Onondaga Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Minoa, New York.
- Location
- 217 East Avenue, Minoa, New York 13116
- CMS Provider Number
- 335548
- Inspections on file
- 28
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 22 (2 serious)
Citation history
Health deficiencies cited at Onondaga Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with a history of falls and multiple medical conditions experienced an unwitnessed fall and was found on the floor by a roommate. Although LPNs and CNAs checked the resident's vitals and safety, there was no documented assessment by a qualified professional, such as an RN or via telehealth, as required by facility policy. The resident's care plan indicated a need for assistance with toileting and mobility, but the required post-fall assessment was not completed or documented.
Surveyors found that two residents did not receive adequate supervision or accident prevention measures as required by their care plans. One resident on aspiration precautions was left unsupervised during meals and given a straw, contrary to orders, while another resident at risk for falls did not have fall mats in place and could not reach their call light. Staff interviews and observations confirmed these deficiencies in supervision and implementation of safety interventions.
A resident with Parkinson's and anxiety was physically abused by an LPN, who pushed them into a wall, causing a nosebleed and fractured nose. The resident's care plan noted behavioral symptoms, but the LPN's response was abusive. Witnesses confirmed the incident, leading to the LPN's arrest and charges of assault and endangering a vulnerable adult.
The facility failed to treat residents with respect and dignity, including incidents of staff having a verbal confrontation in front of a resident, standing over a resident while feeding, not timely removing a disruptive resident, and entering a legally blind resident's room without announcing themselves.
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, with issues including used incontinence briefs left in rooms, broken door handles, missing light fixture covers, exposed wiring, and serving cold beverages in disposable cups. Staff interviews confirmed these practices were not in line with facility policies.
The facility failed to ensure residents received necessary assistance with activities of daily living, including dressing, bathing, and meal supervision. One resident was observed wearing the same nightgown for three days, another did not receive a shower for three weeks, and a third was left to eat alone without supervision. Staff interviews confirmed these deficiencies, which were contrary to the residents' care plans.
The facility failed to ensure timely meal delivery, with meal trays arriving up to 1 hour and 25 minutes late due to kitchen staffing issues. Interviews with residents and staff confirmed the delays, and the Food Service Director acknowledged the problem, citing staffing shortages as the cause.
The facility failed to maintain an effective infection control program and lacked a comprehensive water management plan. Staff did not adhere to PPE protocols for residents on precautions, and there were inconsistencies in Legionella testing, highlighting significant oversights in maintaining a safe environment.
The facility's main kitchen had several deficiencies, including broken cooler and freezer doors, cracked floor tiles, and water leaks, leading to unsanitary conditions. The cleaning policy was not followed, and there was no documented cleaning schedule. Staff interviews revealed that these issues had persisted for months without proper documentation or repairs.
The facility failed to maintain proper temperatures in unit kitchenette refrigerators, with one labeled out of order and another showing discrepancies between recorded and actual temperatures. Staff interviews revealed awareness of the issue, but documentation was not provided when requested.
A resident with chronic kidney disease and acute kidney failure did not receive a recommended follow-up appointment with a nephrologist. Despite multiple notes and attempts to schedule the consult, the appointment was never secured, leading to a significant gap in care. The facility's process for scheduling and tracking consultations was inadequate, resulting in the resident's ongoing dissatisfaction and potential health risks.
The facility failed to provide adequate supervision and a hazard-free environment for two residents. One resident with legal blindness had their bed not in the low position and call bell out of reach, while another resident with dementia was observed wandering unsupervised into other residents' rooms. Staff interviews revealed a lack of adherence to care plans and insufficient monitoring, leading to unsafe conditions.
The facility failed to ensure a resident maintained acceptable nutritional status by not weighing them as ordered, not providing fortified pudding, and not assisting with meals as care planned. The resident had severe protein-calorie malnutrition and required tube feedings and a mechanically altered diet. The resident's weight was not monitored as required, and their nutritional needs were not reassessed. Staff did not consistently assist the resident with eating, leading to low meal intakes.
