral patients to ensure that agency staff are trained in the appropriate response when behaviors occur. Agency staff will be educated on the definition of code Rainbow responses. The agency education policy was revised to include proper response in the event of a behavior. 3. The Director of Nursing or designee will educate all current and future agency staff on appropriate responses when behaviors occur and during code rainbows. 4. The Director of Nursing or designee will audit all current and future agency workers weekly times 3 months and quarterly thereafter to ensure that they receive appropriate training in proper responses when behaviors occur during code Rainbows. The audit is going to ensure that all agency staff is trained. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing is responsible for this plan of correction. *A code Rainbow is code for a behavior: This alerts the special response team to respond to behaviors.
Resident Abuse Due to Inadequate Staff Training
Penalty
Summary
The facility failed to ensure that a resident was free from abuse, neglect, or mistreatment, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was cognitively impaired and had a history of physical and verbal behaviors, was heard yelling from behind a closed door. Upon entering the room, multiple staff members observed the CNA pushing the resident, holding their arms down, and preventing them from leaving the room. Despite attempts by other staff to intervene, the CNA did not release the resident until instructed by a Licensed Practical Nurse (LPN). The resident had been admitted with various diagnoses and was documented as having daily physical and verbal behaviors, rejection of care, and wandering tendencies. The facility's care plan for the resident identified them as being at high risk for abuse and having a potential to abuse others, with interventions in place to manage these risks. However, during the incident, the CNA, who was working through an agency and had not received specific behavior management training from the facility, restrained the resident inappropriately. Interviews with facility staff revealed that agency staff, including the CNA involved, did not receive the same mandatory training on behavior management and de-escalation tactics as regular staff. The facility's policy on abuse prevention was not effectively implemented, as the CNA was not adequately trained to handle the resident's behaviors, leading to the inappropriate physical restraint of the resident. The facility's decision not to provide comprehensive training to agency staff contributed to the deficiency in ensuring the resident's right to be free from abuse and mistreatment.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. Certified Nursing Assistant Number was terminated on 01/12/2025. Resident #1's potential victim of abuse care plan was reviewed and remained appropriate. The abuse policy was reviewed and did not need to be revised. The agency education policy was revised to include proper response in the event of a behavior. 2. All residents have the potential to be affected by this deficient practice. The Director of Nursing will audit all agency staff who provide cares to behavioral patients to ensure that all agency staff are trained in the appropriate response when behaviors occur. 3. The Director of Nursing or designee will educate all current and future agency staff on appropriate response when behaviors occur and the revised agency education policy. 4. The Director of Nursing or designee will audit all current and future agency staff weekly times 3 months and quarterly thereafter to ensure that they receive appropriate training in proper response to behaviors as well as to ensure that they understand the revised agency education policy. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing will be responsible for compliance.
Lack of Training for Agency Staff Leads to Improper Resident Handling
Penalty
Summary
The facility failed to ensure that staff were competent and trained in providing care to a resident with behavioral health issues. Specifically, a Certified Nurse Aide (CNA) from an agency was not trained to manage the behaviors of a resident who exhibited physical and verbal aggression, rejection of care, and wandering. The CNA was observed holding the resident's arms and preventing them from leaving their room, despite the resident's request to do so. This action was contrary to the facility's policy, which emphasizes behavior prevention and intervention training for staff, although agency staff were not included in this training. The resident involved was cognitively intact and had a history of being abusive to caregivers, with poor impulse control and threatening behaviors. The care plan for the resident included interventions such as observing for signs of agitation, redirecting the resident, and consulting psychiatry or psychology as needed. However, on the day of the incident, the CNA was seen physically pushing the resident back into their room and holding their arms, actions that were not aligned with the care plan or facility policy. Interviews with facility staff revealed that the CNA had not received any training in behavior management or the facility's specific Mandt training, which is designed to teach de-escalation tactics. The facility's policy excluded agency staff from this training, and there was no documentation to ensure that agency staff were aware of the facility's behavior code or how to react to residents with behavioral issues. The facility's leadership acknowledged that agency staff were not provided with the necessary training due to time and resource constraints, which contributed to the deficiency in care provided to the resident.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. No agency workers will be placed on 1:1 assignments with patients. The policy for 1:1 assignments was reviewed and updated to reflect that agency staff will not be assigned to 1:1 cares. 