Northern Manor Geriatric Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Nanuet, New York.
- Location
- 199 N Middletown Road, Nanuet, New York 10954
- CMS Provider Number
- 335046
- Inspections on file
- 25
- Latest survey
- December 17, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Northern Manor Geriatric Center Inc during CMS and state inspections, most recent first.
The facility did not ensure residents were treated with dignity during dining, as they were served meals on disposable styrofoam plates and with plastic utensils due to a shortage of regular dishware. Staff interviews revealed a lack of clarity and responsibility regarding the use of disposable dishware, with the Dietitian and Food Services Director acknowledging the issue and the Administrator being aware of the dish shortage.
The facility failed to maintain a safe and homelike environment, with issues such as chipped walls, peeling paint, and a torn shower chair with exposed wood. A dusty fan was also observed blowing on a resident with a tracheostomy. Maintenance and nursing staff were unaware or did not report these issues, indicating lapses in communication and oversight.
The facility did not ensure CNAs received the required 12 hours of in-service education annually, and four CNAs had outdated performance reviews. The Assistant Director of Nursing was responsible for education, and the DON acknowledged a system for training was in place but not fully implemented.
The facility failed to document and educate a resident and ten staff members on COVID-19 vaccination, lacking records for a resident with significant medical conditions and several staff, including the Director of Admissions and various nursing staff. Interviews revealed a lack of systematic tracking of vaccination status, with the Director of Nursing unaware of these deficiencies.
A facility failed to provide a resident and their representative with the Notice of Medicare Non-Coverage at least two days prior to the end of Medicare Part A services. The lack of a specific policy and communication issues among staff led to the oversight, as the Minimum Data Set Coordinator was unaware of the discharge until the day before it occurred, preventing timely notification.
The facility failed to provide written notices of the bed hold policy to residents or their representatives during hospital transfers. This deficiency affected four residents with various medical conditions, including cerebral infarct, anemia, and chronic respiratory failure. Interviews revealed that the facility had not been providing the required notices prior to December 9, 2024.
The facility did not ensure proper labeling and storage of drugs and biologicals, as expired Aspirin and tube feeding formulas were found in medication storage rooms. Staff interviews revealed lapses in adherence to procedures for checking and discarding expired items.
The facility did not adhere to food safety standards by failing to date food items in storage. Undated sandwiches and cheese slices were found in the walk-in refrigerator, and a ham sandwich was undated in a unit refrigerator. The Food Service Director and a CNA were unable to provide information on the dates these items were stored, contrary to facility policy requiring all foods to be labeled and dated.
A facility failed to ensure timely signing of a death certificate by the Medical Director, as required by state law. A resident with severe cognitive impairment and multiple diagnoses was pronounced dead, but the death certificate was signed seven days later, causing delays in processing the body at the funeral home. The Medical Director acknowledged the delay as an anomaly.
A facility failed to offer and document pneumococcal immunization and education for a resident with significant medical conditions. Staff interviews revealed a lack of a system to track vaccine eligibility and administration, leading to missed opportunities for vaccination. The DON was unaware of these issues, despite being informed that there were no problems.
The facility was found to have several environmental deficiencies, including a persistent water leak in the kitchen and widespread issues with chipped paint, dirt, and odors throughout the building. Despite regular environmental rounds by the DON and Administrator, these issues were not effectively addressed, indicating a gap in maintenance and communication. The Director of Maintenance was unaware of some problems, and progress on repairs was slow, with only two rooms being addressed per week.
The facility failed to notify resident representatives of significant changes in three residents' conditions. One resident with severe cognitive impairment had a low heart rate and medication changes without informing their guardian, leading to hospitalization. Another resident was placed on a ventilator without family notification, and a third experienced respiratory distress and was ventilated without family being informed. The facility did not adhere to its policy of immediate notification for significant changes.
The facility failed to protect residents' personal property, with incidents involving missing glasses, a cell phone used post-mortem, and a wallet with fraudulent charges. There was no proper documentation or investigation into these incidents, highlighting a lack of safeguarding measures for residents' belongings.
The facility failed to provide adequate care and documentation for several residents, leading to grievances and potential health risks. A resident with Sickle Cell Disease did not receive timely incontinence care, while another with Multiple Sclerosis had catheter issues that were not promptly addressed. Additional residents reported being left in soiled diapers, and documentation for essential care tasks was often incomplete, indicating systemic issues in care delivery.
