Ontario Center For Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Canandaigua, New York.
- Location
- 3062 County Complex Drive, Canandaigua, New York 14424
- CMS Provider Number
- 335564
- Inspections on file
- 21
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ontario Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain safe and comfortable room temperatures in accordance with its policy, resulting in multiple residents on two floors experiencing cold rooms with measured temperatures in the low 60s and heaters blowing cold air. Several residents reported feeling very cold, including one who woke during the night because their nose was freezing and another who was observed actively shivering in bed despite being covered with a blanket. Staff, including an LPN manager and other nursing staff, acknowledged that areas were extremely cold, described an office as an “ice box,” and reported that residents had complained of the cold and were given blankets while concerns were reported to maintenance and administration.
The facility failed to ensure accurate and complete MDS assessments for multiple residents when cognitive sections, including the BIMS and Section C, were coded as "not assessed" or left incomplete without evidence that interviews could not be performed. Record review showed several quarterly, annual, and admission assessments missing required cognitive data, even when documentation indicated the resident should have been interviewed. A regional social worker reported that interviews not completed within the look-back period were coded as not assessed, while the DON and Administrator stated they were unaware of the incomplete sections and that these issues were not identified through the QAPI process.
Surveyors found that the facility failed to follow its infection control policies in multiple areas. A resident with dysphagia, dementia, and multiple sclerosis, who required assistance with eating, was fed a meal tray that had been stored on a cart containing soiled trays. Another resident with malnutrition, Parkinson’s disease, open wounds, and unhealed pressure ulcers, who was on enhanced barrier precautions, was repositioned in bed by two CNAs wearing only gloves despite posted signage and care plan directives requiring gowns and gloves for high-contact care. In the laundry area, staff reported and were observed sorting soiled linens while wearing gloves and cloth, non-impervious aprons instead of the required impervious gowns, and the Infection Preventionist confirmed this practice did not comply with facility policy and posed contamination concerns.
The facility failed to maintain a functional nurse call system on one resident-use floor, where corridor indicators and audible tones for call stations in multiple rooms did not reset when calls were cleared at the bedside or in bathrooms, and the central nurse call panel had been removed from the nurse station for several months due to malfunction. Maintenance staff reported recurring shorts in the system causing corridor stations to remain lit and sounding until manually reset, while inspection logs from the prior year documented no issues despite these ongoing problems, and the Administrator acknowledged that the second-floor call system had been problematic for an extended period.
The facility failed to follow physician orders and document care for multiple residents. One resident with heart failure and dementia had weekly weights ordered, but several ordered weights were either not obtained or not documented in the electronic record. Another resident with hypertension, dementia, and prior stroke had daily BP and heart rate ordered; however, on multiple days the BP and pulse were signed off as completed without numerical values documented, preventing verification that the vitals were actually taken. A third resident with CHF, COPD, and oxygen dependence was observed on continuous oxygen at a specified liter flow without any corresponding provider order in place at the time, despite staff acknowledging that oxygen is considered a medication and requires a medical order specifying flow rate.
A LTC facility failed to provide adequate care, resulting in neglect of residents' needs. Several residents did not receive timely incontinence and wound care, with some waiting up to 21 hours for assistance. Staffing shortages were a significant issue, as reported by CNAs and LPNs, leading to residents being left in soiled conditions and untreated wounds. The administration was aware of these grievances but did not address the staffing problems, resulting in Immediate Jeopardy being declared by the New York State Department of Health.
During a survey, a facility was found to have insufficient staffing, resulting in residents experiencing extended periods of incontinence and going weeks without showers. Observations revealed that residents were not receiving timely care, with some waiting hours for assistance. Staff confirmed the ongoing staffing issues, citing high call-in rates and difficulties in retaining staff. Despite efforts to address the problem, the facility struggled to maintain adequate staffing levels.
