Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northeast Ctr For Rehabilitation And Brain Injury during CMS and state inspections, most recent first.
A resident with dementia fell in the shower while a CNA turned away and did not maintain continuous 1:1 supervision, another resident fell from bed after a CNA failed to keep the bed low and mats in place per the care plan and ordered neuro checks were not documented, and a third resident with quadriplegia fell from a shower trolley after a CNA completed a mechanical-lift transfer and shower alone despite a 2-person assist requirement.
The facility failed to maintain sufficient CNA and nursing staffing to meet resident needs and its own PAR levels. Staffing sheets showed repeated shortages across day, evening, and night shifts, and staff reported that call-outs were not always replaced, units were often understaffed, and cares such as showers, documentation, turning, and toileting were delayed or left incomplete. The DON and staffing coordinators acknowledged ongoing difficulty meeting staffing targets, especially on evenings, weekends, and nights, with frequent use of agency staff and some units lacking a manager or charge nurse.
Unclean Environment and Missing Personal Property Inventories: Survey observations found cluttered rooms, sticky and debris-covered floors, soiled linens, food debris, liquid spills, odors, and disrepair in resident areas, with staff acknowledging ongoing issues on the unit. In addition, personal property inventories were not completed on admission for two residents, and family members reported missing clothing, a razor, a blanket, and slippers; staff confirmed the missing inventories in the record.
Failure to Investigate Unwitnessed Fall and Injury of Unknown Origin: The facility did not thoroughly investigate a resident’s unexplained hip fracture after multiple prior falls or an unwitnessed bathroom fall that led to a Code Blue. Records showed limited documentation, with only a CNA statement for the fracture case and only one concierge statement for the fall case, while the ADON and Administrator acknowledged that incident reports and investigations should have been completed.
Failure to Provide and Document Required ADL Care: Multiple residents did not receive or have documentation of ordered ADL services. A resident with cognitive intactness but significant personal care needs was repeatedly observed with dandruff, a scaly scalp, and dirty, jagged fingernails while staff said refusals and concerns were not reported. Another dependent resident had missing CNA documentation for turning, positioning, and toileting, and a CNA reported the resident went without cares for long periods and was found soiled. A third resident with dysphagia had only two documented mouth-care entries despite an order for q4h oral care, and other residents had no documented bathing or showers as scheduled.
Feeding tube care was not provided according to established criteria for three residents with enteral tubes. Two residents’ formula bottles were not labeled with the resident name, date, time hung, rate, or nurse initials, and an LPN noted a clog remover was left uncovered at the bedside. For another resident, a dirty feeding tube syringe with apparent residue or mold was found stored in a drawer, and staff stated syringes and clog removers should be stored and dated differently.
Food and drink were not served at palatable, appetizing temperatures during meal service. A test tray showed a lukewarm cheeseburger, cold vegetables and fries, and milk and juice that were not cold to taste, while tray line observation found open cart and cooler doors during meal assembly. The FSD stated the facility used a plate warmer and pellet system but did not have insulated food carts, and cold item temperatures were not taken before service. Residents and a representative also reported cold meals, including cold eggs and food that was always cold.
Failure to include resident representatives in care planning. A resident with dementia, aphasia, impaired mobility, and a history of falls had 1:1 supervision reduced without documented family notification, even though staff had implemented the supervision at the family’s request and later noted the resident still required it for pica behavior. Another resident with severe neurologic and respiratory conditions did not have an initial team care plan meeting until six weeks after admission, despite policy and admin expectations for earlier family involvement.
A resident with anoxic brain injury, CVA, and quadriplegia had a family representative request transfer referrals to other facilities, but the referral process was not documented as started until months later. The social worker said referrals are usually sent and tracked, yet the EMR lacked evidence of any referrals before the packet was emailed to a community transition program, despite the family reporting they had asked for transfer shortly after admission.
A resident with severe neurologic impairment, trach dependence, and a feeding tube returned from the hospital with moisture associated skin damage to the sacral area that later became an unstageable wound. The resident’s representative was not promptly notified of the change in status, and the record lacked documentation that the family was informed of the new skin breakdown.
Verbal Abuse Toward a Dependent Resident During Incontinence Care: A CNA used vulgar language and told a resident they did not like them while providing incontinence care. The resident, who was cognitively intact but dependent for toileting and frequently incontinent, reported feeling insignificant and depressed. Another CNA heard the comments and notified an LPN, and the DON later confirmed the resident’s account was consistent.
Baseline care plans were not documented as being given to two residents or their representatives. One resident was dependent for all cares with chronic respiratory failure, anoxic brain damage, and persistent vegetative state, and the other had intact cognition with maximum assistance needs and diagnoses including cholelithiasis, kidney cancer, and DM. Records showed baseline care plans were completed, but there was no documentation of delivery, mailing, or signed receipt.
