Oneida Health Rehabilitation And Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Oneida, New York.
- Location
- 323 Genesee Street, Oneida, New York 13421
- CMS Provider Number
- 335427
- Inspections on file
- 20
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Oneida Health Rehabilitation And Extended Care during CMS and state inspections, most recent first.
A resident with acute respiratory failure, AFib, and hypertensive heart disease experienced tachycardia, with HR readings escalating despite medication, leading staff to contact the on‑call provider and transfer the resident to the hospital. Facility policy required notifying the resident and/or representative of transfers, including emergency transfers, and documenting the reason and notification in the record. Nursing notes documented the change in condition, provider contact, and transfer, but there was no documentation that the resident’s representative was notified. In interviews, an RN unit manager confirmed representatives should be notified the same day of a change in condition, and an RN involved in the transfer did not recall notifying the representative and believed a supervising RN would do so, acknowledging such notification should be charted.
A resident with right-sided paralysis, severely impaired cognition, and high fall risk was care planned to have a call light within reach and prompt staff response, but surveyors repeatedly observed the call light on the floor and out of reach while the resident was in bed. Staff, including a CNA, an LPN, and an RN manager, confirmed the resident was a fall risk and that all staff were responsible for ensuring call lights were accessible, yet they did not recall seeing the call light on the floor. This reflects a failure to follow the resident’s fall prevention care plan and maintain an environment free of accident hazards.
A resident with chronic respiratory failure and a tracheostomy, who had a Full Code advance directive, was found unresponsive. Two LPNs failed to initiate a Code Blue or perform CPR, despite clear orders and policy, due to not properly checking for the code bracelet and assuming the resident was deceased. The RN Supervisor was notified but also did not immediately initiate resuscitation, leading to a significant delay before CPR was started. The resident was later pronounced deceased in the emergency department.
The facility failed to assist residents with activities of daily living, including grooming and toileting. One resident had unclean fingernails, another was not assisted out of bed for toileting, and a third was not toileted every 2 hours as care planned. Staff interviews confirmed these deficiencies.
The facility did not ensure sufficient nursing staff, leading to deficiencies in resident care, including delayed call bell responses, cold meals, and inadequate assistance with activities of daily living. Residents reported dissatisfaction, and staff confirmed the challenges in providing timely care due to staffing shortages.
The facility failed to maintain an effective infection prevention and control program. A resident with COVID-19 did not have proper transmission-based precautions, and two residents with indwelling medical devices were not placed on enhanced barrier precautions. Additionally, an LPN did not perform hand hygiene between residents during medication administration.
The facility failed to maintain an effective pest control program, resulting in fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms. Observations revealed multiple live and dead flies, and the Environmental Services Manager was unaware of the pest issues in the tub rooms.
The facility failed to maintain the privacy and confidentiality of residents' medical records by leaving electronic medication administration records open and visible on an unattended medication cart in the hallway. An LPN was observed leaving the cart unattended multiple times, displaying residents' photographs and health information to passersby.
The facility failed to develop and implement comprehensive care plans for five residents, omitting critical information such as the use of video monitoring devices, anticoagulants, insulin, and antipsychotics, which are essential for ensuring proper care and monitoring.
The facility failed to provide meaningful activities that met the interests and preferences of two residents. One resident, with vision impairments and difficulty walking, could not attend music activities due to insufficient staff assistance. Another resident, with cognitive and physical limitations, did not leave the unit for activities due to a lack of staff for transfers. Both residents' activity preferences were not adequately supported, and there was insufficient documentation of activity refusals.
A resident admitted with congestive heart failure did not receive the prescribed diuretic medication for five days and was not monitored for weight changes as recommended. The facility's process for entering and checking new admission medications failed, leading to the omission of critical treatment and monitoring instructions.
A resident with sleep apnea received CPAP therapy without a plan for regular cleaning of the equipment, contrary to the facility's policy and professional standards. Staff interviews confirmed the absence of cleaning instructions in the care plan and treatment records, posing a risk of bacterial buildup and infection.
The facility failed to ensure residents were free from significant medication errors. One resident did not receive sacubitril-valsartan for heart failure, and another did not receive multiple medications, including brimonidine tartrate eye drops, ammonium lactate lotion, docusate sodium, and Juven. The LPN incorrectly documented these medications as administered, and there was no evidence of proper communication or documentation regarding the missed doses.