Several residents in the facility did not receive timely incontinence care or assistance with toileting, leading to situations where they were left soiled for extended periods. A resident was found multiple times with urine-soaked clothing and linens, feeling dehumanized by the lack of care. Another resident experienced delays in receiving incontinence care and had not been showered for weeks, leading to embarrassment. Interviews with staff revealed that care was not consistently performed every two to four hours as required, impacting residents' dignity and quality of life.
The facility was found deficient in resident care and management, with issues including neglect in incontinence and wound care, insufficient nursing staff, and a malfunctioning nurse call system. Residents experienced extended periods without necessary care, leading to Immediate Jeopardy. Grievances were not properly investigated, and the facility's Quality Assurance and Performance Improvement committee failed to address these concerns effectively.
The facility failed to maintain a functioning nurse call system, with panels either missing or not operational, and no audible alerts. Observations showed that call buttons in resident rooms did not produce sounds, and overhead lights remained on after cancellation. Staff interviews revealed reliance on visual checks due to non-functional panels, and incomplete testing logs were noted.
The facility failed to ensure proper use of PPE and adherence to masking policies, leading to infection control deficiencies. Staff did not wear gowns during high-contact care for residents on Enhanced Barrier Precautions, and unvaccinated staff were observed without masks during the influenza season. These lapses were acknowledged by the staff involved and the facility administrator.
The facility failed to resolve grievances for two residents, one with bipolar disorder and another with diabetes and ulcers, by not conducting thorough investigations or follow-ups. Despite grievances about inadequate incontinence care and wound dressing changes, the facility did not document staff interviews or actions taken, leading to unresolved issues and dissatisfaction.
Three residents in the facility did not receive timely incontinence care and personal hygiene assistance. A resident with morbid obesity and diabetes did not receive showers for four weeks, while another with a stroke was found soaked in urine due to lack of care. A third resident with Parkinson's disease was left incontinent without assistance. Staff cited high resident assignments and assumptions about residents' abilities as reasons for the deficiencies.
Two residents experienced deficiencies in care, with one not receiving timely wound care due to staffing issues, and another facing a delay in a diagnostic x-ray. The facility failed to adhere to physician orders and ensure proper communication and documentation, impacting the residents' treatment and care.
A resident with a history of Parkinson's disease and malnutrition developed a pressure ulcer due to inadequate incontinence care and lack of timely intervention. The resident was left in a saturated brief for several hours, leading to a pressure ulcer on the buttock that went untreated and undocumented. The facility's policies on skin inspection and incontinence care were not followed, resulting in a deficiency identified during the survey.
The facility failed to provide appropriate catheter care and timely urinalysis collection for two residents, leading to potential risks of urinary tract infections. A resident with a history of UTIs had their catheter drainage bag improperly positioned and a urinalysis was not collected as ordered. Another resident's drainage bag was found at the level of the bladder and on the ground without a barrier. Staff interviews revealed inconsistencies in adhering to facility guidelines for catheter management.
The facility failed to properly store controlled medications, with the second-floor north medication cart containing unsecured controlled drugs and the third-floor medication room having undated and unlabeled pills. Controlled medications were not stored in a permanently affixed compartment, and the medication cart was left unattended, increasing the risk of diversion. The DON confirmed that medications should be stored in a secured cabinet, highlighting a deficiency in storage protocols.
The facility failed to document and educate residents on influenza and pneumococcal vaccinations. Three residents lacked evidence of being offered or educated about the vaccines, with one resident overdue for an update. Staff interviews revealed a lack of awareness and documentation, acknowledged by the Administrator.
A facility failed to provide quarterly personal fund statements to a resident with paranoid schizophrenia, high blood pressure, and diabetes, who was cognitively intact. The resident was unaware of their account balance, which was $9,800.12. The facility's policy required these statements to be provided, but there was no evidence that the resident or their representative received them. The Business Office Manager was unsure if the resident had a representative, but it was confirmed that the resident's brother was their Health Care Proxy.