A resident with end-stage renal disease was found with lidocaine-prilocaine cream at their bedside without a documented assessment for self-administration. The facility's policy required such an assessment, but it was not conducted. Staff interviews confirmed that medications should not be kept at the bedside without a physician order, which was absent in this case.
A resident with dementia and depression, who required an interpreter due to a language barrier, did not have a comprehensive care plan addressing their communication needs or potential victimization risk. Observations showed the resident was not understood by staff, leading to frustration and aggressive behavior. Staff lacked awareness and access to communication tools, despite facility policies on translation services and resident rights.
The facility failed to provide individualized activity programs for two residents, resulting in a deficiency in meeting their physical, mental, and psychosocial well-being. One resident, with depression and an amputation, was not engaged in activities of their choosing due to discomfort and lack of in-room activities. Another resident, with dementia, was observed sitting in the hallway without staff interaction or activities, despite having a care plan that included interests like music and animals. The Activities Director acknowledged insufficient one-to-one visits and ineffective use of the daily chronicle.
A resident with end-stage renal disease did not receive appropriate dialysis care as their dialysis access site dressing was not removed by nursing staff as ordered. The resident had to remove the dressing themselves before their next dialysis session. The facility lacked documented hemodialysis agreements or procedures, and nursing staff failed to monitor the access site properly, leading to a deficiency identified during a survey.
A survey found that a facility failed to properly label and store medications, including insulin pens and an inhaler, on a medication cart. The medications lacked opened or expiration dates, which could affect their effectiveness. An LPN and RN Unit Manager acknowledged the oversight, with the RN confirming monthly audits for expired medications. A pharmacist later clarified the expiration period for the inhaler.
The facility failed to serve food at appropriate temperatures, with test trays showing beef stew and vegetables below required temperatures and French fries cold and undercooked. The Food Service Director acknowledged the issue, citing the lack of plate warmers, and the facility could not provide documentation of test trays.
A resident with dementia and diabetes was served a meal inconsistent with their physician-ordered mechanical soft diet, containing large chunks of beef instead of ground beef. Staff interviews revealed lapses in checking meal consistency, leading to the resident receiving a regular diet meal instead of the required modified diet.
A resident's call bell was repeatedly found out of reach, preventing them from contacting staff for assistance. Despite the facility's policy requiring call bells to be accessible, observations during a survey revealed the call bell on the floor multiple times. Staff interviews confirmed the importance of having the call bell within reach, especially for residents like this one, who had moderately impaired cognition and were dependent on staff for daily activities.
The facility failed to maintain an effective pest control program, leading to evidence of mice in a resident room. A resident reported recent mouse sightings, confirmed by their roommate. Inspection revealed rodent droppings and chewed wrappers inside the heater, which had an open hole allowing pest entry. The Administrator noted that housekeeping and maintenance were responsible for pest management.
Failure to Ensure Qualified Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a resident with a history of falls, chronic obstructive pulmonary disease, hypertension, and anxiety disorder experienced an unwitnessed fall in the evening. The resident was found on the floor by their roommate, and staff documented that vital signs were taken and were stable, with no signs of injury at the time. However, there was no documented evidence that a qualified professional, such as a registered nurse, assessed the resident after the fall, as required by facility policy and professional standards of practice. The facility's Falls Management and Prevention policy required a head-to-toe assessment by a qualified individual following any fall. Documentation from multiple staff members, including certified nurse aides and LPNs, indicated that the resident was checked for safety and vitals were taken, but the assessment by a registered nurse or through telehealth was not completed or documented. Staff interviews revealed that there was no registered nurse in the building during the shift, and although the process was to contact an on-call RN or use telehealth for assessment, this was not done for the resident in question. The resident had a care plan indicating a risk for falls and required assistance with toileting and mobility. Despite these interventions, the resident attempted to toilet independently, resulting in a fall. The lack of a documented assessment by a qualified professional after the incident constituted a failure to provide care in accordance with the resident's care plan and professional standards. The resident expired the following morning, but the report does not link the death directly to the deficiency.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
