Nyack Ridge Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Valley Cottage, New York.
- Location
- 476 Christian Herald Road, Valley Cottage, New York 10989
- CMS Provider Number
- 335365
- Inspections on file
- 23
- Latest survey
- November 4, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Nyack Ridge Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with significant mobility impairments was injured during a transfer when two CNAs, who had not received training on a newly introduced mechanical lift, improperly operated the device, causing it to tilt and strike the resident's head. The incident resulted in a head laceration requiring emergency care. Facility records and staff interviews confirmed that the CNAs had not been in-serviced on the new lift prior to the event, leading to the deficiency.
The 3rd Floor of the facility was found to have pervasive odors of urine and feces, stained and worn shower chairs, and soiled bathrooms, compromising the residents' right to a safe and homelike environment. Staff interviews revealed a lack of effective communication and follow-up on maintenance issues, despite existing policies. The Director of Housekeeping and the Administrator acknowledged the concerns and mentioned planned renovations, but these had not been executed.
The facility failed to complete discharge summaries and communicate effectively with residents and their families, leading to deficiencies in discharge planning. A resident was discharged without a summary, another without education on injectable medications, and a third with incomplete instructions. These failures resulted in inadequate post-discharge care and communication issues.
The facility was found to be consistently understaffed, failing to meet the required nursing staff ratios, leading to delayed responses to resident needs. Residents reported long waits for assistance, including a three-hour delay for pain medication. Family members noted residents with saturated briefs and bed linens. Staff frequently worked overtime to cover shortages, and the facility relied on staffing agencies to fill gaps. The Director of Nursing acknowledged the staffing challenges and ongoing efforts to address them.
Two residents experienced significant weight loss due to inadequate nutritional interventions and monitoring. One resident with dementia was often left confused during meals without assistance, while another resident with schizophrenia was dissatisfied with meals and not offered alternatives. Both residents' care plans lacked reassessment and modification, leading to poor nutritional outcomes.
The facility failed to store and prepare food according to professional standards, with undated and expired food items found in storage areas and improper food temperatures observed. Personal food was also improperly stored in facility refrigerators. The Food Service Director acknowledged these issues but could not explain them.
A resident with cataracts did not receive prescribed eye drops as ordered after surgeries. The facility failed to administer prednisolone drops on time due to medication changes and communication issues with the pharmacy. The resident expressed dissatisfaction with the timing of administration, leading to refusal of the drops. Additionally, ciprofloxacin drops were administered earlier than scheduled before the second surgery.
The facility failed to provide a dignified dining experience for three residents, as staff were observed standing over them while assisting with meals, contrary to policy. Aides acknowledged the inappropriate practice, citing multitasking and staffing shortages. The Nurse Educator confirmed the need for staff to be seated and facing residents to ensure safety and dignity.
A facility failed to properly notify a resident's representative about changes in Medicare coverage due to the resident's moderate cognitive impairment. The resident, diagnosed with dementia and a psychotic disorder, was given notices they could not understand. The Social Work Assistant did not successfully contact the resident's daughter and failed to mail the notices, leading to a deficiency.
The facility did not ensure residents were aware of the grievance process, as all 16 residents at a Resident Council meeting were unaware of how to file a grievance. Observations showed missing postings of grievance procedures, and staff interviews revealed inconsistencies in handling grievances. The Director of Social Services acknowledged the lack of individual resident notification about the grievance process.
A resident with severe cognitive impairment and a high fall risk was found to be using a concave mattress as a restraint without a physician's order or documented consent. The facility's policy requires restraints only for medical symptoms when less restrictive measures fail, but staff used the mattress to prevent falls, not recognizing it as a restraint.
A facility failed to complete a PASRR screening for a resident with bipolar disorder, schizoaffective disorder, and parkinsonism. The SCREEN DOH 695 form was missing documentation for items necessary to determine the need for Level II services. Staff interviews revealed that the oversight was due to a missed review by the Director of Social Services, with the Director of Nursing confirming the Social Worker's responsibility in the process.
A resident with pressure injuries did not receive necessary pressure-relieving devices as ordered by the physician. Despite orders to offload the resident's heels with a pillow, observations showed the absence of a pillow under the resident's legs. Interviews with staff revealed a lack of awareness and adherence to care instructions, contributing to the deficiency in pressure ulcer care.