A resident with respiratory failure and ventilator dependence became unresponsive with agonal breathing and elevated BP, but the chart lacked key documentation of when the MD was called, when symptoms began, and the orders given. The nitroglycerin order, time given, and pre/post VS were not documented, and there was no record of the Medical Director’s involvement or discussion with the family. Staff interviews showed uncertainty about the timing of the event and transfer process.
Failure to consistently implement pressure ulcer prevention measures led to worsening skin breakdown for two residents. One resident with dementia, impaired mobility, and multiple wounds was observed without ordered heel offloading and with inconsistent T&P documentation, despite care plan interventions for an air mattress, pillows, and heel boots. Another resident with anoxic brain injury, CVA, and quadriplegia developed a heel blister and ischial skin breakdown that progressed to a Stage 3 PI while an air mattress listed on the care plan was not actually in place for weeks.
Failure to provide and document ordered ROM services for a resident with impaired ROM and mobility. The resident had chronic respiratory failure, anoxic brain damage, and persistent vegetative state, and the care plan directed passive ROM to both UEs and LEs per schedule. The family said ROM was not provided as expected, therapy staff said the resident was placed on restorative ROM after no progress with therapy, and the PT coordinator reported inconsistent documentation with gaps in the ROM record and a CNA who said care was done but not documented each time.
A resident with TBI, constipation, and incontinence had no documented bowel movements for several shifts despite a bowel care plan, bowel regimen policy, and orders requiring monitoring and escalation after 72 hours without a BM; the resident later had abdominal distention and concern for constipation with possible fecal impaction. Another resident with a Foley catheter had repeated omissions in documentation for catheter care and irrigation across two months, despite orders for daily catheter care, evening irrigation, and routine catheter maintenance, and had positive urine testing associated with UTI findings.
Failure to complete ordered daily weights for a resident with TBI, dysphagia, and cognitive impairment. The resident had recent wt loss and was ordered on daily weights, but multiple weights were not documented and staff said they were unaware of the order or missed the task due to short staffing. The resident was observed eating a full meal tray, while nursing and dietary staff stated nursing was responsible for ensuring the weights were obtained as ordered.
A resident admitted with respiratory failure, anxiety, and ventilator dependence did not receive ordered anxiolytic medication as documented. The MAR showed Clonazepam was held and later not administered because it was awaiting pharmacy delivery and none was in the Pyxis, while an Alprazolam substitute was ordered but not documented as given. Staff gave conflicting accounts about whether the physician or pharmacy was contacted, and the pharmacist later reported Clonazepam was actually on hand in the ADC and no stat delivery was requested.
Delayed Dental Services: A resident with cerebellar stroke syndrome, dysphagia, and dependence for oral hygiene did not receive timely dental services after admission. Staff said residents were usually seen by the dentist within the first 6 weeks, but this resident had not been seen; the resident was observed with a dry mouth, peeling lips, and a white coating on the teeth, and the dentist stated other urgent cases took the available time.
Kitchen staff were observed not following the facility’s hygiene policy for food service safety. A dietary aide was seen in the kitchen without a hair restraint, and another aide on the tray line and the Assistant Food Service Director both had facial hair without beard guards. The Food Service Director stated the facility did not use beard guards in the kitchen, despite the written policy requiring hair restraints and beard guards at all times.
A resident with dementia and a known elopement risk exited through the front door without being stopped by the staff assigned to monitor the entrance. The facility did not realize the resident was missing until police called later that evening after finding the resident walking confused and wet along a roadway. Staff stated nursing relied on front-door personnel to control the exit, and the facility’s investigation identified poor door monitoring by the podium staff.
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.
Failure to Provide Required Supervision and Safe Transfers
Penalty
Summary
The facility failed to ensure a resident received adequate supervision during showering when a CNA left the resident in the shower chair and turned away to pick up dirty linen and retrieve items, during which time the resident stood up and fell. The resident had diagnoses including dementia, falls, and impaired gait and mobility, and the physician order required one-to-one supervision every day and every shift. The incident report and nursing note documented that water was accumulating on the bathroom floor because the shower drain was clogged, and the resident fell while the CNA was present in the shower room but not maintaining continuous supervision. The facility also failed to follow the care plan for another resident who had a history of falls, moderate cognitive impairment, and dependence for transfers and bed mobility. The care plan required the bed to remain in the lowest position and floor mats to be placed at bedside. After care was provided, the CNA did not return the bed to the lowest position and did not place the mats back beside the bed. The resident was later found on the floor next to the bed with abrasions and skin tears, and the record states the fall occurred when the bed was not in the lowest position and the mats were not in place as planned. Neurological checks were ordered after the unwitnessed fall, but there was no documented evidence that they were completed. The facility further failed to provide the required two-person assistance for a resident with anoxic brain injury, post-traumatic seizure, and quadriplegia who required dependent assistance for bed mobility, transfers, and showering. A CNA transferred the resident from bed to a shower trolley using a mechanical lift and showered the resident alone, despite the care plan and facility policy requiring two staff for mechanical assistance transfers. During the shower, the resident fell from the trolley, struck the floor, and sustained bruising, abrasions, and a forehead laceration that required 19 sutures. Interviews and records stated the CNA knew two-person assistance was required but did not obtain help and proceeded with the transfer and shower alone.