Surveyors identified deficiencies in the facility's supervision and accident prevention practices for two residents. One resident with diagnoses including dysphagia, dementia, and acute respiratory failure was on aspiration precautions, requiring a mechanical soft diet, nectar thick liquids, no straws, and partial assistance at meals. Despite these orders and care plan instructions, the resident was observed left alone with their meal tray, not assisted as required, and provided a straw by staff. Multiple staff interviews confirmed a lack of clarity and communication regarding who was responsible for assisting the resident, and staff did not consistently follow the aspiration precaution protocols, including supervision during meals and avoidance of straws. Another resident, with a history of diabetic neuropathy, cataracts, obesity, and a documented risk for falls, did not have all planned fall interventions in place. Observations over several days showed that the resident's bed was not consistently in the lowest position, fall mats were not always in place as care planned, and the call light was frequently out of reach, sometimes on the floor under the bed. The resident reported being unable to get help when needed due to the inaccessible call light. Staff interviews revealed inconsistent understanding and implementation of the care plan interventions, with fall mats not always replaced after meals and the call light not reliably positioned within reach. The facility's failure to ensure adherence to individualized care plans and physician orders resulted in residents not receiving adequate supervision or the necessary interventions to prevent accidents. The lack of proper meal assistance and aspiration precautions for one resident, and the absence of required fall prevention measures for another, were directly observed and confirmed through staff interviews and record reviews.
Resident Abuse by LPN Results in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in harm. The incident involved a resident with a history of Parkinson's Disease, osteopenia, and anxiety, who was known to exhibit behavioral symptoms such as physical outbursts and frequent requests for anxiety medication. On the day of the incident, the resident approached an LPN to ask about anxiety medication. The LPN, in response, pushed the resident into a wall, causing a nosebleed and a fractured nose. This action was witnessed by multiple staff members and another resident, who reported the incident to the Director of Nursing. The resident's care plan had documented their behavioral symptoms and included interventions such as medication management, psychiatric evaluation, and redirection to a less stimulating environment. Despite these measures, the resident's anxiety had reportedly increased, leading to more frequent aggression towards staff. On the day of the incident, the resident's behavior was consistent with their documented history, yet the LPN's response was inappropriate and abusive, resulting in physical harm to the resident. The incident was reported to the facility's administration, and an investigation was initiated. Witnesses corroborated the resident's account of being pushed into the wall by the LPN. The police were notified, and the LPN was subsequently arrested and charged with assault and endangering the welfare of a vulnerable adult. The facility's failure to prevent this abuse highlights a significant deficiency in protecting residents from harm.
Penalty
Summary
Citation DetailsDetails not available.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility did not ensure residents were treated with respect and dignity, impacting six residents. Specifically, an activities aide and an LPN had a verbal confrontation in front of a resident after running out of portable oxygen during a group activity. Additionally, a CNA stood over a resident while assisting them with eating, which was against the facility's policy of being at eye level to ensure comfort and proper visualization of chewing and swallowing. Two anonymous residents also reported being told they could not leave their rooms due to a lack of portable oxygen, which restricted their freedom and self-determination. Another resident exhibited continuous disruptive verbal behaviors in a common area and was not removed timely as planned. The resident was also transported in their wheelchair facing backward by a CNA, which was not dignified or respectful. The facility's policy required residents exhibiting behavioral symptoms to be moved to a quiet, controlled space to calm down, but this was not followed. Interviews with staff confirmed that the resident's behavior was disruptive and should have been managed more appropriately. A legally blind resident experienced a lack of respect for their condition when a CNA entered their room without knocking or announcing themselves. The CNA proceeded to reposition the resident without explaining the actions being taken, which left the resident feeling disoriented and uncomfortable. The facility's policy required staff to knock and introduce themselves before entering a resident's room, especially for those with visual impairments, to maintain a homelike environment and ensure the resident's comfort and dignity.