A resident with severe cognitive impairment and on aspiration precautions was fed a mechanically altered diet by an unqualified transporter due to the absence of licensed nursing staff supervision during mealtime. The transporter, lacking the necessary training, fed the resident in the 3rd Floor Dayroom, where no LPN or RN was present to oversee the meal. The RN Manager, responsible for supervision, left the facility without notice, leading to the deficiency.
Two residents in the facility received oxygen therapy inconsistent with physician orders. One resident with COPD and other conditions was given 3 liters per minute instead of the prescribed 2 liters, with no documentation in the Treatment Administration Record. Another resident with hypertension and respiratory issues was also given 3 liters instead of 2, and their nasal cannula and humidified water bottle were not dated as required by facility policy. LPNs and the DON confirmed these discrepancies.
The facility did not conduct annual performance reviews for CNAs, as required. Six CNAs, employed since 2000 to 2018, lacked documented evaluations within the past year. Interviews with staff revealed that evaluations had not been conducted for several years, with some done sporadically. One CNA reported their last evaluation was in 2012.
A facility failed to provide appropriate dementia care for two residents, lacking individualized activities and proper implementation of care plans. One resident exhibited distressing behaviors without receiving meaningful engagement or prescribed interventions, while another was left disengaged and without recommended medication adjustments. Staff were unaware of necessary interventions, and the facility was short-staffed, impacting care quality.
During a survey, deficiencies were found in the medication storage room of a facility's second floor unit. Unlabeled and expired items, including medications and supplies, were present, and the refrigerator was above the acceptable temperature range. Staff interviews revealed that nurses were responsible for checking these areas every shift, but failed to do so, leading to the deficiencies.
The facility failed to maintain an effective infection control program, as evidenced by improper PPE use for a resident on enhanced barrier precautions, a catheter bag left on the floor for a resident with a history of UTIs, and inadequate hand hygiene by a Wound Care Nurse during treatment of a resident with pressure injuries.
The facility failed to implement an effective antibiotic stewardship program, as they could not provide adequate documentation of antibiotic use tracking for several months. The Infection Control Preventionist, responsible for monitoring antibiotic use, provided an incomplete list lacking critical information such as infection onset dates and laboratory test results. The Director of Nursing confirmed that the Infection Control Preventionist was behind in tracking antibiotic use, indicating a failure in the facility's antibiotic stewardship efforts.
The facility did not maintain an effective pest control program, as evidenced by live and dead roaches found in the kitchen. Despite having a policy for ongoing pest control and bi-weekly treatments, the Food Service Director acknowledged the issue. Pest Management Service reports noted minimal activity and recommended improved sanitary practices. The Director of Maintenance confirmed monthly pest control services.
The facility failed to submit 11 out of 30 resident assessments to CMS within the required 14-day period. Despite a policy mandating timely submission, assessments completed in November were only submitted in January. The MDS Coordinator acknowledged the delay but could not explain it, while the DON was unaware of the issue, highlighting a lack of communication and oversight.
A resident with severe cognitive impairment was involved in an alleged abuse incident with a podiatrist, which was not reported to the state as required. The resident exhibited physical behavioral symptoms and refused care, but the podiatrist continued. The facility's Director of Nursing and Administrator did not report the incident to the state, considering it a complaint rather than a reportable incident.
A facility failed to investigate an alleged abuse incident involving a resident and a podiatrist. The resident, with severe cognitive impairment, became combative during a podiatry procedure. The Director of Nursing did not document a skin assessment or file an incident report, considering it a complaint. The Administrator, informed by the wound doctor, did not report the incident to the state. The Director of Social Services, informed a week later, did not document or refer the resident, who showed no trauma signs. The facility's lack of documentation and reporting led to the deficiency.
A facility failed to document an incident and assessment in a resident's medical record following an alleged abuse incident during a podiatry consult. Despite staff overhearing the incident, no accident or incident report was completed, and the Director of Nursing concluded no abuse occurred. The resident, with severe cognitive impairment, exhibited usual behaviors of resisting care. The lack of documentation and adherence to policy led to the deficiency.