A significant medication administration failure occurred in a LTC facility, where multiple residents did not receive their prescribed medications during a specific shift. The facility's staff failed to document the administration of medications and did not notify physicians of the omissions, as required by policy. Interviews revealed a lack of awareness and communication among staff, contributing to the deficiency.
A resident with a history of cirrhosis and elevated INR was ordered to receive Vitamin K intramuscularly, but the medication was not available, and staff failed to notify the physician. The Vitamin K was administered hours later, but the resident was found unresponsive and pronounced dead. Interviews revealed a lack of communication and monitoring by staff, contributing to the delay in treatment.
A resident with schizophrenia was transferred to a new unit due to verbal aggression, but the receiving unit was not informed of the incident. The resident refused medications and meals, claiming poisoning, but staff failed to notify the medical provider or document the refusals. This led to the resident physically assaulting another resident, highlighting a deficiency in preventing abuse due to communication lapses.
A resident with schizophrenia refused antipsychotic medication and meals, believing they were being poisoned. The refusals were not documented or reported to the medical provider, contrary to facility policy. The following day, the resident became aggressive, leading to hospitalization for psychosis. Staff interviews revealed a lack of communication and documentation regarding the resident's condition.
A resident with schizophrenia and other conditions refused significant medications, including antipsychotics, but staff failed to document the refusal or notify the medical provider. This led to the resident exhibiting aggressive behavior and being hospitalized with psychosis. Staff interviews revealed a lack of adherence to facility protocols for documenting and communicating medication refusals.
A resident reported missing clothing, but the facility failed to document or investigate the grievance as required by their policy. The resident was cognitively intact, yet there was no evidence of a thorough investigation or resolution. Interviews revealed a lack of communication and awareness among staff regarding the grievance process, leading to the deficiency.
A resident with multiple medical conditions reported being sexually assaulted by staff, but the facility failed to report the allegations to the New York State Department of Health. Despite claims by the DON and Administrator of reporting the incident, there was no documentation confirming the report was received or that a 5-day investigative result was submitted.
A resident alleged sexual assault by facility staff, but the LTC facility failed to ensure the allegations were reported to the New York State Department of Health. Despite claims by the DON and Administrator that the incident was reported via a hotline voicemail, there was no documentation confirming receipt or submission of a 5-day investigative report. The resident had multiple diagnoses, including respirator dependence and legal blindness, and was assessed to have intact cognition.
A resident, admitted with several medical conditions and cognitively intact, was not given the opportunity to participate in their care plan meeting. Despite being scheduled, the meeting did not occur, and there was no documentation or rescheduling effort made by the facility.
A resident with an indwelling catheter did not receive documented catheter care on several occasions, leading to a urinary tract infection. Despite physician orders for daily catheter care, documentation was missing for multiple shifts. The resident, with a history of neuromuscular dysfunction of the bladder, was monitored for spiking fevers and elevated white blood cell counts, resulting in a diagnosis of a urinary tract infection. Interviews with staff revealed awareness of the infection, but documentation gaps indicated care was not consistently provided.
The facility failed to ensure sufficient nursing staff, resulting in seven residents on the dementia unit not receiving their scheduled medications during the night shift. Staffing records showed no LPNs and insufficient CNAs, and interviews confirmed the ongoing staffing issues affecting medication administration.
The facility failed to administer scheduled medications to seven residents during specific night shifts due to significant staffing issues. The registered nurse on duty could not cover all units, leading to missed medications for residents with serious conditions. The DON and medical staff were not adequately informed, and the problem had been ongoing for several months.
Use of Disposable Dishware Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and care in a manner that promoted dignity during dining. Observations during the Recertification Survey revealed that residents in the [NAME] 1 and North 1 units were served meals using disposable styrofoam plates and plastic utensils on multiple occasions. Specifically, residents were observed eating from styrofoam plates during lunch and breakfast meals on three separate days. This practice was noted in the dining room and in the hallway outside the North 1 Unit, indicating a widespread issue. Interviews with facility staff, including a Registered Nurse Unit Manager, the Dietitian, the covering Food Services Director, and the facility Administrator, revealed a lack of clarity and responsibility regarding the use of disposable dishware. The Dietitian mentioned a shortage of regular dishware and indicated that the kitchen was responsible for ordering dishes. The Food Services Director acknowledged that the facility should have had backup dishware, and the Administrator was aware of the dish shortage. These interviews highlight a systemic issue in the facility's management of dining resources, leading to the observed deficiency.