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in both the North and South units, as well as the main dining room. On the North unit, surveyors observed used incontinence briefs on the floor and nightstand in resident rooms, a resident who smelled of urine, a broken door handle with sharp edges, and improperly maintained sliding glass door restrictors. Interviews with staff confirmed that used briefs should not be left in resident rooms and that door handles and restrictors should be properly maintained to ensure safety and dignity for residents. On the South unit, surveyors found missing light fixture covers, open light sockets with exposed wiring, and broken door handles in resident rooms. Additionally, there was tape on windows and sliding doors, which had been in place for 1-2 years without proper documentation. Staff interviews revealed that broken equipment should be reported and fixed promptly, and that the tape on windows was not documented or addressed appropriately. In the main dining room, a severely broken table was observed, and residents were served cold beverages in disposable cups, which was not considered homelike. The Food Service Director acknowledged that disposable dishes should only be used in emergencies and that the practice was due to short staffing. Interviews with housekeeping and administrative staff confirmed that broken items should be reported and removed to maintain a safe and clean environment for residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
The facility did not ensure that 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 #1 was observed multiple times over three days wearing the same nightgown, indicating a lack of assistance with dressing. Certified nurse aides confirmed that the resident required assistance with dressing due to poor vision and should have received clean clothing daily, but this was not consistently provided. The resident's care plan and Kardex indicated the need for daily dressing assistance, which was not adhered to by the staff, leading to improper hygiene and potential risk for infection. Resident #12, who required substantial assistance with bathing, reported not receiving a shower until three weeks after admission. The resident's care plan specified shower days twice a week, but the certified nurse aide documentation did not reflect this schedule. Interviews with staff revealed that the resident had not refused care, and the lack of showers was due to time constraints and oversight. This failure to provide regular showers compromised the resident's hygiene and dignity. Resident #35, who required supervision with eating and assistance with transfers, was observed eating alone in their room without supervision on multiple occasions. The resident's care plan indicated the need for supervision during meals and assistance with getting out of bed daily. Staff interviews confirmed that the resident was not consistently offered assistance to get out of bed and was left to eat alone, contrary to the care plan. This lack of supervision and assistance could lead to further health complications and a decline in the resident's condition.
Delayed Meal Service Due to Staffing Issues
Penalty
Summary
The facility did not ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plans of care. Specifically, meal trays were delivered to nursing floors up to 1 hour and 25 minutes after the scheduled mealtimes. The facility's policy on meal service, revised in April 2022, documented that meals would be delivered promptly to assure quality. However, observations on both the North and South Units showed significant delays in meal delivery times, with breakfast carts arriving much later than the scheduled times on multiple occasions. Interviews with residents and staff revealed that the delays were due to the kitchen being short-staffed. A resident mentioned that meals sometimes came late because of staffing issues in the kitchen. Licensed practical nurses and diet technicians confirmed that meals were often late and that the nursing units were not informed of these delays. The Food Service Director acknowledged the staffing issues and stated that they had been told it was acceptable for the North Unit to be served later than scheduled. The registered dietitian, who worked remotely, did not provide oversight to the foodservice staff, further contributing to the issue. The facility failed to adhere to its posted mealtime schedule, resulting in residents receiving their meals late.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in deficiencies for two residents and a lack of a water management plan to reduce the risk of Legionella. Specifically, staff did not adhere to required personal protective equipment (PPE) protocols for residents on transmission-based and enhanced barrier precautions. Resident #45, who had pneumonia and a central line catheter, was observed without proper signage or PPE outside their room. Staff members were seen entering and exiting the room without performing hand hygiene or wearing the necessary PPE, such as gowns and masks. This non-compliance was observed multiple times, indicating a systemic issue in following infection control protocols. Resident #36, who had sepsis and extended-spectrum beta-lactamase resistance, was also not properly managed under enhanced barrier precautions. Staff members were observed entering the resident's room without performing hand hygiene or wearing gowns, despite the presence of an enhanced barrier precaution sign. The staff's lack of awareness and adherence to the required precautions further highlighted the facility's failure to implement an effective infection control program. Additionally, the facility did not have a comprehensive water management plan to address the risk of Legionella. The facility's testing in 2022 and 2023 showed inconsistencies, with one positive result in 2022 and two samples rejected in 2023 without clear documentation. The facility's inability to provide a proper water management plan and the lack of follow-up on the rejected samples, especially the one from the same location as the positive result, demonstrated a significant oversight in maintaining a safe environment for residents and staff.