Resident Injury Due to Untrained Use of New Mechanical Lift
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to diagnoses including amyotrophic lateral sclerosis, muscle weakness, and chronic obstructive pulmonary disease, was injured during a transfer using a new mechanical lift. The resident required two-person assistance and was to be transferred according to facility policy and manufacturer guidelines, which mandated that both staff members be trained on the specific lift in use. However, during the transfer, the mechanical lift tilted and struck the resident's head, resulting in a laceration that required emergency hospital care and staples. Certified Nurse Aides involved in the transfer reported that they had not received in-service training on the new mechanical lift prior to the incident. Both aides described the lift tilting unexpectedly during the transfer, with one aide noting that the base of the lift was not properly expanded and the other stating that the resident was holding onto the bar when the lift began to shake and tilt. The incident was corroborated by the resident, who communicated that one of the aides did not know how to operate the new lift, leading to the bar hitting and cutting their head. Facility records and interviews confirmed that the new mechanical lifts had been assembled and tested by the maintenance team, and that leadership was notified of their arrival. However, the staff involved in the incident had not yet received documented training on the new equipment at the time of the event. The lack of training and unfamiliarity with the new mechanical lift directly contributed to the improper use of the device and the resulting injury to the resident.
Deficient Environmental Conditions on 3rd Floor
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the 3rd Floor, as observed during a recertification and abbreviated survey. The survey revealed pervasive and strong odors of urine and feces throughout the floor, particularly in the dayroom where residents gathered for meals. The environment was further compromised by stained and worn shower chairs, hanging ceiling tiles, and soiled and stained bathrooms in multiple resident rooms. Additionally, the dayroom contained soiled bins of dolls and stuffed animals, marked floors, and damaged walls. Interviews with staff and residents highlighted the inadequacies in maintaining the environment. A resident described their room as shabby and gloomy, while a Certified Nurse Aide acknowledged the need for reporting stains and damages to the maintenance department. A Registered Nurse noted the difficulty in addressing environmental issues due to residents' preferences, and the Director of Housekeeping admitted to the unacceptable state of cleanliness in shared bathrooms. The Director of Maintenance was aware of the conditions but had not received recent repair requests from the 3rd Floor staff. The facility's policies on maintaining a homelike environment and addressing maintenance issues were not effectively implemented. Despite having an electronic ticket system for reporting repairs, there was a lack of communication and follow-up between staff and the maintenance department. The Director of Housekeeping and the Administrator acknowledged the environmental concerns and stated that renovations and repairs were planned, but these had not yet been executed, leaving the 3rd Floor in a substandard condition.
Incomplete Discharge Summaries and Communication Failures
Penalty
Summary
The facility failed to ensure the completion of discharge summaries for three residents reviewed for discharge, leading to deficiencies in communication and planning. Resident #124, who had diagnoses including end-stage renal disease and bladder cancer, was discharged without a documented discharge summary in their electronic medical record. Despite discussions and arrangements for home care services, the discharge summary was not completed, and the responsibility was attributed to the physician, who claimed it was in the hard chart, but it was not located. Resident #247, who was severely cognitively impaired and required insulin and Epogen injections, was discharged without adequate communication with the family regarding the administration of injectable medications. The family reported receiving no education on medication administration, and attempts to contact the facility for guidance were unsuccessful. The discharge occurred on a Saturday, and the nursing staff failed to provide the necessary education, leading to the resident's hospitalization following a fall. Resident #245, with diagnoses of cerebral infarction and anxiety disorder, was discharged with incomplete discharge instructions. The instructions lacked details on follow-up care, safety precautions, and occupational therapy recommendations. The resident's representative expressed concerns about the discharge process, stating that the resident was not ready for discharge and that financial issues were not adequately addressed. The facility's failure to provide a comprehensive discharge plan and communicate effectively with the resident's representative contributed to the deficiency.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. This deficiency was identified during the Recertification and abbreviated surveys conducted from January 6 to January 14, 2025. Multiple residents reported during a Resident Council Group meeting that the facility was short-staffed, leading to delayed responses to call bells. Specifically, one resident reported waiting three hours for pain medication after requesting it. Family members of residents also expressed concerns, noting instances where residents were found with saturated briefs and bed linens. The facility's staffing schedule analysis revealed that from December 6, 2024, to January 6, 2025, the facility was understaffed on all shifts, failing to meet the minimum staffing levels documented in the Facility Assessment. Interviews with nursing staff and the Human Resources/Staffing Coordinator highlighted the facility's reliance on overtime and staffing agencies to fill gaps. Several staff members reported working double shifts, particularly on weekends, to cover shortages. The Human Resources/Staffing Coordinator acknowledged the facility's staffing challenges, particularly for the 7 AM-3 PM shift, and mentioned ongoing efforts to recruit and retain nursing staff. The Director of Nursing also confirmed the staffing challenges and indicated that discussions with upper management were underway to address the issue.