2. All residents who require a 1:1 assignment have the potential to be affected by this deficient practice. The Director of Nursing will audit all patients with a 1:1 order to ensure that no agency workers are assigned to their care. 3. The Director of Nursing or designee will educate all staff, including nursing/administrative staff, responsible for scheduling 1:1 assignments, not to place agency staff on these assignments. 4. The Director of Nursing or designee will audit schedules daily for 3 months and quarterly thereafter to ensure that no agency staff are placed on 1:1 assignments. Findings will be reported to QAPI for further guidance. 5. The Director of Nursing will be responsible for compliance.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that the plan of care for Resident #234 was followed, resulting in inadequate supervision and assistance during a transfer, which led to an accident. Resident #234, who had a diagnosis of Traumatic Brain Injury, Aphasia, and Mood Disorder, required a two-person assist for transfers due to severe cognitive deficits and dependency on staff for all activities of daily living. Despite this requirement, Certified Nurse Aide #25 attempted to transfer the resident alone after a shower, leading to the resident falling and sustaining a laceration to the back of their head, which required eight staples. The incident occurred when Certified Nurse Aide #25, aware of the care plan, chose to transfer the resident without assistance, citing that other staff were busy. The resident rolled off the shower trolley and hit the floor, resulting in a head injury. The facility's care plans documented the resident's risk for falls and the need for a two-person assist, but these were not adhered to during the incident. The deficiency was identified during a recertification and abbreviated survey, highlighting the failure to provide adequate supervision and assistance to prevent accidents.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure proper notification procedures were followed for resident transfers to the hospital, as required by their policy and procedure on Transfer and Discharge Rights. Specifically, the facility did not provide written notices of transfer in a language understood by the residents or their representatives for two residents who were hospitalized. One resident with amyotrophic lateral sclerosis and respiratory failure was transferred without receiving a written notice explaining the reasons for the transfer. Another resident with bipolar disorder and chronic obstructive pulmonary disease, who had a Health Care Proxy, was also transferred without receiving a written notice in a language they understood. Additionally, the facility did not notify the Long Term Care Ombudsman of the hospital transfers for any of the eight residents reviewed. This lack of notification was confirmed during interviews with facility staff, including a social worker and the assistant administrator, who acknowledged the absence of documentation regarding Ombudsman notifications. The Ombudsman also confirmed not receiving any transfer/discharge notices from the facility for the specified period.
Inadequate Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide consistent and sufficient nursing staff to meet the needs of residents on all shifts, as evidenced by resident and family complaints, staff interviews, and review of staffing records. Specifically, a resident did not receive documented showers for nearly a month, and family members reported that residents were asked to hold their urine due to insufficient staffing. The facility's staffing sheets from a one-month period showed that actual staffing levels were consistently below the projected needs outlined in the Facility Assessment, particularly on the Vent and NRP5 units. Interviews with staff, including the Staffing Coordinator, Registered Nurse Unit Manager, Certified Nurse Aides, Director of Nursing, and the Administrator, confirmed the challenges in maintaining adequate staffing levels. Staff reported that low staffing affected their ability to provide timely care, with some shifts operating with significantly fewer aides than required. The Director of Nursing and Administrator acknowledged the difficulty in staffing due to location and population, despite efforts to use agency staff and a corporate recruiter. The deficiency was cited under 10NYCRR 415.13(A)(1) (i-iii).
Inadequate Infection Control and Symptom Tracking
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of an infection surveillance plan that included symptom tracking prior to the initiation of antibiotics for two residents. For Resident #26, a urinalysis and culture/sensitivity were ordered on October 4, 2024, but a urine sample could not be obtained due to the resident's aggressive behavior. Despite this, antibiotics were started on October 8, 2024, without documented evidence of symptom tracking on the Line List for Antibiotic Use. Similarly, Resident #233 exhibited symptoms of blood oozing from the right ear, which was assessed by a Nurse Practitioner on October 18, 2024. Antibiotics were initiated on October 23, 2024, for purulent foul-smelling drainage, yet there was no documented symptom tracking on the Line List. During an interview, the Assistant Director of Nursing/Infection Preventionist confirmed that the facility's antibiotic use is tracked on a line list updated monthly, but it does not include live symptom tracking. Symptoms are recorded on unit-specific 72-hour report sheets but are not consolidated into a facility-wide document. This deficiency indicates a gap in the facility's infection control practices, as symptom tracking is not integrated into the antibiotic use monitoring process, potentially leading to inappropriate antibiotic administration.