The facility failed to assist a resident with quadriplegia and respiratory failure in obtaining dental care despite complaints of tooth pain. The resident had not seen a dentist since admission, and there was no documentation of dental concerns or a consult in their medical record.
The facility failed to ensure food and drink were served at palatable temperatures. Observations during a survey revealed that cold food items were served above the required temperature, and residents reported receiving cold meals due to delays in meal tray distribution. Staff confirmed that the speed of distribution depended on the number of available staff.
The facility failed to ensure proper food storage, preparation, and cleanliness in the main kitchen. Observations revealed stained and sticky floors in the dairy walk-in cooler, food debris under cooler shelves, and improperly stacked pans on the clean drying rack. The Food Service Director confirmed these issues and acknowledged lapses in immediate cleaning and documentation.
A resident with multiple pressure ulcers did not receive necessary treatment and services, including a specialty mattress that was not checked for function for 14 days. The mattress pump was found broken and not operational, leading to further deterioration of the resident's condition. Staff failed to report the broken pump for repair, and the resident's care plan was not adequately followed.
The facility failed to provide a Medicare beneficiary with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 after discontinuation of Medicare Part A services. The resident, who had severe cognitive impairment and multiple diagnoses, did not receive the notice and remained in the facility beyond the end of Medicare coverage. Staff interviews revealed miscommunication regarding the responsibility for issuing the notice.
Failure to Notify Resident Representative of Hospital Transfer After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s designated representative of a transfer to the hospital following a change in condition. Facility policy dated 09/16/2016 required that proper notification of a transfer or discharge be made to the resident and/or representative, including the reason for the transfer, with documentation in the clinical record, and that in an emergency transfer the representative receive written notice within 24 hours. The resident involved had diagnoses including acute respiratory failure with hypoxia, atrial fibrillation, and hypertensive heart disease with heart failure, and physician orders dated 04/11/2025 included monitoring vital signs every shift, metoprolol tartrate for hypertension and heart failure, and lorazepam as needed for anxiety. On 04/12/2025, nursing documentation showed the resident’s pulse was initially 101 and irregular, then later increased to 153, prompting notification of the RN Nursing Supervisor and administration of metoprolol. When the heart rate remained elevated at 140, lorazepam was given, and the on‑call medical provider was contacted. The provider instructed staff to send the resident to the hospital, and the RN Nursing Supervisor documented that the resident was transported to the emergency room for tachycardia. There was no documentation that the resident’s designated representative was notified of the transfer. In interviews, the RN Unit Manager stated representatives should be notified the day a change in condition occurs but was unsure if this resident’s representative had been notified, and the RN who arranged the transfer recalled sending the resident out and speaking with the provider but did not recall speaking with the representative, stating they believed the RN Nursing Supervisor would notify the representative and that such notification should be documented in the chart.
Failure to Maintain Call Light Within Reach for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at high risk for falls had their call light within reach as care planned, resulting in an environment that was not as free of accident hazards as possible. The resident had right-sided paralysis and weakness, severely impaired cognition, and required dependence for dressing, personal hygiene, and bed mobility. The resident’s comprehensive care plan, initiated due to high fall risk related to deconditioning, included interventions such as ensuring the call light was within reach, encouraging use of the call light for assistance, and prompt staff response. A fall risk assessment also documented the resident as a fall risk, with intermittent confusion, chairbound status, and incontinence. Despite these documented interventions, surveyors repeatedly observed the resident lying in bed with the call light on the floor under the top part of the bed and not within reach on multiple dates and times. Staff interviews confirmed that the resident was care planned for falls and that all staff were responsible for ensuring call lights were within reach. A CNA who cared for the resident during the survey week acknowledged the resident was care planned for falls and stated the call light should always be within reach, suggesting a clip could be used to prevent it from falling. An LPN and an RN manager both confirmed the resident was a fall risk with care plan interventions that included having the call light within reach and that all staff entering the room were responsible for ensuring this, but they did not recall seeing the call light on the floor. These observations and statements demonstrate that the care-planned intervention to keep the call light within reach was not consistently implemented.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to honor a resident's advance directive for resuscitation. The resident, who had chronic respiratory failure, a tracheostomy, and was designated as Full Code, was found unresponsive by staff. Despite clear physician orders and care plan documentation indicating the resident's wish for full resuscitative measures, the nurses present did not initiate a Code Blue or begin CPR as required by facility policy and the resident's advance directive. The two LPNs involved assessed the resident and determined the individual was deceased without verifying the presence of the required code bracelet on both arms, as per facility protocol. One LPN only checked one arm for the bracelet and, not seeing it, did not proceed with resuscitation. Both LPNs left the room and notified the RN Supervisor that the resident had expired, but did not call a Code Blue or attempt CPR. The RN Supervisor, upon being notified, prioritized another Code Blue on a different unit, assuming the unresponsive resident had a DNR order due to the lack of an emergent call and absence of a Code Blue being called. It was only after the RN Supervisor returned to the unit and confirmed the resident's Full Code status that a Code Blue was called and CPR was initiated, but this was significantly delayed. The resident was subsequently transported to the emergency department, where resuscitation efforts continued unsuccessfully and the resident was pronounced deceased. Interviews with staff revealed lapses in judgment and failure to follow established protocols for responding to unresponsive residents with Full Code status.