Failure to Maintain Nutritional Status for Two Residents
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable nutritional status, leading to significant weight loss. Resident #80, diagnosed with dementia and osteoarthritis, experienced a weight loss of 15.68% over several months. Despite being on a mechanically altered diet and receiving supplements, there was no documented evidence of reassessment or modification of the care plan to address the weight loss. Observations revealed that Resident #80 often sat confused during meals without staff intervention or assistance, which contributed to poor food intake. Resident #25, with diagnoses including schizophrenia and bipolar disorder, also experienced significant weight loss. The resident's care plan included dietary supplements and a mechanically altered diet, but there was no evidence of reassessment or modification of the care plan following the weight loss. Observations showed that Resident #25 was dissatisfied with meals and did not receive alternatives when requested, leading to inadequate food intake. Both residents' care plans lacked adequate monitoring and documentation of food intake and weight changes. Staff interviews indicated a lack of consistent assistance and encouragement during meals, contributing to the residents' nutritional deficiencies. The facility's failure to implement and monitor effective interventions resulted in significant weight loss for both residents.
Food Storage and Temperature Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in accordance with professional standards for food safety practice. During a recertification survey, it was observed that opened and undated food items were stored in the refrigerators, freezer, and dry storage room. Additionally, personal food belonging to an employee was improperly stored in the facility's freezer and reach-in refrigerator, which were not designated for employee food storage. Expired food items were also found in the emergency food supply and reach-in refrigerator, indicating a lack of proper monitoring and rotation of food items. Furthermore, the facility did not maintain appropriate food temperatures, as hot food was held below the required 135 degrees Fahrenheit on the steam table, and cold turkey was found at 51 degrees Fahrenheit, above the safe temperature of 41 degrees Fahrenheit. These observations were made during a tour of the kitchen and interviews with the Food Service Director, who acknowledged the issues but could not provide explanations for the presence of undated and expired food or the improper food temperatures.
Failure to Administer Eye Drops as Ordered Post-Cataract Surgery
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident #107, who had diagnoses including Dry Eye Syndrome, Edema of unspecified eye, and Diabetic Cataracts, did not receive their prescribed eye drops as ordered by the physician following cataract surgeries. The resident was scheduled to receive prednisolone eye drops post-operatively, but the medication was not administered as per the physician's orders. The April 2024 Medication Administration Record indicated that the eye drops were documented as refused on the day of the surgery, and there was a delay in administering the first dose due to a change in the medication order. Additionally, the resident expressed dissatisfaction with the timing of the medication administration, which led to a refusal of the eye drops. Further issues arose with the administration of ciprofloxacin eye drops, which were intended to be started three days prior to the resident's second cataract surgery. However, the medication was administered earlier than scheduled. Interviews with the resident and the Director of Nursing revealed that there were communication issues with the pharmacy regarding medication availability and changes in orders, contributing to the delay in administration. The Director of Nursing acknowledged that the physician's orders should have been followed and mentioned difficulties with the resident during this period, although no documentation of a plan for nursing staff was provided.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during the recertification survey. Observations revealed that staff members were standing over residents while assisting them with meals, contrary to the facility's policy which mandates that staff should be seated to maintain dignity and ensure safety. Resident #48, who has severe cognitive impairment and requires assistance with eating, was observed being fed by a Certified Nurse Aide who stood over them. Similarly, Resident #345, also with severe cognitive impairment and dependent on staff for eating, was assisted in the same manner. The aide involved acknowledged the inappropriate practice, citing multitasking and staffing shortages as reasons. Resident #30, diagnosed with vascular dementia and requiring assistance with eating, was observed being fed by a Certified Nurse Aide who stood next to the resident without making eye contact. The aide later acknowledged the need to be seated while feeding the resident. The Nurse Educator/Infection Control Preventionist confirmed that staff should be seated and facing residents to monitor for signs of aspiration and ensure the residents are alert while eating. These observations indicate a failure to adhere to the facility's policies on maintaining resident dignity during meal times.