Food Service Safety Deficiencies in Main Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. During the recertification survey, several deficiencies were observed, including disrepair and unclean surfaces in the kitchen. The walk-in cooler and freezer doors were broken and could not close completely, leading to frost and puddles of liquid inside. The cooler floor tiles were cracked and covered with loose rubber mats, and there were large brown spills and food debris present. Additionally, water was dripping through a light fixture, and there were leaks over the aisles in the tray line service area, creating puddles that staff had to walk through. The facility's cleaning policy was not followed, as there was no documented evidence of a kitchen cleaning schedule. Interviews with staff revealed that the kitchen had been in disrepair for months, with issues such as a shattered cooler floor, leaking ceiling, and broken freezer door. The Food Service Director and the Administrator acknowledged the problems but lacked documentation for planned repairs. The kitchen was supposed to be cleaned daily, but this was not documented, contributing to an unsafe and unsanitary environment.
Refrigerator Temperature Maintenance Failure
Penalty
Summary
The facility failed to maintain equipment in safe operating condition, specifically regarding the unit kitchenette refrigerators on both the South and North Units. On the South Unit, an upright refrigerator was labeled as out of order and had an internal temperature of 65 degrees Fahrenheit, while the freezer contained frozen food items. A small black refrigerator on the same unit had a door that did not seal properly, resulting in a measured temperature of 41.7 degrees Fahrenheit. On the North Unit, the refrigerator's thermometer read 58 degrees Fahrenheit, and it contained various food items, including cottage cheese, pureed food, tuna sandwiches, and thickened beverages. Despite the temperature log indicating a temperature of 36 degrees Fahrenheit, the actual temperature was significantly higher, suggesting a discrepancy in the recorded data. Interviews with staff revealed that the Food Service Director was aware of the temperature issues and had ordered a replacement refrigerator for the South Unit, which was redirected to the North Unit when its refrigerator also failed to maintain the proper temperature. The Director of Housekeeping and Laundry was uncertain if a maintenance request form had been completed for the faulty refrigerator. Despite the facility's protocol of checking refrigerator temperatures twice daily, documentation regarding the temperature logs and the South Unit refrigerator was not provided when requested by the surveyors. This lack of documentation and failure to maintain proper refrigerator temperatures led to the deficiency noted in the survey.
Failure to Schedule Nephrology Follow-Up for Resident with Chronic Kidney Disease
Penalty
Summary
The facility failed to ensure that Resident #60 received treatment and care in accordance with professional standards of practice. Resident #60, who was admitted with chronic kidney disease and acute kidney failure, had a recommendation for a follow-up appointment with a nephrologist within one week of discharge from the hospital. Despite multiple documented notes from the physician assistant and interdisciplinary team meetings indicating the need for a nephrology consult, there was no evidence that the follow-up appointment was scheduled or occurred. The resident expressed frustration over the delay and dissatisfaction with their renal diet, which could not be liberalized without nephrology consultation. The facility's process for scheduling and tracking consultations was inadequate. The registered nurse Unit Manager and the physician assistant both indicated that they expected the consults to be scheduled and followed up on, but there was no clear process for ensuring this happened. The Consultation Tracker showed multiple failed attempts to schedule the nephrology appointment, but there was no documented evidence that the medical provider was informed of these failures. The Director of Nursing acknowledged the issue and mentioned ongoing performance improvement audits, but the deficiency persisted. Interviews with the resident, registered nurse Unit Manager, physician assistant, and Director of Nursing revealed a lack of communication and follow-up regarding the nephrology consult. The resident's care plan included a referral to nephrology, but the necessary appointment was never secured. This failure to follow through on critical medical recommendations resulted in a significant gap in the resident's care, highlighting deficiencies in the facility's processes for managing and tracking specialist consultations.