Insufficient Nursing Staffing and Unmet PAR Levels
Penalty
Summary
The facility did not provide consistent sufficient nursing staff to meet resident needs on all shifts. Surveyors found that the facility’s staffing sheets from multiple dates showed staffing below the minimum levels listed in the Facility Assessment, including repeated shortages of CNAs and, on at least one date, nurses. The report states that for 26 of 26 dates reviewed between 05/19/2026 and 06/13/2026, actual staffing was below projected staffing needs for CNAs and nursing staff. Additional staffing sheets from earlier dates in 2025 and 2026 also showed the facility below its projected staffing levels. The Facility Assessment listed projected staffing needs for direct care CNAs, cart LPNs/RNs, unit manager LPNs/RNs, nurse supervisors, and an LPN supervisor. Staffing records showed multiple shifts where the facility lacked several CNAs on day and evening shifts, and one date where it lacked nurses on the day shift as well as CNAs. On one unit, staffing records showed the unit was below CNA PAR levels on day and evening shifts, and on another date the unit was below CNA PAR levels on all three shifts. One night shift had only one CNA on the unit from 5:30 AM to 7:00 AM because one of the two CNAs left early. Interviews with staff and leadership confirmed ongoing staffing problems. CNAs and unit managers reported that call-outs were not always replaced, that units were often staffed with too few aides, and that they could not always complete showers, documentation, or other cares. Several staff stated that evening, weekend, and night shifts were especially difficult to staff, that agency staff were used frequently, and that some units had no manager or charge nurse. The DON and staffing coordinators acknowledged that the facility struggled to meet PAR levels daily and that short staffing affected resident care, including delayed changing, toileting, turning and positioning, and showers being deferred to the next shift. The report also links the staffing deficiency to deficient practice in ADL care under F677.
Unclean Environment and Missing Personal Property Inventories
Penalty
Summary
The facility did not maintain a clean and homelike environment in multiple resident areas. Survey observations documented cluttered rooms with personal effects, open and unopened food products on beds and floors, sticky floors, debris, soiled linens, dirty towels, liquid on the floor, wet garbage cans leaking onto the floor, urine odor in a hallway, and walls that were discolored and worn away. Staff interviews acknowledged that some floors were sticky, that housekeeping was aware of the condition of the floors, and that the NRP5 unit had been a challenge with frequent urination on the floor. A family member also reported that Unit NRP5 was filthy and that medical debris was all over the floor, comparable to walking on fly paper. Resident #19 had diagnoses including anoxic brain damage, cardiovascular accident, and quadriplegia, and the admission assessment documented moderately impaired cognition and dependence for lower body dressing. The resident's electronic record did not contain a list of personal items on admission. The resident's family member reported missing clothing and an electric razor, and stated the razor was reimbursed but the clothing was not. A social worker stated it was their responsibility to complete a personal items list on admission, but they could not find one in the record and found later lists dated months after admission. Resident #40's family member reported that a missing blanket had been found but slippers were still missing, and stated there was no inventory taken when the resident was admitted. The Director of Social Work stated that all personal belongings should be logged in on admission and placed in the medical record, but Resident #40 did not have an inventory completed. A social worker also confirmed that Resident #40 did not have an inventory of personal belongings and noted that another resident's inventory was also missing.
Failure to Investigate Unwitnessed Fall and Injury of Unknown Origin
Penalty
Summary
The facility did not thoroughly investigate injuries of unknown origin and an unwitnessed fall for two residents. For one resident with Lewy Body Dementia, Parkinson’s disease, and major depression, the resident had multiple prior falls and then developed hip pain, inability to move the left leg, and an externally rotated left foot before being sent to the hospital, where a comminuted left intertrochanteric fracture was diagnosed. The facility documented that the event did not result in harm and answered that there was no reasonable concern that staff action or inaction caused harm, but there was no documented injury-of-unknown-origin investigation, no documented look-back to determine how the fracture occurred, and no staff interviews beyond a CNA statement. For the second resident, who had anoxic brain injury, a tracheostomy, malignant neoplasm of the head, face, and neck, and severely impaired cognition, staff responded to a Code Blue after the resident was discovered on the bathroom floor with the door closed and water running. CPR was started, the tracheostomy was replaced, and the resident was transferred to the hospital after return of heart rate. The record contained a nursing supervisor note, a respiratory note, and one concierge statement, but there was no documented accident and incident report, no additional statements, and no investigation of the events leading to the unwitnessed fall. During interviews, the Administrative LPN stated the fracture case was one of the first reports completed in the QA role and that they did not think about injury of unknown origin, did not ask how the injury occurred, and did not do a 72-hour look-back with staff interviews. The Administrator stated the resident should have been asked what happened and that a look-back to the prior three days should have been completed, and acknowledged there was no documentation showing how the injury happened. For the unwitnessed fall, the ADON stated an incident report and investigation should have been completed, and the Administrator also stated one should have been completed but was uncertain why only one statement was available.