Deficiencies in Facility Maintenance and Resident Safety
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents across four units, as observed during the recertification and abbreviated surveys. On the Center 3 Unit, multiple rooms exhibited chipped walls, peeling paint, and holes, which were not reported or addressed by the maintenance department. The Director of Maintenance was unaware of these issues, and environmental rounds were conducted approximately every seven weeks, with the last round on the Center 3 Unit occurring about a month prior. Nursing staff, including Certified Nurse Aides and a Registered Nurse Unit Manager, did not observe or report the damage, indicating a lack of communication and oversight in maintaining the facility's environment. Additionally, on the Center 1 Unit, a resident reported using a shower chair with a torn seat and wet, exposed wood, which posed a risk during showers. Despite being aware of the issue, the Infection Preventionist/Assistant Director of Nursing did not remove the chair from service, and it continued to be used by Certified Nurse Aides. Furthermore, a dusty fan was observed blowing on a resident with a tracheostomy, which was concerning for their health. The Infection Preventionist acknowledged the issue and stated that housekeeping was responsible for cleaning the fans, but the problem persisted. These deficiencies highlight lapses in maintenance, communication, and adherence to facility policies designed to ensure resident safety and comfort.
Deficiency in CNA In-Service Education and Performance Reviews
Penalty
Summary
The facility failed to ensure that each Certified Nurse Aide (CNA) received the required twelve hours of in-service education per year based on their individual performance review. Specifically, one CNA did not receive the mandatory in-service education for the year 2023. Additionally, the annual performance reviews for four CNAs were not up to date. The CNAs involved were hired between 1993 and 2023, and their performance evaluations were either undated or not completed. The Assistant Director of Nursing was responsible for providing CNA education, while the Director of Nursing acknowledged that a system was in place for mandatory training but was still working on identifying those not up to date with their training. The Director of Nursing also confirmed that the CNA evaluations were not current.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that all residents and staff were properly screened, educated, and offered the COVID-19 vaccine, as evidenced by the lack of documented immunization records for one resident and ten staff members. Specifically, there was no evidence that Resident #193, who had significant medical conditions including intracranial injury, respiratory failure, and a tracheostomy, received education about the COVID-19 vaccine, was offered the vaccine, or declined it. This oversight occurred despite the facility's policy requiring such actions upon admission or hire. Additionally, the facility did not maintain documentation of COVID-19 vaccination status for several staff members, including the Director of Admissions, multiple Certified Nurse Aides, Licensed Practical Nurses, an Occupational Therapist, a Registered Nurse, and a Cook. Interviews with facility staff revealed a lack of a systematic approach to track vaccination status and eligibility, with the Infection Preventionist admitting to not having a record of vaccine status for all residents. The Director of Nursing was unaware of the tracking deficiencies, despite the importance of vaccines in disease prevention.
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 one resident 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. There was no documented evidence of a policy specific to the Notice of Medicare Non-Coverage or the two-day requirement to provide notice to the beneficiary or representative. The progress note from August 27, 2024, indicated that the Notice of Medicare Non-Coverage was not provided to the resident and their family representative. Interviews with facility staff revealed a lack of communication and awareness regarding the resident's pending discharge. The Minimum Data Set Coordinator stated they were not aware of the discharge until the day before it occurred, which prevented them from issuing the notice within the required timeframe. The Director of Social Work had met with the resident's spouse to discuss discharge but did not ensure the notice was provided. Additionally, the Regional Director of Nursing confirmed that the facility did not have a separate policy for the Notice of Medicare Non-Coverage, contributing to the oversight.
Failure to Provide Written Bed Hold Policy Notices
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during transfers to the hospital. This deficiency was identified during the recertification and abbreviated surveys conducted from December 3 to December 10, 2024. The facility's bed hold policy, dated March 2018, requires that written information regarding bed hold rights and limitations be provided to residents or their representatives prior to or at the time of transfer, or as soon as practicable following an emergency transfer. However, for four residents reviewed for hospitalization, there was no documented evidence that such written notices were provided. The deficiency involved four residents with various medical conditions, including cerebral infarct, hemiplegia, hypertensive heart disease, anemia, urinary tract infection, schizophrenia, chronic respiratory failure, and dependence on a ventilator. These residents were transferred to the hospital for different reasons, such as evaluation post-fall, behavioral symptoms, and fever. Interviews with the Director of Social Work and the Assistant Administrator revealed that the facility had not been providing the required written notices of the bed hold policy to residents or their representatives prior to December 9, 2024.