Failure to Properly Notify Resident's Representative of Medicare Coverage Changes
Penalty
Summary
The facility failed to ensure that a resident with moderate cognitive impairment was properly informed about changes in Medicare coverage. Specifically, the resident, who had diagnoses including dementia and a psychotic disorder, was given a Notice of Medicare Non-Coverage and an Advanced Beneficiary Notice of Non-Coverage. These notices were provided despite the resident's inability to comprehend the content due to their cognitive condition. The resident was unable to sign the notices, and the facility's policy required that such notices be communicated to the resident's family or representative when the resident is unable to understand them. The Social Work Assistant, responsible for delivering these notices, acknowledged that they did not successfully contact the resident's daughter, who was the information source for the resident's assessments. The Social Work Assistant left a voicemail but did not send the notices via mail to ensure the daughter received them. The Director of Social Work confirmed that the notices should have been sent to the resident's daughter instead of being presented to the resident. The facility did not use certified mail to confirm delivery of the notices, which contributed to the deficiency.
Lack of Resident Awareness of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and their rights to file grievances without discrimination or reprisal. During a Resident Council meeting, all 16 residents in attendance reported not knowing how to file a grievance. The facility's grievance policy, last reviewed in October 2021, stated that residents would be informed orally and in writing of their right to make complaints. However, there was no evidence in the Resident Council minutes from October to December 2024 that the grievance process was reviewed with its members. Additionally, observations revealed that information about the grievance process, ombudsman contact, and complaint hotline was not adequately posted throughout the facility. Interviews with various staff members, including registered nurses, licensed practical nurses, certified nurse aides, and the Director of Social Services, indicated a lack of awareness and consistency in handling grievances. Staff members generally reported that they would inform supervisors or specific departments about complaints but were not aware of any formal grievance forms for residents. The Director of Social Services, who is the Grievance Officer, acknowledged that residents were not individually informed about the grievance process and that grievance forms were available in the social service binder on each unit. The Director also noted that the information boards would be updated to include necessary grievance process details.
Improper Use of Restraints for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. This deficiency was identified during a recertification survey, where it was observed that a concave mattress was used for a resident to prevent falls, despite the absence of a physician's order. The resident, who had a history of schizophrenia, bipolar disorder, and chronic obstructive pulmonary disease, was noted to have severe cognitive impairment and a high risk for falls. The concave mattress was intended to prevent the resident from getting out of bed, which was considered a restraint as it restricted the resident's freedom of movement. The facility's policy on the use of restraints specifies that such devices should only be used when necessary to treat a medical symptom and when less restrictive interventions are not effective. However, the use of the concave mattress for the resident was not documented as a physician-ordered intervention, nor was there evidence of consent from the resident or their family. Interviews with facility staff revealed that the concave mattress was used as a safety precaution to prevent falls, but it was not recognized as a restraint by the staff, indicating a lack of adherence to the facility's restraint policy.
Incomplete PASRR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a complete preadmission screening for a resident with a mental disorder, as required by the Preadmission Screening and Resident Review (PASRR) program. This deficiency was identified during a recertification survey, where it was found that the SCREEN DOH 695 form for a resident with bipolar disorder, schizoaffective disorder, and parkinsonism was incomplete. Specifically, the form lacked documentation for items 27 through 30, which are necessary for determining the need for Level II services when a serious mental illness is indicated. Interviews with facility staff revealed that the Director of Social Services and the Director of Nursing acknowledged the oversight. The Director of Social Services admitted to missing the review of the PASRR SCREEN for the resident, while the Director of Nursing confirmed that the Social Worker was responsible for reviewing the SCREEN form before accepting the resident. The incomplete form was not identified until the survey, indicating a lapse in the facility's process for coordinating assessments with the PASRR program.
Failure to Provide Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, a resident with schizophrenia, pressure injuries, and chronic obstructive pulmonary disease did not receive pressure-relieving devices as ordered by the physician to promote pressure ulcer healing. The resident had two unstageable pressure injuries upon admission, which later included a Stage 3 injury on the right heel. Despite physician orders to offload the resident's heels with a pillow, observations on multiple occasions revealed that the resident did not have a pillow under their legs while in bed. Interviews with facility staff, including a CNA and LPN, confirmed that the resident had orders for heel offloading with a pillow, but the staff failed to ensure compliance with these orders. The CNA was unaware of where to find care instructions and relied on verbal reports from nurses. The Wound Care Nurse also observed the absence of a pillow under the resident's legs and had to request nursing staff to find one. This lack of adherence to the care plan and physician orders contributed to the deficiency in providing appropriate pressure ulcer care.