Removal Plan
- Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were suspended immediately following the incident.
- Facility policies for Basic Life Support and Cardiopulmonary Resuscitation, Code Blue, Cardiopulmonary Resuscitation Certification, Advance Directives and Determination of Death were all reviewed and completed.
- Re-education and staff knowledge competencies of licensed nursing staff and certified nurse aides for Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure, were initiated.
- The facility would add and conduct cardiopulmonary resuscitation and basic life support training to a semi-annual schedule with competencies.
- The facility would add and conduct semi-annual cardiopulmonary resuscitation drills across all shifts.
- All residents' Advance Directives were audited and completed.
- All residents' Full Code (heart symbol) bracelets were audited and completed.
- All licensed staffs' cardiopulmonary resuscitation certifications were audited and completed.
- All staff present on the unit at the time of the incident were interviewed.
- Resident #1's medical record and staff statements were reviewed and completed.
- A Root Cause Analysis of the incident and Quality Assurance and Performance Improvement meeting was initiated and completed.
- Resident deaths in the last six (6) months were reviewed.
- A Quality Assurance and Performance Improvement for Basic Life Support and Cardiopulmonary Resuscitation was initiated.
- Licensed Practical Nurse #1 was terminated from employment and reported to the New York State Office of Professions Licensing Board.
- Licensed Practical Nurse #2 was terminated from employment and reported to the New York State Office of Professions Licensing Board.
- There would be unannounced, random staff knowledge competencies for Code Blue and Cardiopulmonary Resuscitation and the results would be reported to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing monitoring. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- Mock Code and Cardiopulmonary Resuscitation Drills and post-review would be done across all shifts. The performance reviews/results would be presented to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Director of Education.
- The audits on Full Code (cardiopulmonary resuscitation) identifier bracelets would be done and results would be reported to the Quality Assurance and Performance Improvement Committee. The Quality Assurance and Performance Improvement Committee would then determine the need for ongoing reporting. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- An audit tool was developed to track every admission and re-admission's Advanced Directives. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- A comprehensive education syllabus was in development for presentation at orientation and annually on the following topics: Advance Directives, Code Blue, Cardiopulmonary Resuscitation, and Nurse Scope of Duties. The responsible party would be the Director of Nursing/Assistant Director of Nursing.
- All licensed nursing staff were educated on Acute Changes in Condition: Basic Life Support and Cardiopulmonary Resuscitation, and Code Blue Procedure.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #12 had unclean and untrimmed fingernails despite being observed multiple times over several days. The resident's care plan required total assistance for showering and extensive assistance for personal hygiene, but these needs were not met. Interviews with staff confirmed that nail care should have been performed during the resident's shower, but it was not done, placing the resident at risk for infection and injury. Resident #40 was not assisted out of bed for toileting, despite their care plan indicating they required substantial assistance and had a scheduled toileting routine. The resident expressed a desire to get out of bed and use the bathroom but stated that staff did not assist them due to a previous fall. Observations and interviews revealed that the resident had not been out of bed for toileting for six months, leading to the use of incontinence briefs instead. Resident #58 was not assisted with toileting every 2 hours as care planned. The resident, who had severely impaired cognition and required extensive assistance with toileting, was observed to have gone over 4 hours without being toileted. Staff interviews indicated a lack of adherence to the care plan, with the certified nurse aide admitting to not providing the necessary toileting assistance and failing to inform the nurse. This neglect in following the care plan put the resident at risk for skin breakdown and other complications.