Deficiencies in Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as observed during a recertification survey. Specifically, rooms labeled as [ROOM NUMBER] A/B were found to have walls in disrepair with holes, scratches, chipped paint, and brown stains. The privacy curtains were soiled and stained, and the rooms emitted an odor of urine. Despite the rooms being scheduled for daily cleaning, the Director of Housekeeping acknowledged the presence of the odor and the lack of cleanliness. Additionally, the Maintenance Assistant was unaware of the disrepair and stated that there was no documented evidence of these issues being logged for maintenance. Furthermore, the facility did not ensure the cleanliness of feeding tube pumps and poles for five residents on the VENT unit. Observations revealed that the tube feeding pumps for these residents contained dried formula. The Regional Director of Housekeeping and the Director of Housekeeping both indicated that the pumps should be cleaned during the daily room cleaning process, but this was not being consistently executed. These deficiencies highlight a failure in both housekeeping and maintenance services to provide a safe and comfortable environment for residents.
Failure to Resolve and Document Grievances
Penalty
Summary
The facility failed to make prompt efforts to resolve grievances or inform the complainant of the grievance investigation outcome for two residents. For one resident with severe cognitive impairment and diagnoses including Anoxic Brain Injury and Hypoxic Ischemic Encephalopathy, six grievances were documented but not logged in the grievance book, and there was no evidence that the complainant was notified of the outcome. The resident's family member was unaware of how to complete a grievance and had not been informed of any filed grievances or their outcomes. The facility's Grievance Officer, responsible for documenting and following up on grievances, was on sick leave, and the administrator was unaware of why the grievances were not recorded or communicated. Another resident, who was cognitively intact, had a friend who attempted to file a verbal complaint regarding taking the resident out on pass. The complaint was not documented in the grievance log, and the friend did not receive a complaint form despite requesting one. The social worker acknowledged the friend's attempt to file a complaint and directed them to the Liaison for assistance, but the grievance was not documented. The Grievance Officer and Liaison were unavailable for interviews, leaving the complaint unresolved and undocumented.
Failure to Protect Residents from Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents. Resident #102, who has a history of physical aggression and verbal aggression, was not properly monitored according to their care plan and physician orders. On the day of the incident, Resident #102 exhibited verbally aggressive behavior multiple times, which was not reported to the nurse. Later that day, Resident #102 physically assaulted Resident #73 by punching them in the head. The care plan for Resident #102 required close visual observation and intervention in cases of agitation, which was not followed by the staff. The incident occurred because the Community Support Specialist assigned to Resident #102 did not maintain the required one-to-one supervision and failed to report the escalating verbal aggression to the nurse. The Director of Nursing confirmed that the staff member did not follow Resident #102 down the hallway, leading to the altercation. The facility's policy on increased supervision and close visual observation was not adhered to, resulting in the physical altercation between the residents. The staff member involved was terminated for violating the care plan requirements.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure that baseline care plans were developed and implemented for three residents within 48 hours of their admission, as required by their policy. Resident #676, who was admitted with amyotrophic lateral sclerosis and respiratory failure, did not have a baseline care plan developed within the specified timeframe. Similarly, Resident #677, admitted with bipolar disorder and chronic obstructive pulmonary disease, also lacked a timely baseline care plan. Additionally, Resident #208, who had severe cognitive impairment due to cerebral infarction and acute respiratory failure, did not have a baseline care plan completed until several days after admission. Interviews with facility staff revealed systemic issues in the process of developing baseline care plans. The Assistant Director of Nursing noted that the baseline care plan form does not automatically populate in the electronic medical record, requiring the admitting nurse to manually trigger it. The Director of Nursing stated that unit nurse managers were responsible for completing these plans, with nursing supervisors covering admissions during weekends. However, there was a lack of awareness of issues related to baseline care plans, indicating a breakdown in communication and oversight within the facility's management team.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living, specifically bathing, received the necessary care. Resident #212, who had diagnoses including an unspecified injury of the cervical spinal cord and required dependent assistance with personal care, did not receive showers as scheduled. Despite being scheduled for showers on Wednesday and Friday evenings, the resident only received a limited number of showers over several months. The resident reported the issue to the Unit Manager, but the problem persisted. Interviews with staff revealed that showers were often forgotten, and there was a lack of communication and documentation regarding missed showers. Resident #177, who had severe cognitive impairment and was dependent on staff for all activities of daily living, also did not receive showers as scheduled. The documentation showed significant gaps in shower records, with no showers documented for a period of over a month. The Unit Manager and Director of Nursing were unaware of the extent of the missed showers, and it was suggested that low staffing levels contributed to the lack of documentation and care. The Director of Nursing acknowledged the issue with shower documentation and stated that it had been an ongoing problem. Despite the facility's policy requiring showers to be scheduled and provided, the lack of adherence to this policy resulted in residents not receiving the necessary care to maintain personal hygiene. The failure to provide scheduled showers and the lack of proper documentation and follow-up by the staff and management led to the deficiency identified during the survey.