Failure to Provide and Document Required ADL Care
Penalty
Summary
The facility failed to ensure residents who were unable to perform activities of daily living received the necessary care and services for multiple residents reviewed for ADLs. The deficiency was based on observations, record review, and interviews during the abbreviated survey. The facility policy stated that ADL care is provided to help residents return to their maximum level of independence, and the CNA documentation policy required resident care to be documented before the end of the shift, with the unit nurse responsible for ensuring completion. Resident #11, who had diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, xerosis cutis, and need for assistance with personal care, was observed multiple times with a scaly, dandruff-covered scalp, dandruff flakes on clothing, and bilateral long, dirty, jagged fingernails. The resident assessment showed the resident was cognitively intact but needed assistance with eating, personal hygiene, toileting hygiene, bed mobility, and transfers, and was frequently incontinent of bowel and bladder. The care plan and CNA profile card called for bathing, hair care, nail care, and showering on scheduled days, but staff stated the resident frequently refused showers and that bed baths were often provided instead. Staff also stated the resident’s dandruff and nail condition had not been reported to nursing staff, and the unit manager observed the scalp and nails and noted the resident would allow nail care when asked. Resident #5, who had diagnoses including cerebral infarction with hemiplegia/hemiparesis and restlessness/agitation, was dependent for all cares and transfers and incontinent of bowel and bladder. The care plan required turning and positioning every two to three hours and toileting checks every two to three hours, but CNA task documentation was missing or absent for large portions of the reviewed shifts from 04/12/2026 through 04/14/2026. The assistant administrator stated the documentation could not be provided and that the CNAs assigned did not complete it. A CNA assigned to the resident stated they provided cares but did not document them, while another CNA who was present as a sitter for the roommate stated the resident was not toileted or repositioned for long periods, was found soiled with urine and feces, and did not receive cares until staff were alerted. Staff also acknowledged the unit had staffing and documentation problems. Resident #7, who had cerebellar stroke syndrome, dysphagia, and required maximal assistance for oral hygiene, had a physician order for mouth care every four hours and as needed. The treatment record for April showed only two documented mouth care entries, with the remainder blank. The unit manager stated the order was every four hours and used mouth swabs, while the ADON stated the order appeared to have been started and then discontinued the same day and not reinstated. Resident #37 had no documented shower or bathing during the two-week admission, and Resident #50 was observed on multiple occasions sweaty with no documented evidence that showers were provided twice weekly as scheduled.
Feeding Tube Supplies and Formula Were Not Properly Labeled or Stored
Penalty
Summary
Feeding tube care was not provided according to established criteria for accuracy and infection control for three residents with enteral feeding tubes. For one resident with a history of cerebral infarction, congestive heart failure, and dysphagia, the quarterly MDS documented moderate cognitive intactness and dependence on staff for nutrition via gastrostomy tube. The physician ordered Jevity 1.5 at 70 mL continuous starting at 5 PM, along with ordered water flushes and medication flushes. During observation, the resident’s formula bottle was not labeled with the resident’s name, date, time, rate, or nurse initials, and an enteral feeding tube clog remover was found uncovered on the bedside table. An LPN stated the formula should have been labeled and was unsure how long the clog remover had been left open to air. For another resident with head injury, dysphagia, and diabetes, the quarterly MDS documented severely compromised cognition and total dependence for care and feeding. The physician ordered Nutren 2.0 via pump at 60 mL per hour overnight with scheduled water flushes and medication flushes. During observation, the resident’s formula bottle was also not labeled with the resident’s name, date, time, rate, or nurse initials. An LPN stated the bottle should have been dated when hung and that a clog remover should be stored in its package and discarded after 24 hours. For a third resident with anoxic brain damage and dysphagia, the MDS documented severely impaired cognition, dependence for all care, and a feeding tube. Observation found a dirty feeding tube syringe in a plastic bag in the top drawer with apparent remnant medication or mold and no date on the bag. The RN stated the syringe should not have been stored there and did not know how long it had been in the drawer; the ADON stated syringes could be used for 24 hours and should be stored in their bag, and that clog removers were not multi-use.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not provided at a palatable, attractive, and safe temperature during lunch meal service on the Rehab unit. On 07/21/2026, food cart #1 arrived at 11:56 AM and food cart #2 arrived at 12:04 PM, with trays passed until 12:24 PM. Both cart doors were left open during tray passing. The test tray showed a cheeseburger at 106 degrees Fahrenheit with cheese not melted and described as lukewarm, vegetable blend at 104 degrees Fahrenheit and cold to taste, french fries at 100 degrees Fahrenheit and cold with a tough texture, milk at 60 degrees Fahrenheit and not cold to taste, and juice at 66 degrees Fahrenheit and not cold to taste. Coffee and cream of rice were documented as warm but acceptable. During tray line observation in the kitchen, the milk cooler door was left open while meal trays were being built. The facility’s food temperature log for the 11 AM meal documented hot items on the steam table before plating, including a cheeseburger at 172 degrees Fahrenheit and vegetable blend at 174 degrees Fahrenheit, but no temperatures were recorded for the french fries, cream of rice, milk, or juice. The Food Service Director stated the facility used a plate warmer and pellet system but did not have insulated food carts, and that cold food temperatures were not obtained before meal service. The director also stated the milk cooler had been running high the prior month and had been repaired, and that leaving the cooler door open during tray line was typical procedure. Resident and representative interviews also described food as cold, including reports that breakfast was the coldest meal, with cold eggs and sometimes warm toast, and that the food was always cold or not edible.