Staffing Shortages Lead to Deficiencies in Resident Care
Penalty
Summary
The facility did not ensure sufficient nursing staff to meet the needs of all residents, leading to deficiencies in resident care. During a confidential resident group meeting, residents reported that their call bells were not answered timely, and meals were not served hot due to staff shortages. The facility's staffing schedule from 4/9/2024 to 4/12/2024 showed that the actual staffing levels were consistently below the desired numbers for registered nurses, licensed practical nurses, and certified nurse aides across all shifts. This staffing shortfall affected the quality of care provided to residents, as evidenced by specific incidents involving inadequate assistance with activities of daily living, such as toileting and mobility, and delays in meal service, resulting in food being served at unappetizing temperatures. Additionally, residents were not provided with meaningful activities that met their interests and preferences due to the lack of staff. For example, one resident who required assistance of two staff members for care was not able to participate in activities or receive timely care, leading to extended wait times for essential services. Interviews with staff confirmed that the lack of sufficient personnel made it difficult to provide timely and adequate care to residents. The facility's administrator acknowledged the staffing issues and mentioned ongoing efforts to recruit and retain staff, including job fairs, pay rate increases, and sign-on bonuses. However, the immediate impact of the staffing shortages was evident in the compromised quality of care and resident dissatisfaction. The facility's policy on nursing service staffing and the facility assessment indicated that the staffing plan was based on resident needs, but the actual staffing levels did not meet these requirements during the survey period.
Infection Control Deficiencies
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #280 was admitted to the facility with a diagnosis of COVID-19, and transmission-based precautions were not maintained. Observations revealed that staff did not consistently use the required personal protective equipment (PPE), such as N95 masks and eye protection, and the signage outside the resident's room was incorrect, leading to confusion about the necessary precautions. Additionally, there was no dirty linen receptacle set up in or outside the resident's room, and staff were observed not following proper hand hygiene protocols. Residents #37 and #105, who had indwelling medical devices, were not placed on enhanced barrier precautions as required. Observations showed that the rooms of these residents did not have the necessary signage indicating enhanced barrier precautions, and staff did not consistently wear gowns and gloves when providing care. Interviews with staff revealed a lack of understanding and inconsistent implementation of the enhanced barrier precautions, which are critical for preventing the spread of infections among residents with indwelling medical devices. During a medication administration observation, an LPN did not perform hand hygiene between residents, which is a fundamental practice to prevent the spread of infections. The LPN was observed handling medications and interacting with multiple residents without performing hand hygiene, even when entering and exiting rooms with enhanced barrier precautions. This failure to adhere to basic infection control practices further compromised the safety and well-being of the residents in the facility.