Deficiencies in Resident Care and Follow-Up
Penalty
Summary
The facility failed to provide appropriate follow-up care for three residents, leading to deficiencies in their treatment. Resident #573, who had a newly placed suprapubic catheter, did not receive a follow-up urology appointment as recommended. The resident's catheter became blocked, causing distress and requiring an emergency change by the nursing staff. The facility's inability to arrange transportation for the resident to attend the urology appointment contributed to this deficiency. Resident #677, who was admitted with a diagnosis of bipolar disorder and cognitive communication deficit, did not receive a neurology consultation as recommended in their hospital discharge instructions. The admitting nurse and nurse practitioner failed to order the necessary consultation, and the facility faced challenges in arranging transportation for outside consultations due to changes in the transportation service provider. Resident #87, who had a progressive neurological condition and contractures, was observed in a high back chair with poor positioning, indicating a lack of appropriate care for their condition. The resident's condition had changed, necessitating a new intervention, but the facility did not adequately address the resident's positioning needs. Communication issues between the nursing staff and rehabilitation services further contributed to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for Resident #676, who was admitted with redness on their buttocks. Despite being at risk for pressure ulcers due to conditions such as amyotrophic lateral sclerosis and respiratory failure, the resident did not receive a comprehensive skin assessment until a stage 3 facility-acquired sacral pressure sore developed. The facility's policy required a risk assessment upon admission and weekly skin evaluations, but these were not properly conducted or documented for Resident #676. Upon admission, Resident #676 was noted to have two small red areas on the buttocks, but there was no documented evidence of a treatment regime or ongoing skin assessments to address these areas. The resident's care plan included interventions such as weekly skin assessments and turning/positioning every two hours, but these measures were not effectively implemented. The facility's new skin assessment software did not interface with the electronic medical record, leading to documentation gaps and communication issues among the nursing staff. Interviews with the Assistant Director of Nursing and the physician revealed that the facility's staffing and documentation practices contributed to the deficiency. The Assistant Director of Nursing acknowledged the lack of documentation and oversight in monitoring Resident #676's skin condition. The physician noted that the facility's staffing levels were insufficient to match hospital standards, impacting the ability to prevent pressure ulcers. The facility's failure to conduct timely and accurate skin assessments and implement preventive measures resulted in the development of a stage 3 pressure ulcer for Resident #676.
Medication Order Transcription Error
Penalty
Summary
The facility failed to ensure that a resident's total program of care, including medications and treatments, was reviewed at each visit. This deficiency was identified during a recertification and abbreviated survey, where it was found that a Nurse Practitioner did not review and ensure the accuracy of transcribed medication orders upon a resident's admission. The resident, who had diagnoses of bipolar disorder and mononeuropathy, was admitted with specific medication orders from the hospital, which included Gabapentin and Seroquel. However, the orders were incorrectly transcribed, leading to the administration of these medications at incorrect times. The error was discovered when a family member alerted the Nurse Practitioner about the incorrect medication reconciliation. Despite the facility's policy requiring licensed staff to verify and transcribe orders accurately, the Nurse Practitioner admitted to focusing primarily on dosage rather than administration timing when signing off on transcribed orders. This oversight resulted in the resident receiving medications at 9 AM instead of the prescribed times, which were corrected only after the family member's intervention.
