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 July 2026. Survey timing is at the state agency's discretion.
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The facility did not ensure CNAs received the required 12 hours of in-service education annually, and four CNAs had outdated performance reviews.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.
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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.
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Nursing homes near Nanuet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Valley Center For Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 13 | 0 |
| Friedwald Center For Rehab And Nursing, L L C | 2.8 mi | ★★★★★ | 4 | 0 |
| Northern Metropolitan Res Health Care Facility Inc | 2.9 mi | ★★★★★ | 2 | 0 |
| Nyack Ridge Rehabilitation And Nursing Center | 3.7 mi | ★★★★★ | 1 | 0 |
| Tolstoy Foundation Rehabilitation And Nrsg Center | 4.3 mi | ★★★★★ | 40 | 2 |
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