Failure to Include Resident Representatives in Care Planning
Penalty
Summary
The facility did not ensure that the resident and/or the resident representative participated in the development and implementation of the person-centered plan of care for two residents. For one resident with diagnoses including dementia, aphasia, and abnormal gait and mobility, the Minimum Data Set documented severely impaired cognition, dependence for many activities, and family participation in assessment and goal setting. The resident had a physician order for one-to-one supervision every shift and every day, but the facility removed the one-to-one supervision on the 7 AM to 3 PM shift without documented discussion with or notification to the family. Nursing, physician, social work, and progress notes from the period reviewed did not show evidence that the family was informed of the change, and later documentation showed the resident continued to require one-to-one supervision for pica behavior. During observations and interviews, the resident was seen lying in bed without supervision, and a CNA stated the resident was no longer on one-to-one supervision. The resident’s representative stated the facility would discontinue supervision without informing or consulting the family. Staff interviews indicated the resident had a history of falls, multiple falls after admission, and that one-to-one supervision had been implemented at the family’s request. Staff also stated they re-evaluated supervision and might adjust it, but could not provide specific dates when the family was informed, and the communication was not documented in the electronic medical record. For a second resident with chronic respiratory failure, trach dependence, anoxic brain damage, dysphagia with feeding tube, and persistent vegetative state, the baseline care plan was discussed with the representative, but the initial team care plan meeting did not occur until six weeks after admission. The facility’s policy stated the resident and representative were to be informed of the initial plan of care and invited to care plan meetings, and the administrator stated the initial team care plan meeting with family should occur within the first one to two weeks of admission. Staff explained the delay by citing staffing issues and the former director’s resignation, and the resident’s representative stated they had to wait six weeks for the meeting.
Failure to Document and Initiate Requested Transfer Referrals
Penalty
Summary
The facility failed to ensure Resident #19’s representative could make choices about discharge planning and transfer arrangements. Resident #19 had diagnoses including anoxic brain damage, cardiovascular accident, and quadriplegia, and the admission MDS dated 06/12/2025 documented moderately impaired cognition with substantial to maximal assistance needed for upper body dressing and dependence for lower body dressing. The discharge planning notes dated 06/04/2025 and 06/10/2025 documented the resident wished to return home with family, and the 06/10/2025 care conference summary noted the family member had applied for Social Security and the Traumatic Brain Injury Waiver program. The resident representative requested referrals be sent to other facilities for transfer in June 2025, but there was no documented evidence that referrals were started until 09/09/2025. A grievance form dated 06/17/2025 completed by Social Worker #16 documented a call to the family member about a referral packet being sent, but this was not documented in the electronic medical record. During interview, the family member stated they had asked for transfer to a different facility shortly after admission and that the social worker took four months to do anything, while the social worker stated they usually send referrals and follow up, but could not find documented evidence of any referrals sent prior to 09/09/2025.
Failure to Notify Representative of New Skin Breakdown
Penalty
Summary
The facility did not ensure that a resident’s representative was promptly notified of a change in status involving skin breakdown. Resident #6, who had diagnoses including chronic respiratory failure with trach dependence, anoxic brain damage, dysphagia with feeding tube, and persistent vegetative state, was dependent for all care. After a hospitalization, the resident returned to the facility with moisture associated skin damage to the sacral/coccyx area, which was documented in a nursing progress note and physician order on 04/03/2026. The wound was later documented as unstageable on 04/08/2026, with a physician order the next day describing an unstageable necrotic sacral wound. The resident’s designated representative was not informed of the skin breakdown when the resident was readmitted from the hospital, and the record did not contain documentation that the family was notified of the new wound. During interview, the family member stated they learned of the wounds when the resident was sent to the hospital, and the Unit Manager RN stated that family is typically called after hospitalization to update them on events such as wounds and medication changes, but there was no note in the medical record showing that this occurred for Resident #6.