Failure to Conduct Timely CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months, as required. Specifically, two of five randomly selected CNAs did not have documented performance reviews within the past year. The Director of Human Resources acknowledged the absence of these reviews and stated that the unit manager was responsible for completing them. However, the Registered Nurse Unit Manager reported not being trained to conduct performance reviews and had not received a list of staff due for reviews. The Director of Nursing was unaware that the reviews were not being completed, indicating a breakdown in communication and oversight within the facility's management structure.
Failure to Provide Required Psychiatric Consultation
Penalty
Summary
The facility failed to ensure that a resident diagnosed with bipolar disorder received necessary behavioral health services, specifically a psychiatric consultation, as per the comprehensive assessment and plan of care. The resident, who was moderately cognitively impaired and on antipsychotic medication, was not evaluated by a psychiatrist in accordance with a physician's order. Despite the resident's documented need for a psychiatric evaluation due to anxiety and potential side effects from psychotropic medication, there was no evidence of a psychiatry consultation being conducted. The deficiency was attributed to a transition in the facility's psychiatric services provider, which resulted in a backlog of psychiatric evaluations and consultations. The facility's new psychiatric provider, a Physician Assistant, was unable to meet the demand due to limited availability, evaluating only 10 residents every two weeks. This change from a previous psychiatrist who provided approximately 20 hours a week left the facility unable to address the psychiatric needs of all residents requiring such services.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
During a recertification survey conducted from November 13 to November 21, 2024, it was observed that the facility failed to provide a dignified dining experience for residents. Specifically, a Certified Nurse Aide (CNA) was seen standing while feeding two residents, which is contrary to the expected practice of sitting to ensure a respectful and comfortable dining experience for the residents. On November 18, 2024, at 12:05 PM, the CNA was observed standing while feeding Resident #42, and upon being directed by another staff member to sit, the CNA mentioned that their back was hurting and they were short. Later, at 12:36 PM, the same CNA was again observed standing while feeding Resident #239. In an interview conducted on November 19, 2024, the CNA admitted to forgetting the requirement to sit while feeding residents.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure that residents and/or their designated representatives were fully informed of their right to an expedited review of a service termination. Specifically, for two residents reviewed for Beneficiary Protection, the facility did not provide the Notice of Medicare Non-Coverage form CMS-10123 at least two days prior to the end of Medicare Part A covered services. The facility's policy requires that this notice be given to the resident or their legal representative with a minimum notice of two days, and if the resident is incompetent, the notice should be delivered to the legal representative. However, there was no documented evidence that the notice was provided to the designated representatives of the two residents involved. For one resident, the Rehabilitation Assistant attempted to contact the family but was unsuccessful and did not document the attempted contact. For the other resident, the Rehabilitation Assistant did not make any calls to the family, as the resident's parents had passed away and another family member had expressed disinterest in being involved with financial matters. In both cases, the Administrator signed the Notice of Medicare Non-Coverage without ensuring that the designated representatives were informed, as required by the facility's policy. The Administrator stated that they would expect the Rehabilitation Assistant to document attempts to contact the family, but this was not done in these instances.
Failure to Monitor Resident's Weight Timely
Penalty
Summary
The facility failed to ensure timely weight measurements for a resident with significant weight loss, as per physician orders. Resident #208, who had diagnoses including Cerebral Infarction, Acute Respiratory Failure, and Type 2 Diabetes, was supposed to have weekly weights taken from admission on 10/24/24 to 11/14/24, followed by monthly weights. However, after a significant weight loss was noted on 11/7/24, there was no documented evidence of weights being taken between 11/7/24 and 11/19/24. The resident's weight dropped from 183 lbs on 10/24/24 to 166 lbs on 11/7/24, indicating a 9.29% weight loss. Interviews with facility staff revealed that a 'weigh now' order was placed on 11/14/24 but was not executed. The Registered Nurse Unit Manager and the Director of Nursing acknowledged the failure to obtain the weight as ordered, and the physician was unaware that the weight was not obtained. The dietician had adjusted the resident's tube feeding regimen, but the lack of timely weight monitoring hindered the ability to assess the effectiveness of these adjustments. This deficiency highlights a lapse in following physician orders and monitoring the resident's nutritional status effectively.