The facility failed to notify the Ombudsman of resident transfers and discharges, as required by regulations. Three residents with various medical conditions were transferred to the hospital multiple times, but the Ombudsman did not receive the necessary notices. The Director of Social Work admitted that notices had not been sent since October 2024, and the Administrator was unaware of this issue.
A resident with multiple health conditions and impaired cognition was left unattended with medications in a common area, contrary to facility policy. The resident was not assessed for self-administration, and the responsible LPN did not confirm medication ingestion. The DON acknowledged the error, emphasizing the need for supervision during medication administration.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers, as required. Three residents were transferred without receiving the necessary notification. Interviews revealed that staff, including the Business Office Manager and Unit Manager, were unaware of the notification process, leading to non-compliance with regulations.
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary personal hygiene services. Two residents with significant medical conditions did not receive assistance with shaving, hair washing, and nail care, despite being scheduled for showers and requiring assistance. Observations revealed unshaven appearances, unwashed hair, and dirty fingernails, indicating a lack of adequate care.
A resident requiring a Hoyer lift for safe transfers was moved without the device due to a lack of available slings. Despite staff complaints and management's awareness of the issue, no adequate follow-up or assessment was conducted to resolve the shortage of slings.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within its own policy range of 71 to 81 degrees Fahrenheit on the second and third floors, resulting in multiple residents being exposed to cold ambient air. On a day when outside temperatures ranged from 20 to 29 degrees Fahrenheit with snow, surveyors measured room temperatures as low as 60.3 degrees Fahrenheit, with heaters blowing cold air. One resident reported their room was “freezing,” stated they were always cold, and indicated maintenance had said the heater needed bleeding but had not returned; temperatures in this room were measured between 65.8 and 69.1 degrees Fahrenheit. Another resident reported waking in the middle of the night because their nose was freezing, with room temperatures measured at 60.3 degrees Fahrenheit and 57.6 degrees Fahrenheit above the heater, which was also blowing cold air. Additional observations showed a resident in bed with a blanket up to their neck, actively shivering, in a room where the ambient temperature was 64.8 degrees Fahrenheit. Staff interviews corroborated that the environment was very cold: an LPN manager stated they were working at the nurse’s station because their office was “an ice box,” and another LPN reported that residents had complained of feeling cold at the start of their shift and that they had provided blankets and reported concerns to maintenance and administration. A resident in a common area on the second floor also stated it was really cold and that they had just been given a blanket. Leadership interviews confirmed awareness that the heating system had shut off and that pumps had been shut down and restarted, during which time residents on the affected floors experienced cold room temperatures below the facility’s stated comfort range.
Inaccurate and Incomplete MDS Cognitive Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status, particularly in the area of cognitive assessment. Surveyors’ review of MDS records showed that multiple residents had assessments in which the Brief Interview for Mental Status (BIMS) or Section C (cognitive patterns) was coded as “not assessed” or left incomplete without documentation that the interview could not be completed. One resident’s quarterly assessment, another resident’s annual assessment, and a third resident’s comprehensive admission assessment all documented the BIMS as not assessed. Another resident’s admission assessment showed Section C as not assessed, and a further admission assessment documented Section C as not assessed despite indicating the resident should have been interviewed. Two quarterly assessments for another resident also documented the BIMS as not assessed. During interviews, the Regional Social Worker stated that if interviews were not completed within the look-back period, the assessment would be coded as not assessed. The DON reported being unaware that sections of assessments were incomplete. In a joint interview with the Administrator, DON, and Regional Administrator, the Administrator stated they did not know why assessments were missing information and acknowledged that incomplete assessments had not been identified through the facility’s Quality Assurance and Performance Improvement (QAPI) process. The MDS Coordinator was unavailable for interview during the recertification survey. These findings were cited under 10 New York Codes, Rules and Regulations 415.11(a)(1).