Ineffective Pest Control Program
Penalty
Summary
The facility did not maintain an effective pest control program, resulting in the presence of fruit flies in the main kitchen and drain flies in the 2nd, 3rd, and 4th floor tub rooms. Observations made during the recertification survey revealed 15 live fruit flies in the dish machine area of the main kitchen, 3 live and multiple dead drain flies in the 4th floor tub room, 15 live drain flies in the 2nd floor tub room, and 10 live and multiple dead drain flies in the 3rd floor tub room. The third-party pest control vendor service inspection reports from 11/17/2023 to 4/10/2024 did not document the presence of these pests, despite the facility's Pest Activity/Sightings Log indicating fruit flies in the main kitchen on multiple occasions between January and April 2024. During an interview, the Environmental Services Manager stated they were unaware of the drain flies in the 2nd, 3rd, and 4th floor tub rooms and that these rooms were actively used by residents. They also mentioned that the fruit fly traps in the 4th floor tub room were not placed by the environmental services or maintenance departments. The manager expected staff to report pest sightings via phone calls, after which they would contact the pest control vendor. However, they were not aware of the main kitchen's internal pest log sheet and acknowledged that the monthly pest control vendor service inspection reports did not document any fruit flies or drain flies during the specified period.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility did not ensure residents' right to privacy and confidentiality of medical records was maintained for three residents. Specifically, the electronic medication administration records that displayed health information for these residents were left open on the medication cart and were visible to passersby in the hallway. During continuous observation, the medication cart was found unattended multiple times with the computer screen displaying photographs and identifying health information of the residents, making it visible to anyone passing by. Licensed practical nurse #8 was observed leaving the medication cart unattended with the screen open while administering medications to residents and obtaining equipment. The Assistant Director of Nursing confirmed that it was inappropriate for the electronic Medication Administration Record to be left open in the hallway and that there was a button to lock the screen to hide residents' personal health information. The facility policy on patient confidentiality was not followed, leading to a breach of resident privacy.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the development and implementation of a comprehensive person-centered care plan for five of six residents reviewed during the recertification survey. Specifically, Resident #58's care plan did not include the use of a video monitoring device in their room, despite the device being in place due to the resident's history of sexual delusions. The camera was observed in the resident's room, and staff confirmed its use, but it was not documented in the care plan, which is essential for maintaining the resident's dignity and ensuring staff awareness of the monitoring device. Resident #43's care plan did not include the use of anticoagulants or insulin, despite the resident receiving these medications daily for conditions such as diabetes and atrial fibrillation. The absence of these critical medications in the care plan means that staff may not be aware of the necessary precautions and monitoring required for the resident's safety, such as watching for signs of hyperglycemia, hypoglycemia, and bleeding risks. Similarly, Resident #97's care plan did not include the use of antipsychotics, even though the resident was receiving Seroquel for dementia with psychotic disturbances. The lack of documentation in the care plan could lead to staff being unaware of the medication's side effects and necessary monitoring. Interviews with staff, including registered nurses and the Assistant Director of Nursing, confirmed that medications should be included in the care plans to ensure proper care and monitoring, highlighting a significant oversight in the facility's care planning process.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being. Specifically, two residents were not provided meaningful activities that met their interests and preferences. Resident #40, who had diagnoses including macular degeneration, glaucoma, and difficulty walking, expressed that they were unable to attend music activities due to insufficient staff to assist them out of bed. The resident also mentioned a fear of being left in a chair and not being put back to bed after activities. Despite the resident's interest in music and going outside, there was no documented evidence of staff offering these activities or the resident refusing them. The Director of Activities acknowledged that staff might not invite the resident to activities due to perceived continuous refusals, and there was no documentation of the reasons for these refusals. Resident #79, who had diagnoses including limitation of activities due to disability, adjustment disorder with depressed mood, and cognitive communication deficit, also did not receive activities that met their preferences. The resident's care plan indicated a preference for music, being around animals, keeping up with the news, and going outside. However, the resident's representative and staff interviews revealed that the resident did not leave the unit to attend activities due to insufficient staff to assist with transfers. The resident was observed in bed or in a recliner chair during the survey period, and the activity records showed limited participation in activities. Staff confirmed that the resident enjoyed music, television, and fidget toys but rarely saw activities staff on the unit and had not attended any recent activities. The Director of Activities stated that activities were important for the residents' quality of life and acknowledged that Resident #79 loved video games, which were provided but could not be left alone with the resident. The resident's family played games with them during visits. The Director also noted that the resident had recently watched a movie but had refused some activities. The facility's failure to provide meaningful activities that met the residents' interests and preferences was evident in the lack of staff support and documentation of activity refusals.
Failure to Administer Diuretic and Monitor Weights for Resident with Congestive Heart Failure
Penalty
Summary
The facility did not ensure that Resident #278 received treatment and care in accordance with professional standards of practice. Resident #278, who was admitted with congestive heart failure, had hospital discharge orders for torsemide and instructions for monitoring weights. However, the torsemide was not ordered until five days after admission, and weights were not monitored as recommended. The facility's policy required that physician orders be entered into the electronic record and checked by two nurses on admission, but this process failed in the case of Resident #278. The resident's hospital discharge summary documented a diagnosis of chronic combined heart failure and included specific instructions for torsemide administration and weight monitoring. Despite this, the facility's admission assessment did not include an admission weight, and the initial physician orders did not include torsemide or weight monitoring. The resident expressed concern about not receiving their diuretic for the first few days and not being weighed daily as instructed. Interviews with facility staff revealed that the process for entering and checking new admission medications involved multiple steps, including reconciliation from the hospital discharge summary and a second check by another registered nurse. However, this process was not followed correctly for Resident #278, resulting in the omission of the critical diuretic medication and weight monitoring. Staff acknowledged the importance of these orders for a resident with congestive heart failure and recognized the potential adverse effects of not receiving the prescribed treatment.