Verbal Abuse Toward a Dependent Resident During Incontinence Care
Penalty
Summary
The facility failed to ensure that Resident #13 was free from verbal and mental abuse when a Certified Nurse Aide used vulgar language and told the resident that they did not like them while providing care for bowel incontinence. Resident #13 had diagnoses including traumatic subdural hemorrhage to the brain, hepatic encephalopathy, and hemiplegia affecting the dominant right side. The quarterly MDS dated 9/30/2025 documented intact cognition and dependence for toileting hygiene and toileting transfers, and the resident was frequently incontinent of bladder and always incontinent of bowel. The care plan identified the resident as vulnerable due to physical and cognitive disabilities and directed staff to check and change the resident every two to three hours and as needed. The incident report documented that on 10/19/2025 the resident reported the CNA’s comments, and the facility investigation concluded there was sufficient cause to believe abuse had occurred. During later interviews, Resident #13 stated the CNA took their time with care, said they hated the resident, and made comments that made the resident feel insignificant and depressed. Another CNA stated they heard the resident report being covered in feces and heard the CNA make the vulgar comments, and they informed an LPN. The LPN confirmed they were told what the resident reported, and the DON stated the resident was alert and oriented and remained consistent in describing what the CNA had said.
Baseline care plans were not documented as provided to residents or representatives
Penalty
Summary
Baseline care plans were not documented as being provided to the resident or the resident representative for two residents reviewed for resident rights. For one resident, who was admitted with chronic respiratory failure, anoxic brain damage, and persistent vegetative state and was dependent for all cares, the record showed a baseline care plan was developed and signed by the Nurse Manager, and a nursing note documented that the nurse spoke with the resident’s representative by phone about the 48-hour care plan and a care plan meeting. However, there was no documentation that the baseline care plan summary was given to the representative, no signature from the representative, and no indication that it was mailed. The resident’s representative later stated they did not receive a copy, while staff interviews reflected differing understandings about whether the plan had been provided. For the second resident, who was admitted with cholelithiasis, kidney cancer, and diabetes mellitus and had intact cognition with maximum assistance needed for several transfers, the record showed a baseline care plan was developed with medication orders, diagnoses, diet order, and follow-up needs, and it was signed by the RN supervisor. A nursing progress note stated the baseline care plan was written out and was to be discussed with the responsible party, but there was no documentation that it was actually provided to the resident or responsible party. Interviews confirmed there were no checked boxes showing the resident, responsible party, or legal guardian received the summary and no documentation that it had been mailed.
Incomplete documentation during resident respiratory distress and transfer
Penalty
Summary
The facility did not ensure treatment and care were provided in accordance with professional standards of practice for a resident who was admitted with diagnoses including respiratory failure, anxiety disorder, and ventilator dependence. The deficiency involved a change in condition when the resident became unresponsive, had agonal breathing, and had elevated blood pressure. The record did not document the time the physician was called, when the symptoms began, or the orders that were given during the event. The documentation also did not include the nitroglycerin order, the time it was administered, or the resident’s vital signs before and after the medication was given. The nursing notes reflected that the resident had blood pressure 170/112, pulse 124, respiratory distress, and was nonresponsive, with nitroglycerin paste applied and no effect, but the chart lacked the required details surrounding the medication administration and response. There was also no documentation of the Medical Director’s involvement or the conversation with the family member. Interviews with staff showed uncertainty about the timing and sequence of events. The LPN stated they remembered agonal breathing and that it took a while for the ambulance to come, but they were unsure when the nitroglycerin patch was applied and found no documented vital signs after it was given. The RN stated they sent a text update to the physician and later a text to send the resident to the hospital, and described a process requiring Medical Director permission before transfer. The family member stated the resident was found unresponsive around 1:30 PM, was questioned about whether they wanted hospital transfer because of DNR status, and was not sent out until after 3:00 PM.
Failure to Consistently Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to provide consistent pressure ulcer prevention and treatment for two residents who developed pressure injuries while in the facility. The report states that the facility did not ensure care was consistent with professional standards to prevent pressure ulcers, and that turning and positioning, pressure-relieving devices, and other care plan interventions were not consistently implemented or documented for the residents reviewed. One resident had diagnoses including dementia, impaired gait and mobility, and falls, and later developed multiple pressure injuries while in the facility, including wounds to the sacrum, right malleolus, and left heel. The resident’s care plan included interventions such as turning and repositioning every 2 to 4 hours, a pressure relief mattress, offloading heels with pillows when in bed, and bilateral heel boots when out of bed. However, the CNA care log for one month documented turning and positioning completed on only 35 of 93 shifts, with omissions or documentation that it was not completed on the remaining shifts. During observations, the resident was seen in bed with heels directly on the mattress, without a pillow between the legs, and without heel boots or other protective devices in use when sitting in a reclining wheelchair. Staff interviews confirmed that the resident had developed wounds at the facility and that the interventions on the care plan were expected to be followed and documented. Another resident had diagnoses including anoxic brain damage, stroke, and quadriplegia, and was dependent on staff for bed mobility and transfers. The resident was identified as at moderate risk for pressure sores and later developed a fluid-filled blister to the right heel and skin breakdown to the buttocks and ischial areas. The care plan was updated to include an air mattress on 06/01/2025, but the air mattress was not placed until 06/20/2025. During that period, the wound progressed from a blister and moisture-associated skin damage to a Stage 3 pressure injury of the right ischial tuberosity. Interviews and record review showed that the resident was incontinent, unable to reposition independently, and had care plan interventions that included pressure relief measures, but the air mattress was not in place when documented on the care plan and the wound worsened before the mattress was installed.