Resident Fed by Unqualified Staff Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure that a resident remained free from accident hazards, as evidenced by an incident involving Resident #44, who was fed a mechanically altered diet by unqualified and unsupervised staff. Resident #44, who had diagnoses including dementia, seizures, and vomiting, was severely cognitively impaired and totally dependent on staff for eating. The resident was on a mechanically altered diet and required close supervision for oral intake due to aspiration precautions. However, on 1/6/2025, the resident was fed by Transporter #23, who was not trained or certified to provide feeding assistance to residents with swallowing impairments. The facility's policies and job descriptions outlined the responsibilities of staff in providing appropriate care and supervision during meals. The Licensed Practical Nurse was responsible for overseeing meal delivery and consumption, while the Registered Nurse Manager was tasked with supervising the Floor Dayroom during resident meals. Despite these guidelines, there was no Licensed Practical Nurse or Registered Nurse present to supervise the 3rd Floor Dayroom while residents ate, leaving Transporter #23 to feed Resident #44 without the necessary training or supervision. Transporter #23, who was hired approximately four months prior, stated that their job responsibilities did not include feeding residents and that they did not possess the credentials to be a Certified Nursing Assistant or meet the paid feeding assistant training requirements. The absence of qualified nursing staff during the meal led to Transporter #23 feeding Resident #44, placing the resident at risk for aspiration. The Registered Nurse Manager, who was scheduled to supervise the dinner, left the facility without informing anyone and subsequently resigned, contributing to the lack of supervision during the incident.
Deficiency in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the comprehensive person-centered care plan for two residents. Resident #46, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Bipolar Disorder, was observed receiving oxygen therapy at 3 liters per minute, contrary to the physician's order of 2 liters per minute. There was no documentation of oxygen therapy in the Treatment Administration Record from October 2024 to January 2025, as confirmed by Licensed Practical Nurse #9 and the Director of Nursing. Resident #107, with diagnoses including hypertension, wheezing, and cough, was also provided oxygen at 3 liters per minute, despite a physician's order for 2 liters. Additionally, the nasal cannula and humidified water bottle were not dated, which was against the facility's policy. Licensed Practical Nurse #10 and the Assistant Director of Nursing acknowledged the oversight, noting that the nasal cannula tubing should have been changed and dated weekly.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance reviews at least once every 12 months, as required. During the recertification survey, it was found that six randomly selected CNAs, who had been employed at the facility for periods ranging from 2000 to 2018, did not have documented performance evaluations within the past year. Interviews with the Human Resources/Staffing Coordinator, Nurse Educator, and Director of Nursing revealed that performance evaluations had not been conducted for several years, with some evaluations occurring sporadically. One CNA reported that their last performance evaluation was in 2012, despite having worked at the facility since 2007.
Inadequate Dementia Care and Lack of Individualized Activities
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with dementia, as evidenced by the cases of two residents. Resident #30, who had diagnoses of unspecified dementia and anxiety disorder, did not receive person-centered, individualized care or meaningful activities that aligned with their preferences and customary routines. Despite having a comprehensive care plan that included therapeutic activities and interventions for restless behavior, there was no documented evidence of meaningful activities being provided. Observations showed Resident #30 in distress, with behaviors such as screaming and physical agitation, and without the prescribed knee pads to prevent injury from crawling. Additionally, there was a lack of communication and implementation of a recommended gradual dose reduction of quetiapine, as suggested by a psychiatry consult. Resident #122, also diagnosed with unspecified dementia and depression, was found to be severely cognitively impaired and had highly impaired vision. The care plan for Resident #122 included interventions such as 1-to-1 room visits and therapeutic activities, but observations revealed the resident was often left alone in their room, disengaged, and without meaningful activities. The resident's television was off or not in their line of sight, and there was no music or other forms of engagement provided. Despite a psychiatry consult recommending a reduction in olanzapine dosage, there was no evidence of this being communicated or implemented. The facility's policies and procedures for dementia care and the Reflection Group were not effectively implemented. Staff interviews revealed a lack of awareness and communication regarding the interventions and recommendations for residents with dementia. The Director of Social Work and other staff members were not fully informed or involved in the development and implementation of individualized care plans. Additionally, the facility was short-staffed, and there was a lack of trained personnel to facilitate activities for residents with dementia, leading to inadequate care and engagement for these residents.