Expired Medications and Biologicals Found in Storage Rooms
Penalty
Summary
The facility failed to ensure that all drugs and biologicals in two of four medication storage rooms were labeled and stored according to professional standards. During the recertification survey, it was observed that a bottle of Aspirin 325 mg tablets with an expiration date of October 2024 was found on the shelf in the Center 1 Unit medication storage room. Additionally, two bottles of tube feeding formula, Vital and Jevity, with expiration dates of December 1, 2024, and May 1, 2024, respectively, were found in the Center 1 North Unit medication room. These expired items were not removed from the storage areas as required by the facility's policy. Interviews with staff revealed a lack of adherence to the facility's procedures for checking and discarding expired medications and biologicals. The LPN stated that the nurse manager was responsible for checking the medications, while the RN Unit Manager confirmed that all nurses were supposed to check medications each shift before transferring them to their medication carts. The Director of Nursing indicated that nurse managers should check medication storage rooms weekly, and the pharmacy should conduct quarterly checks. However, the expired items remained in the storage rooms, indicating a failure in the implementation of these procedures.
Food Storage Deficiency Due to Undated Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety, as observed during a recertification survey. Specifically, undated food items were found in the walk-in refrigerator and one of the unit food refrigerators. The facility's policy requires all foods to be covered, labeled, and dated, and for resident food items to be dated with a use-by date. However, during an observation, two undated sandwiches were found in the walk-in refrigerator, and the Food Service Director stated they were made that day, which was why they were not dated. Additionally, five single cheese slices were observed on a plate without a date, and the Food Service Director could not provide information on when the cheese was placed in the refrigerator. Furthermore, an undated, wrapped ham sandwich was found in the unit refrigerator, and a Certified Nurse Aide was unable to determine how long it had been there.
Delayed Signing of Death Certificate by Medical Director
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled their responsibility for the timely implementation of resident care policies, specifically in the signing of a death certificate. This deficiency was identified during a survey when it was found that the Medical Director did not sign the death certificate for a resident who had passed away, within the required 72-hour timeframe as mandated by State Public Health Law 4041. The resident, who had diagnoses including subdural hematoma, atrial fibrillation, and coronary artery disease, was pronounced dead at 9:30 PM, and the Medical Director was notified. However, the death certificate was not signed until seven days later, which was a significant delay beyond the stipulated period. The delay in signing the death certificate resulted in the body of the deceased remaining in the freezer at the funeral home, as the funeral home director had to repeatedly contact the facility to have the certificate signed. Interviews conducted during the survey revealed that the Medical Director acknowledged the delay, describing it as an anomaly. The facility's policy required the primary healthcare provider or designee to complete and sign a death certificate in accordance with state or county law, which was not adhered to in this instance.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey, specifically for one resident who had diagnoses including intracranial injury with loss of consciousness, respiratory failure, and tracheostomy. There was no documented evidence that this resident was offered, declined, or educated on the pneumococcal immunization. Interviews with facility staff revealed gaps in the process of collecting and documenting vaccine status. The Registered Nurse Unit Manager acknowledged that vaccines were supposed to be offered upon admission, but they missed obtaining the vaccine status for the resident in question. The Infection Preventionist admitted that there was no system in place to track which residents were vaccine eligible or who had declined the vaccine. The Director of Nursing was unaware of the lack of vaccine tracking and had been informed that there were no problems with vaccine administration and education.
Environmental Deficiencies in Facility
Penalty
Summary
The facility was found to have several environmental deficiencies during an abbreviated survey. Observations revealed that the kitchen floor had a pool of water approximately two inches deep near the washing machine, which had been leaking for a week. Despite a vendor's visit to repair the leak, the issue remained unresolved. Additionally, multiple areas within the facility exhibited chipped paint, scratched surfaces, scuff marks, visible dirt, stains, peeling wallpaper, and foul odors, indicating a lack of maintenance and cleanliness. Interviews with staff highlighted a lack of effective communication and follow-up regarding maintenance issues. The Dietary Aide mentioned that the leak had been reported, but the repairs were incomplete. The Director of Maintenance was unaware of the water issue in the kitchen, indicating a gap in the reporting and addressing of maintenance concerns. The Director of Maintenance also acknowledged that some rooms required touch-up paint jobs, but progress was slow, with only two rooms being addressed per week. The Director of Nursing and the Administrator both stated that environmental rounds were conducted regularly to identify and address issues. However, the persistence of the deficiencies suggests that these rounds were not effectively identifying or resolving problems in a timely manner. The Administrator mentioned that repairs typically take a day or two to complete, but the ongoing issues indicate that this timeline was not being met consistently. The facility's failure to maintain a functional, sanitary, and comfortable environment for residents, staff, and the public was evident in the survey findings.