Failure to Provide and Document Ordered ROM Services
Penalty
Summary
The facility failed to ensure that needed range of motion services were provided for a resident with impaired ROM and mobility. Resident #6 had diagnoses including chronic respiratory failure, anoxic brain damage, and persistent vegetative state, and the admission MDS documented that the resident was in a persistent vegetative state and dependent on staff for all cares. The restorative nursing care plan dated 02/04/2026 directed staff to provide passive ROM for both upper and lower extremities per schedule. During interviews, the resident’s family member stated the facility did not provide ROM treatments twice a week as they had been informed. The Occupational Therapist stated the resident had not made progress after a few weeks of therapy and was placed on the restorative program for ROM, with sessions that may have lasted 15 to 30 minutes twice a week in addition to care provided by CNAs. The Physical Therapy Coordinator stated the functional support program was provided through a designated CNA, but the documented treatment dates for ROM were inconsistent and showed gaps, including a two-week period without documentation. The coordinator also stated the CNA reported performing the care but not documenting each session.
Missed bowel monitoring and incomplete Foley catheter care documentation
Penalty
Summary
The facility did not ensure that bowel movements were monitored and documented for a resident with traumatic brain injury, constipation, dysphagia, moderate cognitive impairment, and dependence for eating and personal hygiene. The resident was incontinent of bowel and bladder, and the bowel/constipation care plan directed staff to monitor bowel status daily, record bowel movements every shift, and report changes. The bowel regimen policy stated that CNAs were responsible for documenting and reporting bowel movements, and licensed staff were to monitor the bowel record and initiate the bowel protocol when a resident had not moved their bowels for three days. For one month reviewed, the CNA bowel record showed a large bowel movement on one day and then no documented bowel movements for six days, spanning 17 shifts, before a loose stool was recorded. A nurse note documented that the resident’s mother reported a stomachache, the abdomen was slightly distended, and the last bowel movement had been loose during the overnight. The NP documented concern for infrequent bowel movements, abdominal distention, and possible overflow diarrhea in the setting of fecal impaction, with the clinical picture reflecting constipation and possible fecal impaction requiring escalation of the bowel regimen. Staff interviews stated bowel records were important, that the bowel protocol should have been initiated after 72 hours without a bowel movement, and that the resident was taking tramadol, which was described as constipating. The facility also did not ensure consistent documentation of catheter care and catheter irrigation for a resident with cerebral palsy, hypertension, overactive bladder, and an indwelling Foley catheter. The resident’s care plan and physician orders required daily catheter care every shift, irrigation every evening shift, weekly drainage bag changes, and monthly catheter changes. Review of the treatment administration record showed multiple omissions for catheter care and irrigation in two separate months, and the resident had positive urine testing associated with urinary tract infection findings. Staff interviews stated catheter care included checking the insertion site, drainage bag, urine color, and sediment, and the ADON stated missed documentation was not acceptable and that omissions could contribute to urinary tract infection.
Failure to Complete Ordered Daily Weights
Penalty
Summary
The facility did not ensure that a resident with traumatic brain injury, constipation, and dysphagia received the necessary care to maintain acceptable body weight, as daily weights ordered by the physician on 05/06/2026 were not implemented. The resident’s quarterly MDS documented moderate cognitive impairment and substantial assistance needs for eating and oral hygiene. The care plan for nutrition directed staff to provide the diet per physician order and monitor weight per physician order, and the physician orders included a regular ground diet with nectar thick liquids and two times portions. Record review showed no documented weights on multiple dates in May 2026, including 05/07, 05/09, 05/13 through 05/16, 05/18 through 05/20, 05/22 through 05/27, and 05/30 through 05/31. During observation, the resident was being fed in the room and the lunch tray included Ensure Plus nectar thickened, water, juice, two tuna sandwiches, two egg salad sandwiches, mashed potatoes, and extra gravy; on return visit, the resident had consumed all food on the tray. A CNA stated they had not checked the electronic record and were not aware the resident was to be weighed daily. The LPN unit manager stated the resident had recent weight loss and daily weights were a monitoring intervention, but many dates lacked documented weights and weights were often missed because of short staffing. The Director of Dietary Services stated the resident had weight loss in April and was placed on daily weights so any further loss could be caught early, and that nursing was responsible for ensuring the weights were obtained as ordered.