Deficiency in Medication Storage and Expiration Management
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with accepted professional standards, specifically regarding expiration dates and proper storage. During a recertification survey, expired medications were found in one of the five medication storage rooms and one of eight medication carts on the Vent Unit. Additionally, a Lantus Insulin Pen was not discarded after 28 days of being open, as required. The facility's policy mandates that medications be stored in a manner that maintains their integrity and ensures resident safety, with expired or discontinued medications removed and disposed of according to policy. Furthermore, a medication refrigerator containing Lorazepam, a controlled substance, was not secured to a permanent fixture, which is a requirement for controlled substances. Interviews with staff, including LPNs and the Director of Nursing, revealed that there is an expectation for floor nurses and Unit Managers to check medication carts and rooms for expired medications. However, the Director of Nursing acknowledged that unit refrigerators are not bolted to the floor or another permanent fixture. The Pharmacy Consultant confirmed that while the pharmacy checks medication carts quarterly, it is ultimately the facility's responsibility to ensure compliance with medication storage standards.
Resident Abuse Incident Involving Community Support Specialist
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Community Support Specialist (CSS) who hit a resident in the face. The incident occurred when the resident, who has a history of dementia, cognitive communication deficit, and mood disorders, threw food at the CSS. The CSS, whose job description did not include assisting with meal trays, reacted by striking the resident. Witnesses, including a Certified Nursing Assistant and a Licensed Practical Nurse, confirmed the CSS's actions, noting that the resident was hit hard enough for the sound to echo in the room. The resident involved in the incident had a documented history of behavioral issues, including physical aggression and resistance to care, as noted in their behavior care plan. Despite these known behaviors, a care plan to address potential victimization of abuse was not initiated until the day of the incident. The facility's investigation concluded that abuse could not be substantiated due to the reactive nature of the incident, lack of injury, and absence of willful intent. However, the CSS's response was deemed inappropriate, and the incident was reported to the facility's administration shortly after it occurred. Interviews with facility staff revealed that the CSS was not supposed to be interacting with the resident, as they were assigned to another resident on close visual observation. The Director of Community Support Specialists acknowledged that the CSS should have used de-escalation techniques instead of reacting physically. The Director of Nursing and the Administrator were informed of the incident promptly, and the CSS was removed from the unit to ensure the resident's safety. The facility's policy mandates thorough investigation and documentation of all alleged abuse incidents, but the incident highlighted a lapse in adherence to these protocols.
Delayed Reporting of Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an investigation into a physical abuse allegation to the New York State Department of Health within the required 5 working days. The incident involved a resident with severe cognitive impairment, including dementia and other mood disorders, who was allegedly hit in the face by a Community Support Specialist after the resident threw food at them. The incident was witnessed by a Licensed Practical Nurse and a Certified Nurse Assistant. The facility's investigation concluded that the abuse was unsubstantiated due to the reactive nature of the incident, lack of injury, and absence of willful intent. Despite the investigation being completed, the facility submitted the 5-day investigative report late, on 3/26/2024, which was 2 days past the required submission date. Additionally, the report initially submitted on 3/21/2024 contained incorrect case numbers and incident dates, which contributed to the delay. The administrator acknowledged the error during an interview, stating that the case number was mistakenly associated with another case. This oversight resulted in non-compliance with state reporting requirements.
Failure to Develop Comprehensive Care Plan for Resident at Risk of Abuse
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for a resident who was at risk for abuse by staff and other residents. The resident, diagnosed with dementia, cognitive communication deficit, unspecified mood disorder, anxiety, and depression, exhibited severe cognitive impairment and physical behavioral symptoms towards others. Despite these assessments, the facility did not initiate a comprehensive care plan with interventions to prevent abuse until after an abuse allegation incident occurred. The behavior care plan documented multiple instances of the resident's combative and aggressive behavior towards staff and peers, yet no care plan addressing the potential for abuse was initiated until the day of the incident. Interviews with facility staff revealed a lack of clarity and consistency in the process of initiating and updating care plans. The Director of Nursing and other staff members indicated that the responsibility for initiating care plans upon admission fell to the admitting nurse, with follow-up by the unit manager. However, the care plans for potential abuse were not initiated in a timely manner, despite the resident's known behavioral issues. This oversight highlights a failure in the facility's procedures for ensuring that all necessary care plans are in place and reviewed promptly after admission.