Failure to Ensure Adequate Supervision and Hazard-Free Environment
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, leading to deficiencies in care. Resident #379, who had legal blindness and a history of falls, was found with their bed not in the low position and their call bell out of reach on multiple occasions. Despite care plan interventions specifying the need for a low bed and accessible call bell, staff failed to consistently implement these measures. Observations revealed that the resident's bed was often at hip or mid-thigh height, and the call bell was sometimes on the floor, posing a significant fall risk. Interviews with staff indicated a lack of awareness and adherence to the care plan requirements for this resident, highlighting a gap in communication and training regarding fall prevention protocols. Resident #42, diagnosed with dementia and glaucoma, was observed wandering unsupervised into other residents' rooms and beds. The resident's care plan did not include interventions for wandering or risk for victimization, despite their behavior posing potential safety risks. Staff interviews revealed that the resident had been found in other residents' beds and rooms, which could lead to victimization or other safety issues. The care instructions did not document the need for a wander alert device or increased supervision, and staff were unaware of any specific interventions for this resident's wandering behavior. The lack of appropriate monitoring and care plan updates for Resident #42 further demonstrated the facility's failure to provide a safe environment. The facility's policies on falls management and behavior management were not effectively implemented for these residents. The interdisciplinary team did not adequately identify and implement necessary interventions to reduce fall risks and manage wandering behaviors. The deficiencies observed in the care of Residents #379 and #42 indicate a broader issue with the facility's adherence to its own policies and procedures, resulting in unsafe conditions for the residents.
Failure to Maintain Nutritional Status and Provide Meal Assistance
Penalty
Summary
The facility did not ensure that Resident #75 maintained acceptable parameters of nutritional status. Specifically, the resident was not weighed as ordered, did not receive fortified pudding, and was not assisted with meals as care planned. The resident had a diagnosis of severe protein-calorie malnutrition, dysphagia, and gastrostomy status. The resident's care plan included tube feedings and a mechanically altered diet, but the resident was also supposed to receive pureed solids and honey thick liquids. However, the resident's meal intakes were consistently low, and they were not provided with all the items on their meal tray, such as fortified pudding. The resident's weight was not monitored as required. The resident was weighed on admission and once more on 4/26/2024, showing a weight loss of 2.9 pounds. There were no additional documented weights after 4/26/2024, despite the requirement for weekly weights. The registered diet technician and other staff acknowledged the missing weights and the importance of monitoring the resident's nutritional status. The resident's nutritional needs were not reassessed since admission, and the resident's intake of fortified foods and other nutritional support was not adequately managed. The resident was also not assisted with meals as care planned. Observations showed that the resident's meal trays were often left untouched, and staff did not assist the resident with eating. The care plan documented that the resident was dependent on one person for eating, but staff did not consistently provide the necessary assistance. Interviews with staff revealed that there was a lack of communication and adherence to the care plan, resulting in the resident not receiving the required support during meals.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident's ability to safely self-administer medications was clinically appropriate. Specifically, Resident #45, who had end-stage renal disease and was dependent on hemodialysis, was found with a tube of lidocaine-prilocaine cream at their bedside. There was no documented evidence that the resident was assessed for their ability to self-administer this medication. The facility's policy required an assessment of a resident's mental and physical abilities to determine if self-administration was appropriate, and if not, medications were to be administered by a nurse. However, this assessment was not conducted for Resident #45. Observations during the survey revealed that the resident applied the cream to their dialysis access site before and sometimes after dialysis sessions, with the knowledge of the facility staff. Despite this, there was no physician order for the cream or instructions for self-administration. Interviews with facility staff, including a certified nurse aide and a licensed practical nurse, indicated that medications should not be kept at the bedside without a physician order, and the cream should have been stored in the medication cart. The Regional Registered Nurse confirmed that no order existed for Resident #45 to self-administer medications, and the cream should have been removed from the resident's room.