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with accepted professional standards, as observed during a recertification survey. In the second floor unit medication storage room, surveyors found several deficiencies, including an unlabeled tube of bacitracin zinc ointment, an open unlabeled flush bag, and expired items such as three bags of Nutren 2.0 feeding, two Pleurx Drainage Kits, two boxes of COVID-19 Antigen Self Tests, and one disposable sampling kit. Additionally, the medication storage refrigerator was found to be at 50 degrees Fahrenheit, which is above the acceptable temperature range, with the last recorded temperature check being outdated. Interviews with staff revealed that the nurses were responsible for checking the medication storage room every shift to ensure expired and unlabeled items were removed. Licensed Practical Nurse #9 acknowledged the presence of expired and unlabeled items and the refrigerator's temperature issue, indicating that these should have been addressed. Nurse Manager #1 confirmed that the nursing staff should routinely check feedings, medications, and equipment, and report any temperature discrepancies to maintenance. The failure to adhere to these protocols resulted in the observed deficiencies.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Resident #69, who was on enhanced barrier precautions due to a Stage 3 pressure ulcer and other medical conditions, did not have the appropriate signage outside their room until several days after the precautions were ordered. A certified nurse aide was observed providing care to this resident without wearing the required personal protective equipment (PPE), despite being aware of the enhanced barrier precautions. The Infection Control Preventionist acknowledged the lapse in ensuring staff awareness and compliance with PPE requirements. Resident #121, who had a history of urinary tract infections and an indwelling urinary catheter, was found with their catheter bag lying directly on the floor, contrary to the facility's policy and physician orders. The catheter bag was also not covered with a privacy bag as required. Interviews with the resident and staff confirmed the recurrent issue of urinary tract infections and the improper handling of the catheter bag, which should have been kept off the floor to prevent infection. Resident #25, who had multiple pressure injuries, received wound care from the Wound Care Nurse who did not adhere to proper infection control practices. The nurse failed to wash their hands adequately, did not use soap, and did not don a gown as required for enhanced barrier precautions. Additionally, the nurse handled non-sterile surfaces and personal items without proper hand hygiene, and left soiled bandages and gloves in an open garbage container. These actions were contrary to the expected standards of care and infection control protocols, as acknowledged by the Wound Care Nurse during an interview.
Deficiency in Antibiotic Stewardship Program Implementation
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program as required, which was identified during a recertification survey. The deficiency was noted when the facility could not provide adequate documentation of antibiotic use tracking for the months of November 2024, December 2024, and January 2025. The facility's policy on antibiotic stewardship, updated in 2024, outlined the need to monitor antibiotic use among residents, including the communication of laboratory results and clinical situations to prescribers. However, the Infection Control Preventionist, responsible for tracking antibiotic use, provided an incomplete list of residents on antibiotic therapy that lacked critical information such as infection onset dates, laboratory test results, frequency and duration of antibiotic therapy, and the indication for antibiotic use. Interviews with the Infection Control Preventionist and the Director of Nursing revealed that the Infection Control Preventionist was behind in tracking antibiotic use and maintaining the necessary documentation. The Director of Nursing confirmed that the Infection Control Preventionist was the primary person responsible for the Antibiotic Stewardship Program, which included maintaining the line list, obtaining laboratory information, and coordinating with physicians and nurse practitioners. The lack of complete and accurate documentation indicated a failure in the facility's antibiotic stewardship efforts, as required by 10 NYCRR 415.19 (a)(1,3).
Pest Control Deficiency in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live and dead roaches in the kitchen. During a kitchen observation, a live roach was seen crawling on the wall, and a dead roach was found on the floor next to the kitchen tray line. The facility's policy, updated in December 2024, stated that there should be an ongoing pest control program to keep the building free of insects and rodents. However, the Food Service Director acknowledged the presence of roaches and mentioned that the facility had bi-weekly pest control treatments. Pest Management Service Inspection Reports from October to December 2024 indicated that on one occasion, the kitchen was closed and locked, preventing service, and on another occasion, minimal activity was observed with a recommendation to increase sanitary practices in the kitchen. The Director of Maintenance stated that pest control services were provided monthly, including all kitchen areas.