Failure to Notify Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to ensure that the resident representatives were immediately informed of significant changes in the residents' physical status or treatment needs. This deficiency was identified during an abbreviated survey for three residents. Resident #17, who had severe cognitive impairment, underwent an electrocardiogram that revealed bradycardia, leading to the discontinuation of their anti-hypertension medication. However, the resident's guardian was not informed of this significant change in diagnosis and treatment. The guardian only discovered the issue when reviewing paperwork for a doctor's appointment, which eventually led to the resident being hospitalized and receiving a pacemaker. Resident #19, who was severely cognitively impaired and dependent on a respirator, was transitioned from a tracheostomy collar to a ventilator. Despite this significant change in respiratory support, there was no documented evidence that the resident's family was notified. The family discovered the change during a visit, indicating a lack of communication from the facility regarding the resident's condition. Resident #20, also severely cognitively impaired, experienced respiratory distress and was placed on a ventilator after vomiting and having decreased oxygen saturation. There was no documented evidence that the resident's family was informed of these critical changes in the resident's condition. The facility's policy required immediate notification of significant changes, but this was not adhered to, resulting in a failure to communicate vital information to the residents' representatives.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect residents from the misappropriation of their personal property, as evidenced by incidents involving three residents. Resident #14's advocate reported that the resident's glasses went missing during a hospitalization, and upon return, the facility provided glasses that did not belong to the resident. There was no documented inventory of the resident's belongings, and no investigation was conducted regarding the missing glasses. Resident #16's family reported that the resident's cell phone was used by someone in the facility after the resident's death, and the phone was never returned. The family had to deactivate the phone service themselves. The Director of Social Services was unaware of the missing phone and no investigation was initiated. Resident #17's guardian discovered that the resident's wallet was missing shortly after admission, with fraudulent charges appearing on the resident's debit card, including a charge from the facility. There was no inventory form for the wallet, and the Director of Social Services was not informed of the missing wallet or the fraudulent charges. The facility lacked proper documentation and investigation into these incidents, indicating a failure to safeguard residents' personal property.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by the lack of documentation and timely care for several residents. For instance, Resident #1, who was admitted with conditions such as Sickle Cell Disease and Chronic Pain Syndrome, did not receive documented bladder/bowel incontinence care on multiple occasions over a two-month period. This resident also filed a grievance about not receiving timely care, which was corroborated by a CNA who admitted to being overwhelmed due to staffing shortages. Resident #14, diagnosed with Multiple Sclerosis and other conditions, was observed with a catheter leg bag while in bed, contrary to standard practice. The resident's catheter was found clogged, leading to signs of an impending infection, which was not promptly addressed by the nursing staff. Similarly, Resident #15, with Chronic Respiratory Failure, reported being left in soiled diapers for extended periods, leading to discomfort and a urinary tract infection. Documentation showed numerous instances where incontinence care was not recorded as completed. Other residents, such as Resident #16 and Resident #19, also experienced lapses in care. Resident #16's family reported long waits for assistance, resulting in the resident sitting in soiled diapers, while Resident #19's care plan for pressure ulcers was not consistently followed, as indicated by missing documentation for necessary interventions like turning and positioning. Resident #21's records also showed incomplete documentation for essential care tasks, highlighting a systemic issue with care delivery and documentation within the facility.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the omission of scheduled medications for 13 out of 19 residents on the Center 2 Unit during a specific shift. On 06/09/2024, residents did not receive their prescribed medications between 7:30 AM and 3:30 PM, and there was no documentation in the Medication Administration Record (MAR) to indicate that the medications were administered. Additionally, there was no notification to the physicians regarding the missed doses, which is a requirement according to the facility's Medication Administration policy. The report highlights several residents with various medical conditions who did not receive their medications as prescribed. For instance, one resident with Sickle Cell Disease and Chronic Pain Syndrome did not receive their scheduled dose of Hydrocodone-Acetaminophen, while another resident with Type 2 Diabetes Mellitus and Cerebral Infarction missed multiple medications, including Ceftriaxone and Gabapentin. The absence of documentation and communication regarding these omissions indicates a significant lapse in the facility's medication administration process. Interviews with facility staff revealed a lack of awareness and communication about the missed medications. The Nurse Practitioner and Medical Director were not informed of the omissions, and the Licensed Practical Nurse scheduled for the shift was a no-show. The Registered Nurse Unit Manager and Supervisor also failed to take appropriate action upon discovering the issue. This lack of coordination and adherence to protocol contributed to the deficiency, as the facility did not ensure that residents received their necessary medications in a timely manner.