Failure to Ensure Proper Cleaning of CPAP Equipment
Penalty
Summary
The facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, Resident #278, who had diagnoses including acute on chronic congestive heart failure, hypertensive heart disease, and sleep apnea, received continuous positive airway pressure (CPAP) therapy without a plan to regularly clean the machine to prevent contamination. The facility's policy required daily cleaning of the mask cushion and humidifier tub, and weekly cleaning of the tubing, but these instructions were not included in the resident's care plan or treatment administration records. The resident expressed concerns about the lack of cleaning, and staff interviews confirmed that cleaning instructions were missing from the treatment records, which could lead to bacterial buildup and potential infections. The deficiency was observed during a recertification survey conducted from 4/9/2024 to 4/12/2024. Interviews with various staff members, including a registered nurse supervisor, a licensed practical nurse, and a respiratory therapist, revealed that the CPAP therapy required orders for use and cleaning, but these were not documented in the resident's care plan or electronic health records. The staff acknowledged that the lack of proper cleaning could result in respiratory infections. The facility failed to follow its own policy and the manufacturer's recommendations for maintaining the CPAP equipment, leading to a potential risk for the resident's health.
Significant Medication Errors Identified
Penalty
Summary
The facility did not ensure that residents were free from significant medication errors for two of the five residents reviewed. Specifically, one resident did not receive sacubitril-valsartan, a medication used to treat heart failure, as ordered. During a medication pass observation, the LPN failed to administer the sacubitril-valsartan and incorrectly documented it as given. The LPN later claimed the medication was discontinued and the pharmacy was notified, but there was no documented evidence to support this claim. Attempts to follow up with the LPN were unsuccessful, and the physician was not informed of the missed medication. Another resident did not receive multiple medications as ordered, including brimonidine tartrate eye drops for glaucoma, ammonium lactate lotion for dry skin, docusate sodium for constipation, and Juven, a protein supplement. During a medication pass observation, these medications were not administered, yet the LPN signed off on the Medication Administration Record as if they had been given. The Assistant Director of Nursing confirmed that staff should follow medication orders and document accurately if medications are not given. The physician caring for this resident was not made aware of the missed medications, which could have led to negative effects on the resident's health. The facility's policy on Medication Transcription and Administration, reviewed in 2020, was not followed, leading to these significant medication errors. The policy required medications to be administered accurately and safely, with proper documentation. The failure to adhere to this policy resulted in residents not receiving essential medications for their medical conditions, and there was a lack of communication and documentation regarding the missed doses.
Failure to Provide Dental Services
Penalty
Summary
The facility did not assist Resident #102 in obtaining routine and emergency dental care despite the resident's complaints of tooth pain and concerns about tooth decay. The resident, who had diagnoses including complete quadriplegia, acute and chronic respiratory failure, and ventilator dependence, had not seen a dentist since their admission in December 2023. The resident expressed concerns about the potential danger of bacteria from their mouth entering their respiratory tract, which could be particularly harmful given their compromised respiratory status. Despite informing a nurse about the tooth pain, there was no documentation of dental concerns or a dental consult in the resident's medical record. Interviews with staff revealed that the facility's policy required a dental consult to be ordered on admission, but this was not done for Resident #102. The Assistant Director of Nursing confirmed that a dentist visited the facility weekly and that dental consults should be ordered by the nurse handling admission orders. However, Resident #102 had not been seen by a dentist, and there was no comprehensive care plan addressing the resident's oral health concerns. The failure to provide necessary dental care was acknowledged by the staff, who recognized the increased risk of infection for residents with respiratory compromise.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility did not ensure that food and drink provided to residents were palatable, flavorful, and served at appetizing temperatures. During the recertification survey, it was observed that food temperatures were not maintained as per the facility's policy. Specifically, during the lunch meal on 4/12/2024, cold food items were served at temperatures higher than the required 41 degrees Fahrenheit. For instance, milk was measured at 48 degrees Fahrenheit, apple juice at 47 degrees Fahrenheit, tossed salad at 60 degrees Fahrenheit, and cut fruit bowl at 49 degrees Fahrenheit. This discrepancy was confirmed by the Food Service Director, who acknowledged the difficulty in maintaining proper temperatures when hot and cold food items were kept in the same meal cart. Interviews with residents and staff revealed that meals were often served cold due to delays in meal tray distribution. Resident #66 and Resident #4 both reported receiving cold meals, with Resident #66 preferring to eat in their room and Resident #4 requiring assistance with meals. Additionally, during a resident meeting, 12 anonymous residents expressed concerns about the timely distribution of meal trays, attributing delays to insufficient staff. Certified nurse aide #14 confirmed that the speed of meal tray distribution depended on the number of staff available, and meal carts were not separated based on where residents ate their meals.