Medication Not Available for Resident Anxiety Order
Penalty
Summary
The facility did not ensure medications were available to meet the needs of Resident #18, who was admitted with diagnoses including respiratory failure, anxiety disorder, and ventilator dependence. On admission, the resident had orders for Clonazepam 0.5 mg via gastrostomy tube for anxiety, including a one-time order and then an order for Clonazepam every 8 hours. The record also showed an order for Alprazolam 0.5 mg via gastrostomy tube after Clonazepam was documented as not in stock. The medication administration record documented that Clonazepam was held because the physician was aware and it was not to start until the next day, and later that it was not administered because the physician was aware and the medication was awaiting pharmacy delivery, with none in the Pyxis automated medication dispensing cabinet. There was no documented evidence that the Alprazolam order was given. A nursing progress note documented the resident was awake most of the shift and repeatedly ringing the call bell for brief changes and peri-care. During interviews, staff gave conflicting accounts about the medication issue and who notified the physician. One RN stated Clonazepam was out of stock and the resident was ordered something else, but did not know whether the medication had been obtained or the pharmacy called. The ADON stated the physician was notified and ordered the medication held, but did not know who made the call and did not know if the pharmacy was contacted. The pharmacist later stated the facility had 9 tablets of Clonazepam on hand in the automated dispensing cabinet, did not receive an off-schedule delivery request, and did not receive the resident’s prescription until later that evening.
Delayed Dental Services
Penalty
Summary
The facility did not ensure necessary dental services were provided in a timely manner for one resident who was reviewed for dental services. The resident was admitted with diagnoses including cerebellar stroke syndrome, dysphagia, and need for assistance with personal care. The admission MDS dated 04/08/2026 documented intact cognition and maximal assistance needed for oral hygiene, and there was no documented evidence of a dental care plan for the resident. During observation on 06/02/2026, the resident was reclined in a therapy room chair and had a dry mouth, peeling lips, and teeth with a white coating. Staff interviews indicated residents were usually seen by the dentist within the first six weeks of admission and were automatically seen with or without an order, but this resident had not been seen. The medical secretary stated the dentist provided services twice a month and that the resident was added to the dental list after an email request, with an April schedule showing the resident was to be seen, but the dentist sometimes did not see everyone on the list. The dentist stated new admissions were usually seen within 30 days, but this resident was likely not seen because other residents requiring extractions and pain consultations took the available time during the visit.
Kitchen staff not using required hair restraints and beard guards
Penalty
Summary
The facility failed to ensure that food was prepared and served in accordance with professional standards for food service safety. During the abbreviated survey, a dietary aide was observed walking across the kitchen without a hair restraint to obtain one after forgetting to put it back on after lunch. In the same kitchen observation, a dietary aide working on the tray line had a full beard without a beard guard, and the Assistant Food Service Director had a small beard/goatee without a beard guard. During interview, the Food Service Director stated the facility did not use beard guards in the kitchen, and the Assistant Food Service Director appeared surprised that a beard guard would be required for a small beard/goatee. The facility’s revised kitchen hygiene policy stated that hair restraints and beard guards were to be used at all times in the kitchen area.
Failure to Supervise an Elopement-Risk Resident at the Front Door
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and that residents received adequate supervision to prevent accidents for a resident who was assessed at risk for elopement. The resident had diagnoses including dementia, cognitive communication deficit, and depression, and the facility’s elopement/wandering assessment identified the resident as an elopement risk because of the ability to physically leave the building. The resident’s care plan stated the resident would remain safe in the facility and included elopement-related monitoring. On the evening of the incident, the resident was last seen walking around off the unit and then exited the facility through the front door without intervention from staff assigned to monitor the entrance. The resident was able to leave the building without being stopped or questioned. The facility did not realize the resident was missing until police contacted the facility later that evening after the resident had already been found walking on a state route in the rain and transported for evaluation. Police and hospital documentation described the resident as confused, wet, shivering, and unable to estimate how long they had been outside. The officer reported the resident was walking on the shoulder of the road, seemed very confused about time, place, and current events, and had a bleeding left hand. Facility staff later stated that nursing staff relied on front door personnel to monitor the exit, and the facility investigation identified substandard entry door monitoring by the personnel assigned to the podium.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Katrine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ten Broeck Commons | 1.3 mi | ★★★★★ | 10 | 0 |
| Ferncliff Nursing Home Co Inc | 3.9 mi | ★★★★★ | 1 | 0 |
| Golden Hill Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 2 | 0 |
| The Baptist Home At Brookmeade | 6.3 mi | ★★★★★ | 0 | 0 |
| Renaissance Rehabilitation And Nursing Care Center | 10.5 mi | ★★★★★ | 12 | 0 |
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