Failure to Administer Timely Medication Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in clinical practice for a resident who was reviewed for medication administration. The resident, who had a history of cirrhosis of the liver, type 2 diabetes mellitus, and a fracture of the left femur, was noted to have an elevated Prothrombin Time (PT) and International Normalizing Ratio (INR), indicating that their blood was taking longer than normal to clot. The physician ordered a 10mg dose of Vitamin K to be administered intramuscularly to address this issue. However, the Vitamin K was not readily available in the facility, and the staff failed to notify the physician about its unavailability. The Vitamin K was eventually delivered and administered several hours later, but by that time, the resident was found unresponsive and was pronounced dead. Interviews with the Nurse Practitioner and the Director of Nursing revealed that there was a lack of communication and monitoring by the staff, which contributed to the delay in administering the medication. The Nurse Practitioner stated that they would have ordered an oral dose or sent the resident to the hospital if they had been informed about the unavailability of the intramuscular dose. The Medical Director noted that while the resident had a history of high INR due to cirrhosis and was not actively bleeding, the Vitamin K should have been administered promptly as it was not a routine medication. The Medical Director also mentioned that the delay in treatment might not have directly caused the resident's death, but the lack of timely administration and communication was a significant concern. The facility's anticoagulation therapy policy required staff to monitor residents and notify physicians of any issues, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse Due to Communication Lapses
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by an incident involving two residents. Resident #3, who had a history of schizophrenia and was on psychoactive medications, was transferred to a different unit due to verbal aggression with their roommate. However, the receiving unit was not informed of the verbal aggression incident that prompted the transfer. This lack of communication led to Resident #3 physically assaulting Resident #4, resulting in Resident #4 being punched in the face and subsequently transferred to the hospital for psychosis. The facility's policy on abuse, revised in December 2022, prohibits mistreatment, neglect, and abuse of residents by anyone, including staff and other residents. Despite this policy, there were significant lapses in communication and documentation. On April 11, 2024, Resident #3 refused all medications and meals, claiming that staff were trying to poison them. This refusal was not documented properly, and the medical provider was not notified. The following day, Resident #3 continued to exhibit behavioral symptoms, including verbal outbursts and hallucinations, yet the staff failed to communicate these issues to the receiving unit or the medical provider. Interviews with staff revealed that there was a breakdown in communication regarding Resident #3's medication refusals and behavioral symptoms. The staff on duty during the incidents did not follow the protocol of notifying the medical provider or documenting the refusals in the Medication Administration Record. Additionally, the receiving unit was not informed of the reasons for Resident #3's transfer, which contributed to the subsequent altercation with Resident #4. This series of inactions and communication failures led to the deficiency in ensuring residents' right to be free from abuse.
Failure to Address Medication Refusals and Behavioral Symptoms
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizophrenia, hypertension, and hyperlipidemia. The resident, who had intact cognition and required supervision with daily activities, refused their antipsychotic medication, Haldol, as well as other medications and meals on a specific day. Despite the refusals and the resident's delusional belief that they were being poisoned, the medical provider was not notified, and the refusals were not consistently documented in the Medication Administration Record. The facility's policy required that medication refusals and unusual behaviors be reported to the medical provider, but this was not done. Interviews with staff revealed that the LPN on duty during the evening shift was aware of the refusals but did not notify the medical provider or the supervisor. The RN Supervisor on duty was also not informed of any concerns regarding the resident's medication refusals or behavioral symptoms. The primary physician and nurse practitioner were not made aware of the resident's condition, despite being present in the facility. The following day, the resident exhibited aggressive behavior, including a verbal altercation and physical assault on their roommate, leading to their transfer to a different unit and eventual hospitalization for psychosis. The lack of communication and documentation regarding the resident's medication refusals and behavioral symptoms contributed to the escalation of the resident's condition, resulting in a deficiency in the facility's provision of behavioral health care.