Delayed Submission of Resident Assessments
Penalty
Summary
The facility failed to ensure timely submission of completed resident assessments to the Centers for Medicaid and Medicare Services (CMS) within the required 14-day period. Specifically, 11 out of 30 Minimum Data Set (MDS) assessments were not submitted on time. The facility's policy, revised in January 2024, mandates that each department complete their responsibilities no later than 14 days from the Assessment Reference date. However, the review revealed that assessments for several residents, with completion dates ranging from November 14, 2024, to November 22, 2024, were all submitted on January 5, 2025, well beyond the stipulated timeframe. Interviews conducted during the survey revealed a lack of awareness and accountability regarding the delay. The Minimum Data Set Coordinator acknowledged the issue but could not provide a reason for the delay, stating it was the first occurrence of such an issue. The Director of Nursing was unaware of the delay and indicated that the responsibility for timely submission lay with the Minimum Data Set Coordinator. This lack of communication and oversight contributed to the failure in meeting regulatory guidelines.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident and a podiatrist to the New York State Department of Health within the required timeframe. The incident was reported to the Director of Nursing and the Administrator, but there was no documented evidence that it was reported to the state agency as required by the facility's policy. The policy mandates immediate reporting of all alleged violations to the Administrator, State Agency, and other required agencies within specific timeframes. The incident involved a resident with severe cognitive impairment, who was admitted with diagnoses including metabolic encephalopathy and hemiplegia. The resident had a care plan indicating a potential for abuse. During the incident, the resident exhibited physical behavioral symptoms and kicked at the podiatrist during care. Staff present during the incident reported that the resident was refusing care, but the podiatrist continued. Despite this, the Director of Nursing concluded that there was no abuse substantiated based on interviews and observations, noting no evidence of injury or adverse effects. Interviews with staff revealed that the incident was not reported to the state because it was considered a complaint rather than an incident warranting a report. The Director of Nursing and the Administrator both stated that they did not believe the incident met the criteria for reporting to the state. The Administrator was informed of the incident on the day it occurred but was not present at the facility. The lack of reporting to the state agency constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident and a podiatrist. On the day of the incident, the Director of Nursing and the Administrator were informed of the alleged abuse, but there was no documented evidence of an accident/incident report being completed. Additionally, there was no documented skin assessment by a Registered Nurse, no interviews conducted with other residents seen by the podiatrist on the day of the incident, and the complainant was not interviewed until the following day. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status score of 00/15. The podiatry consult noted that the resident became combative during the procedure, which was stopped. Despite this, the Director of Nursing did not document a skin assessment in the resident's medical record, and no incident report was filed because it was considered a complaint rather than an incident. The Administrator, who was not present at the facility on the day of the incident, was informed by the wound doctor about the resident's distress but did not report the incident to the New York State Department of Health. Interviews with staff revealed that the Director of Nursing and the Administrator did not return calls regarding the incident until the following day. The Director of Social Services, informed about the incident a week later, did not document any notes in the resident's chart or make any referrals, as the resident showed no signs of trauma and was unaware of the incident. The facility's failure to document and report the incident, as well as to conduct a thorough investigation, led to the deficiency.
Failure to Document Incident and Assessment in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's medical records were accurately completed and contained a record of the assessment performed, as required by professional standards. Specifically, on March 28, 2024, an incident involving alleged abuse occurred during a podiatry toenail trimming consult for Resident #1, who was admitted with diagnoses including metabolic encephalopathy, hemiplegia, and adult failure to thrive. Despite the incident being overheard by staff, there was no documented assessment in the electronic medical record of Resident #1. The facility's Accident/Incidents reporting policy requires that a licensed nurse document the facts and sequence of events in the nurse's notes. However, there was no documented evidence of an accident or incident report for Resident #1 from January to March 2024. Interviews revealed that the Director of Nursing and the Registered Nurse Unit Manager did not document their findings of the examination because they did not observe any injuries, and they did not believe the incident warranted an incident report. The Director of Nursing conducted an investigation and obtained verbal statements from involved staff, concluding that there was no abuse substantiated. The investigation revealed that Resident #1 exhibited behaviors such as resisting care, which was considered usual for them. The family was not notified, and the incident was not reported to the state, as it was deemed a complaint rather than an incident. The lack of documentation and failure to follow the facility's policy for incident reporting led to the deficiency.
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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