Failure to Ensure Timely Medication Administration
Penalty
Summary
The facility failed to ensure timely acquiring, receiving, and administering medications for two residents. Resident #2, who was prescribed Dronabinol for appetite stimulation, missed 46 doses due to the medication being unavailable. Despite the pharmacy notifying the facility that the medication was out of stock, there was no documentation in the Medication Administration Record (MAR) or nursing progress notes explaining the missed doses or indicating that the physician was notified. The resident's medication was received sporadically, and there were significant gaps in administration, with no documented evidence of follow-up actions taken by the facility to address the issue. Resident #5, who was prescribed Bupropion for depression, missed 8 doses of the medication. The MAR indicated that the medication was not administered on several occasions, with notes on two dates stating that the facility was waiting for the pharmacy to deliver the medication. The resident reported not always receiving their medication and was informed by nurses that the medication had been sent to another unit. There was no consistent documentation in the MAR or nursing progress notes explaining the missed doses or indicating that the physician was notified. Interviews with nursing staff revealed inconsistencies in the process of notifying the physician and documenting missed doses. Some nurses stated they would notify the Nurse Practitioner and document in the MAR, while others admitted to not writing notes. The pharmacist confirmed that it was the facility's responsibility to notify the provider if a medication was on backorder. The lack of proper documentation and follow-up actions contributed to the deficiency in pharmaceutical services for these residents.
Significant Medication Errors
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors, as evidenced by the cases of two residents. Resident #2, who was prescribed Dronabinol for appetite stimulation, missed 46 doses due to the medication being unavailable. There was no documentation in the Medication Administration Record (MAR) or nursing progress notes explaining why the medication was not given, nor was there evidence that the physician was notified about the missed doses. The facility's policy required that the nurse contact the Nursing Supervisor and the pharmacy if a medication was unavailable, and notify the physician if a replacement could not be obtained. However, this protocol was not followed, leading to significant lapses in medication administration for Resident #2. Resident #5, who was prescribed Bupropion for depression, missed 8 doses of the medication. The MAR indicated that the medication was not administered on specific dates, with notes on two occasions stating that they were waiting for the pharmacy to deliver. The resident reported that they did not always receive their Bupropion and were told by nurses that the medication went to another unit. Interviews with nursing staff revealed that the protocol for documenting and notifying the Nurse Practitioner when a medication was not given was not consistently followed. The facility's failure to ensure the timely and accurate administration of prescribed medications for these residents constitutes a significant medication error. The lack of proper documentation and communication with the physician or pharmacy about the unavailability of medications further exacerbated the issue, leading to multiple missed doses for both residents. This deficiency highlights a critical lapse in the facility's medication administration process and adherence to its own policies and procedures.
Failure to Provide Prescribed Double Portions to Resident
Penalty
Summary
The facility did not ensure that a resident's dietary needs and choices were met, specifically for a resident with diagnoses including benign prostatic hyperplasia, obstructive uropathy, and depression. The resident was on a therapeutic diet that included double portions, as documented in the comprehensive care plan and physician orders. However, during meal observations on two separate occasions, the resident did not receive the prescribed double portions. Instead, the resident received only one sandwich when the meal ticket indicated they should have received two sandwiches. This discrepancy was confirmed through interviews with the Food Service Director, the Registered Nurse Unit Manager, and the line supervisor, all of whom acknowledged that the resident should have received double portions as per the dietary recommendations and meal ticket instructions. The Admission Minimum Data Set (MDS) dated 11/13/23 documented that the resident's cognition was intact and that they were on a therapeutic diet. A nutrition progress note dated 11/15/23 also confirmed that the resident was supposed to receive double portions of protein entrees at all meals. Despite these clear instructions, the resident did not receive the appropriate portions during meal observations on 12/19/2023 and 12/21/2023. The staff involved in meal preparation and delivery acknowledged the error, indicating a lapse in ensuring that the resident's dietary needs were met as prescribed.