Deficiencies in Food Storage and Cleanliness in Main Kitchen
Penalty
Summary
The facility did not ensure the storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in the main kitchen. Observations made during the survey revealed that the floor of the dairy walk-in cooler was stained and sticky, and the floor under the walk-in cooler shelves had food items and other debris. Additionally, there were 18 pans improperly stacked on the clean drying rack, with the bottom of one pan in direct contact with the cooking side of another, posing a potential contamination risk. The Food Service Director confirmed these findings and acknowledged that the pans should have been moved to the back storage room and that the stickiness in the dairy walk-in cooler was due to a spilled gelatin product that was not cleaned up immediately by the staff who spilled it. The facility's documentation indicated that the night supervisor was responsible for ensuring the general cleanliness of the kitchen and that the stock person was responsible for cleaning under the shelves in the coolers and freezer. However, the Food Service Director admitted that the staff did not always document when issues were identified and verbally instructed to be fixed. The undated Food Service-Receiver Performance Evaluation Form and the Master Cleaning Schedule also outlined responsibilities for cleaning the walk-in refrigerators and freezers, but these procedures were not adequately followed, leading to the observed deficiencies.
Failure to Ensure Proper Pressure Ulcer Care
Penalty
Summary
The facility did not ensure that a resident with pressure ulcers received the necessary treatment and services to promote wound healing, prevent infection, and prevent new pressure ulcers from developing. Specifically, the resident developed facility-acquired pressure ulcers and had a physician order for a specialty mattress, which was not checked for function for 14 days after it was ordered. The mattress was observed not connected to the pump, and the pump was not operational. The resident had multiple diagnoses, including a left femur fracture and facility-acquired Stage 2 pressure ulcers on the back and sacral region. The resident was cognitively intact, dependent for bed mobility and transfers, and had pressure ulcers that were not present on admission. The resident's care plan included turning and repositioning every 2 hours, treatment per physician order, and pressure-relieving boots, which the resident frequently refused. Despite these measures, the resident developed additional pressure ulcers, and there was no documented evidence that the specialty mattress was checked for functioning every shift as ordered. Observations revealed that the air mattress pump was not operational, and the tubing was not connected. Licensed practical nurses documented that the mattress function was checked, but the pump was found to be broken and not functioning. Interviews with staff confirmed that the air mattress was not in use despite being ordered, and the broken pump device was not reported for repair. The Assistant Director of Nursing acknowledged that the air mattress was essential for reducing pressure and preventing further deterioration of the resident's pressure ulcers.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the appropriate liability and appeal notices to a Medicare beneficiary, specifically for a resident who remained in the facility after the discontinuation of Medicare Part A services. The resident, who had severe cognitive impairment and was admitted with diagnoses including a left femur fracture, depression, and cerebral palsy, did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055. The resident's Medicare Part A skilled services ended on 2/24/2024, but the notice was not issued, and the resident stayed in the facility until 3/12/2024. Interviews with facility staff revealed a lack of clarity regarding the responsibility for issuing the SNF ABN. The patient account supervisor acknowledged that the notice should have been issued within 48 hours prior to the termination of Medicare Part A services. However, the Director of Social Work believed that the business office was responsible for issuing the notice and was unaware that the resident should have received it. This miscommunication led to the failure to provide the necessary notice to the resident or their representative.
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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