Failure to Document and Communicate Medication Refusal
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the case of a resident who refused their prescribed medications, including antipsychotic, anticoagulant, cardiovascular, and steroid/bronchodilator medications. On the day in question, the resident refused their medications, but there was no consistent documentation in the Medication Administration Record (MAR) of the refusal, nor was there evidence that the medical provider was notified of the missed medications. This lack of documentation and communication led to a significant event the following day when the resident exhibited aggressive behavior and was subsequently hospitalized with a diagnosis of psychosis. The resident in question had a medical history that included schizophrenia, hypertension, and hyperlipidemia, and was on a regimen of medications to manage these conditions. Despite the facility's policy requiring documentation of medication administration and notification of the medical provider in cases of refusal, the staff failed to adhere to these protocols. Interviews with various staff members revealed that the resident's refusal of medications was known but not properly documented or communicated to the medical provider, which was a deviation from the expected procedure. The failure to document and communicate the resident's medication refusal and subsequent behavioral symptoms was a significant oversight. Staff members, including the Registered Nurse and Licensed Practical Nurse on duty, acknowledged the resident's refusal but did not take the necessary steps to inform the medical provider or document the refusal in the MAR. This lack of action contributed to the resident's deterioration in condition, culminating in an aggressive incident and hospitalization.
Failure to Resolve Resident Grievance on Missing Clothing
Penalty
Summary
The facility failed to ensure grievances were resolved in a timely manner, as evidenced by the case of a resident who reported missing clothing. The facility's policy requires that grievances be investigated and resolved within seven business days, with the Director of Social Work acting as the Grievance Officer. However, there was no documented evidence of a thorough investigation into the missing clothing reported by the resident and their family representative. The resident, who was cognitively intact, had no documentation in the Social Services Progress Notes regarding the grievance, and the clothing inventory log did not reflect the missing items. Interviews with staff revealed a lack of awareness and communication regarding the grievance process. The social worker, who was responsible for handling grievances, was not informed of the missing property, and the administrator did not ensure a grievance form was completed. The front desk receptionist and the Director of Housekeeping and Laundry described a process for logging clothing, but there was confusion and inconsistency in following this process. The administrator acknowledged that if a grievance was not documented, they were unsure why it was not addressed, indicating a breakdown in the facility's grievance handling procedures.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the New York State Department of Health as required by state law. The resident, who had diagnoses including dependence on a respirator, neuromuscular dysfunction of the bladder, and legal blindness, reported being sexually assaulted by facility staff on two occasions. Despite the resident's cognitive intactness, as indicated by a BIMS score of 13/15, there was no documented evidence that the allegations were reported to the appropriate authorities. Interviews with the Director of Nursing and the Administrator revealed inconsistencies in the reporting process. The Director of Nursing claimed to have left a voicemail on the hotline and mentioned a police badge number in their statements, but there was no police report on file. The Administrator stated they called the allegation into the State hotline and followed up with a call to the Metropolitan Area Regional Office, but there was no documentation confirming the report was received. Additionally, there was no evidence of a 5-day investigative result report being submitted, as required by regulations.
Failure to Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to the New York State Department of Health as required. Specifically, a resident alleged they were sexually assaulted three times by facility staff on two consecutive days. Despite the seriousness of the allegations, there was no documented confirmation or receipt of reporting the allegation or the results of the investigation to the New York State Department of Health. This deficiency was identified during an abbreviated survey, which reviewed the cases of three residents, including the resident who made the allegations. The resident involved in the allegations was admitted to the facility with multiple diagnoses, including dependence on a respirator, neuromuscular dysfunction of the bladder, and legal blindness. The resident was assessed to have intact cognition, despite unclear speech and severely impaired vision. The facility's Director of Nursing and Administrator both claimed that the allegation was reported to the state via a hotline voicemail, but there was no documentation to confirm that the report was received or that a 5-day investigative result report was submitted. The facility's phone call log showed a call to the hotline, but lacked confirmation of receipt or follow-up documentation.
Resident Not Included in Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident was given the opportunity to participate in their care plan meeting, as required by regulations. This deficiency was identified during an abbreviated survey for one of the three residents reviewed for care plans. The resident in question was admitted with diagnoses including a urinary tract infection, benign neoplasm of the meninges, and seizures. The admission Minimum Data Set (MDS) indicated that the resident was cognitively intact and capable of understanding and being understood by others. Despite this, there was no documented evidence that the resident or their representative/family was invited to or attended a care plan meeting during their stay from January 30, 2023, to March 16, 2023. An interview with a social worker revealed that a care plan meeting was scheduled for February 28, 2023, but it did not occur, and there was no documentation explaining why or any attempt to reschedule the meeting.