Failure to Address Language Barrier and Victimization Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a language barrier and potential risk of victimization. The resident, diagnosed with dementia and depression, had a documented need for an interpreter as their preferred language was not English. Despite this, the comprehensive care plan did not include specific interventions for the resident's language barrier or their potential to become a victim of verbal or physical abuse. Observations and interviews revealed that staff were not equipped with the necessary tools or information to effectively communicate with the resident, leading to frustration and aggressive behavior from the resident. During the survey, it was observed that the resident attempted to communicate with staff and other residents but was not understood due to the language barrier. The resident was seen trying to stand unassisted and was harshly yelled at by another resident, with no staff present to intervene. Interviews with staff indicated a lack of awareness and availability of communication tools such as picture charts or telephone translator services, which were supposed to be part of the resident's care plan. Staff members admitted to using gestures and simple language to communicate but were unaware of any specific interventions for the resident's communication needs. The facility's policies on translation services, resident rights, and behavior management were not effectively implemented for this resident. The lack of a comprehensive care plan addressing the resident's language barrier and potential victimization risk resulted in unmet needs and increased frustration for the resident. Staff interviews highlighted the importance of communication tools, yet these were not consistently available or utilized, further exacerbating the resident's communication challenges and behavioral issues.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide ongoing programs to support residents in their choice of activities, as evidenced by the cases of two residents. Resident #13, who has depression and a left lower leg amputation, was not offered meaningful activities of their choosing. Despite having a care plan that included interests such as music, Bingo, and pet therapy, the resident was not engaged in these activities. Observations and interviews revealed that Resident #13 often stayed in bed due to discomfort from their chair and was not provided with in-room activities. The Activities Director acknowledged that one-to-one room visits were lacking, and the resident's refusals to participate in activities were not adequately addressed or care planned. Resident #36, diagnosed with metabolic encephalopathy and dementia, was also not provided with activities that matched their preferences. The resident was observed sitting in the hallway for extended periods without staff interaction or activities being offered. Although the care plan included interests such as music and animals, these were not reflected in the resident's daily routine. The Activities Director admitted that the resident's care plan did not document a family interview and that one-to-one visits were insufficient. The daily chronicle provided to the resident was not effectively utilized, as the resident required assistance to engage with the activities included. Overall, the facility's failure to implement individualized activity programs for these residents highlights a deficiency in meeting the physical, mental, and psychosocial well-being of its residents. The lack of meaningful engagement and the absence of tailored interventions for residents who refuse or are unable to participate in group activities contributed to this deficiency.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident requiring such services, as observed during a recertification survey. The resident, diagnosed with end-stage renal disease and dependent on renal dialysis, had a physician's order to remove the dialysis access site dressing 6-8 hours after dialysis. However, the dressing was not removed as scheduled, and the resident reported having to remove it themselves before their next dialysis session. The facility did not have documented evidence of a hemodialysis agreement or policy and procedures, and initially claimed they had no residents receiving dialysis. Observations and interviews revealed that the resident's fistula access site was not monitored or the dressing removed by nursing staff as ordered. The resident stated that nursing staff rarely checked their fistula and never removed the dressing, leading them to do it themselves. On multiple occasions, the resident was seen with a dressing fully covering their left upper arm, indicating that the dressing had not been removed as per the physician's order. The Treatment Administration Record documented the dressing removal order, but it was not followed, and the resident was marked as out of the facility during the scheduled dressing removal time. Interviews with nursing staff and a regional registered nurse confirmed the oversight. The LPN responsible for the resident's care stated they monitored the access site but did not realize the dressing was still in place. The regional registered nurse emphasized the importance of removing the dressing as ordered to properly monitor the access site for complications and signs of infection. The failure to adhere to the physician's order and monitor the dialysis access site appropriately led to the deficiency identified during the survey.