Improper Storage of Refrigerated Food
Penalty
Summary
The facility did not ensure proper storage of refrigerated food in accordance with professional standards for food safety. During a tour of the facility kitchen, surveyors observed that the walk-in refrigerator contained a pan with meat marinated in a brown liquid and a small plastic container with a green paste, both of which were unlabeled and undated. The facility's policy and procedure for cold food storage and shelf life required that foods be labeled with the date made or received and discarded after three days. Interviews with the Food Service Director and Assistant Food Service Director confirmed that the containers should have been dated and labeled to ensure food safety and prevent staff from being unaware of the contents and duration of storage.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility did not ensure that two residents were free from abuse and neglect, leading to a physical altercation. Resident #1, who had moderate cognitive impairment and a history of behavioral issues, was involved in a verbal altercation with Resident #4. Despite being separated initially, the two residents later had another altercation where Resident #1 was punched in the face by Resident #4, resulting in a bleeding lip for Resident #1. The facility's policy on abuse, which includes the willful infliction of injury and resulting physical harm, was not adequately followed to prevent this incident. Resident #1 had a behavior care plan that included interventions such as providing one-to-one supervision as needed and avoiding overstimulation. However, these interventions were not effectively implemented, as evidenced by the altercation. Resident #4 also had a behavior care plan that documented a risk for victimization and physical aggression towards peers. Despite these documented risks, the facility failed to provide adequate supervision and separation to prevent the altercation. Interviews with staff revealed inconsistencies in the reporting and follow-up of the incident. The Director of Nursing and the Administrator had differing views on whether the incident constituted abuse, and there was no documented evidence of immediate psychiatric follow-up for the residents involved. The facility's response to the incident, including moving Resident #1 to a different unit and separating the residents for 72 hours, was not sufficient to address the underlying issues of inadequate supervision and failure to follow behavior care plans effectively.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse were reported within the required 24-hour timeframe. Specifically, the facility failed to report an incident involving resident-to-resident abuse where one resident was found bleeding from the mouth after allegedly being punched by another resident. The incident was documented in the facility's accident/incident report, but the New York State Department of Health was not contacted regarding the altercation. The facility's investigation ruled out abuse, mistreatment, and neglect, citing inconsistencies in the residents' statements and the lack of direct observation of the incident. However, the facility did not follow the mandated reporting procedures for such incidents. Resident #1, who has diagnoses including cerebral vascular attack, anxiety disorder, psychotic disorder, and flaccid hemiplegia, was found with a bleeding mouth after an unwitnessed altercation with another resident. Despite the resident's moderate cognitive impairment and the physical evidence of injury, the facility did not report the incident to the appropriate authorities. Interviews with the Nurse Practitioner and the Administrator revealed that the incident was not communicated to the medical staff, and the decision not to report was based on the perceived inconsistencies in the resident's account of the event. The Administrator believed the investigation was thorough and did not warrant reporting, despite the lack of a comprehensive review of all notes and the absence of close visual observation of the involved residents.
Failure to Monitor Resident's Weight as Prescribed
Penalty
Summary
The facility did not ensure that necessary monitoring was performed to maintain weight and prevent loss for a resident with a history of weight fluctuations. The resident, who had diagnoses including Cerebral Vascular Accident (CVA) and Psychotic Disorder, had physician orders for monthly weights that were not carried out as prescribed. Despite the resident's ability to eat independently and having no dental issues, weights were missing for several months, and there was no documentation of the resident refusing weights. The Dietician Tech noted the missing weights and communicated the need for weights to the Unit Managers and Registered Nurse Unit Manager (RNUM), but no action was taken. The Dietician Tech also discussed the issue in morning meetings, but the problem persisted. Interviews with staff revealed that the Certified Nurses Assistants (CNAs) were aware of the need to obtain weights and would inform nurses if they encountered difficulties. However, the Administrator and Nurse Practitioner were not aware of the missing weights, and there was no documentation of the resident refusing weights. The facility failed to follow the physician's orders for monthly weights, leading to a deficiency in monitoring the resident's nutritional status.
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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