Failure to Provide Documented Catheter Care Leads to UTI
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services, as evidenced by the lack of documented catheter care for the resident on seven occasions in December 2023. The resident, who had a history of neuromuscular dysfunction of the bladder, was admitted with several diagnoses, including dependence on a respirator, legal blindness, and frequent bowel incontinence. A physician's order required catheter care every day and every shift, but documentation revealed that this care was not provided on multiple shifts between December 2 and December 6, 2023. The resident was monitored for spiking fevers and elevated white blood cell counts, which led to a diagnosis of a urinary tract infection. A nurse practitioner's progress notes indicated that the resident had a low-grade fever and elevated white blood cell count, prompting the initiation of an antibiotic treatment for a presumed urinary tract infection. Lab results confirmed the presence of a urinary tract infection, with findings of cloudy urine, a large amount of leukocyte esterase, and many bacteria, among other indicators. Interviews with staff, including the Director of Nursing, the attending physician, and a certified nurse assistant, revealed that the resident's condition was being monitored, and there was an awareness of the catheter-related infection. However, there was no indication of any limitation in the care provided, according to the attending physician. The certified nurse assistant mentioned that if there was no signature in the documentation box, it indicated that the assignment was not completed. Attempts to reach another staff member for further information were unsuccessful.
Inadequate Staffing Leads to Missed Medications
Penalty
Summary
The facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being for seven residents. Specifically, on the night shift of 3/3/2024, the residents on the third-floor dementia unit did not receive their scheduled medications due to inadequate staffing. The scheduled Licensed Practical Nurse (LPN) did not arrive for their shift, and the night nursing supervisor was unable to administer the residents' medications due to being called to other units. The facility's staffing records revealed that there was no LPN scheduled for the 11:30 PM to 7:30 AM shift on 3/2/2024 and 3/3/2024, and only two Certified Nursing Aides (CNAs) were present. This staffing shortage resulted in multiple residents not receiving their medications as documented in their Medication Administration Records (MARs). For example, Resident #1 missed several medications on multiple dates, and similar patterns were observed for Residents #2 through #7, all of whom had various diagnoses including dementia, anxiety, hypertension, and other conditions. Interviews with staff members, including Registered Nurse Supervisors and CNAs, confirmed the staffing issues. The Registered Nurse Supervisor on duty during the night shift of 3/3/2024 stated that they were unable to cover all units and administer medications due to the lack of nursing staff. The Nurse Practitioner and Attending Physician also acknowledged ongoing staffing issues that had been affecting medication administration for several months. The Director of Nursing was aware of the staffing gaps but was unable to fill the openings, leading to the observed deficiencies.
Significant Medication Errors Due to Staffing Issues
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors, as evidenced by the failure to administer scheduled medications to seven residents during specific shifts. The registered nurse on duty did not follow physician orders to administer medications during the 11:30 PM to 7 AM shift on multiple dates in February and March 2024. The Medication Administration Records (MAR) for these residents showed that various medications were not signed out as being administered, indicating that the residents did not receive their prescribed treatments. This issue affected residents with serious conditions such as schizoaffective disorder, post-traumatic stress disorder, seizures, dementia, anxiety, insomnia, hypertension, and diabetes mellitus, among others. Interviews with the nursing staff and administration revealed that the facility was experiencing significant staffing issues, particularly during night shifts. The Registered Nurse supervisor for the night shift admitted that they were unable to administer medications to all residents due to being short-staffed and having to cover multiple units. The Director of Nursing (DON) and the Nurse Practitioner were not adequately informed about the missed medications, and the DON acknowledged that they did not receive the text message about the staffing issue until the following morning. The Nurse Practitioner and the Attending Physician both confirmed that the problem of missed medications due to staffing shortages had been ongoing for several months. The facility's policy on medication errors requires staff to prevent, identify, and manage medication errors appropriately, including notifying the physician and taking corrective actions. However, the policy was not effectively followed in this case. The DON stated that they routinely run medication administration reports to identify missed medications and inform the medical team, but this process was not adequately executed during the incidents in question. The facility's ongoing staffing issues were cited as a primary reason for the failure to administer medications, and the DON mentioned efforts to mitigate these issues by trying to fill positions and staff each unit and shift adequately.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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