Improper Labeling and Storage of Medications
Penalty
Summary
During a recertification survey, it was observed that the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with accepted professional principles. Specifically, on the South unit's medication cart #2, an insulin lispro pen for one resident, an insulin glargine pen for another resident, and an Anoro Ellipta inhaler for a third resident were found without opened or expiration dates. This lack of labeling could potentially compromise the effectiveness of the medications, as insulin is known to expire 28 days after opening, and the inhaler expires 6 weeks after being opened. Licensed Practical Nurse #31 acknowledged the oversight, stating that the nurse who opens the medication is responsible for dating it, and that insulin should be checked for expiration before administration. Registered Nurse Unit Manager #5 confirmed that cart audits are conducted monthly to check for expired medications and reiterated the importance of dating insulin pens. However, there was uncertainty regarding the need for dating inhalers, which was later clarified by a pharmacist who informed that the Anoro Ellipta inhaler expires 6 weeks after opening.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and appetizing, as evidenced by the findings during the recertification survey. On two separate occasions, test trays revealed that food items were served at temperatures below the facility's standards. On the first occasion, beef stew was served at 114 degrees Fahrenheit and a green and yellow bean mix at 108 degrees Fahrenheit, both below the required 140 degrees Fahrenheit. On the second occasion, French-fried potatoes were found to be cold and undercooked, and other food items were also below the appropriate serving temperatures. Interviews and observations indicated that the facility's meal service policy, which required meals to be served promptly to maintain adequate temperature and appearance, was not adhered to. The Food Service Director acknowledged the temperature discrepancies and noted the absence of plate warmers as a contributing factor. Additionally, the facility failed to provide documentation of test trays when requested, indicating a lack of proper monitoring and record-keeping. A resident had previously complained about cold food, further highlighting the issue.
Failure to Provide Diet Consistent with Resident's Needs
Penalty
Summary
The facility failed to provide a diet in a form designed to meet the individual needs of a resident, specifically Resident #33, during a recertification survey. The resident, who had diagnoses including dementia, diabetes, and cervicalgia, was supposed to receive a controlled carbohydrate, mechanical soft texture diet with thin liquids as per the physician's order. However, during an observation, the resident was served a lunch tray that contained beef stew with chunks of beef larger than one inch, which was inconsistent with the mechanical soft diet requirement. The facility's menu extension sheets specified that the mechanical soft beef stew should be ground with no peas, but this was not followed. Interviews with staff revealed a lack of adherence to the facility's policy on modified food consistency. Certified Nurse Aide #15 admitted to not checking the tray and ticket for every resident, while the Supervisor #36 acknowledged that the beef stew prepared for the resident was intended for a regular diet, not a mechanical soft diet. The Food Service Director confirmed that kitchen staff were responsible for ensuring the correct consistency of meals, and the Speech Language Pathologist emphasized the importance of providing the correct food consistency to prevent complications such as aspiration, weight loss, and malnutrition.
Resident Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that Resident #35 had a means of directly contacting staff for assistance, as their call bell was consistently found to be out of reach. This deficiency was identified during a recertification survey conducted from May 6 to May 10, 2024. The facility's policy, revised in August 2019, emphasized the importance of timely response to call bells to ensure high-quality resident outcomes. Resident #35, who had moderately impaired cognition and was dependent on staff for various activities, was observed multiple times with their call bell on the floor and out of reach, despite their comprehensive care plan indicating the need for the call bell to be within reach to mitigate fall risks. Interviews with facility staff, including a certified nurse aide, a licensed practical nurse, and a registered nurse unit manager, confirmed that call bells should be within residents' reach to allow them to communicate their needs or potential emergencies. The staff acknowledged that Resident #35 was capable of using the call bell and that it was crucial for it to be accessible. The repeated observations of the call bell being out of reach highlighted a failure in adhering to the facility's policy and ensuring the resident's safety and ability to communicate needs.
Pest Control Deficiency in Resident Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in evidence of mice in a resident room. The third-party pest control vendor had previously treated the room for mice and rodents on multiple occasions earlier in the year. However, during the recertification survey, a resident reported recent sightings of mice in their room, including one that emerged from the heater and ran into the hall. The resident's roommate confirmed these sightings. Upon inspection, the Director of Housekeeping and Laundry found rodent droppings and chewed candy wrappers inside the heater unit in the resident's room. The heater had an open hole in its casing, allowing pests to enter and exit. The exterior of the heater was also observed to have metal slats with gaps, providing no barrier against pests. The Administrator acknowledged that both housekeeping and maintenance were responsible for pest management and emphasized the importance of keeping the facility free of pests to prevent disease spread.
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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