Failure to Implement Infection Control Practices for Meal Service, PPE Use, and Soiled Linen Handling
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy and regulation. For one resident with dysphagia, dementia, progressive multiple sclerosis, severe cognitive impairment, and a need for staff assistance with eating, staff did not provide a clean meal tray. Surveyors observed that after lunch carts arrived on the unit and staff began placing used trays into one of the carts, a certified nursing assistant (CNA) retrieved this resident’s untouched meal tray from the same cart that already contained soiled trays. The CNA then provided this tray and fed the resident at bedside. The LPN manager, Infection Preventionist, and Director of Nursing each stated that the tray should not have been retrieved from a cart containing soiled trays and that this practice posed an infection control concern and a risk for contamination and potential spread of infection. The facility also did not follow its Enhanced Barrier Precautions policy for a second resident who had malnutrition, Parkinson’s disease, several open wounds, severe cognitive impairment, and several unhealed pressure ulcers. The resident’s care plan and CNA Kardex documented that the resident was on enhanced barrier precautions, with interventions including wearing a gown and gloves during high-contact care. Despite a sign posted outside the room indicating enhanced barrier precautions, surveyors observed two CNAs repositioning the resident in bed while wearing only gloves and no gowns. The Infection Preventionist stated that failure to wear appropriate PPE during high-contact care posed a risk for contamination and potential spread of infection to other residents. In addition, the facility did not ensure proper handling of soiled linens in accordance with its policies. The facility’s policies required staff to wear gloves and impervious (waterproof) gowns or yellow precaution gowns when sorting soiled linen. However, in the designated laundry area, a laundry assistant reported that staff wore gloves and cloth aprons while sorting soiled laundry and that the aprons were laundered every few days. The Infection Preventionist examined the aprons and confirmed they were cloth and not impervious, and stated that sorting soiled laundry without an impervious gown posed a risk for contamination and potential spread of infection due to lack of protection against soak-through contamination. Leadership later stated they were unaware that staff were sorting soiled laundry wearing cloth aprons and that this practice was not sanitary.
Failure to Maintain Functional Nurse Call System on Second Floor
Penalty
Summary
The deficiency involves the facility’s failure to properly maintain a functional nurse call system on the second floor, including resident bathrooms and bathing areas. The facility’s electrical equipment policy required patient care related electrical equipment to be tested before first use, after repairs or modifications, and at least annually, with documentation of all tests, repairs, and modifications maintained on site. During observation, the surveyor noted a nurse call system visible indicator with an audible tone on the ceiling at the intersection of the East and North corridors on the second floor. When nurse call stations in several resident rooms (205, 206, 209, 216, and 231) were activated and then reset at the bedside or in the bathrooms, the corridor visible indicator and audible tone remained on and would not reset as intended. Further observation showed that there was no central nurse call panel at the second-floor nurse station. Maintenance staff reported that the panel had been removed for a few months because it had stopped working and that the system was in the process of being bid out for replacement. Maintenance also acknowledged ongoing issues with shorts in the system, causing corridor stations to stay lit and the tone to continue sounding until the system was manually reset, after which it would work properly only for a time. Record review revealed that the most recent inspection logs for the second-floor nurse call system were dated several months earlier and did not document any problems or recommendations, despite the ongoing issues described by staff. The Administrator confirmed that the second-floor call system had been problematic shortly after the last survey and that the main panel had been removed from the second floor months prior to the current survey.
Failure to Follow Physician Orders and Document Weights, Vitals, and Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure services were provided in accordance with professional standards of quality for multiple residents in the areas of nutrition, medication monitoring, and respiratory care. For a resident with hypertension, heart failure, and dementia, the comprehensive care plan and a physician’s order required weekly weights and notification of a provider for a weight gain of five pounds or more. Review of the electronic medical record, including the Medication and Treatment Administration Records, progress notes, and Weights and Vitals Summary, showed that weights were not obtained for 2 of 10 ordered instances and that there was no documented evidence of recorded weights for 4 of 10 instances. The DON acknowledged that weights were expected weekly per orders and that the nurse should document them in the Weights and Vitals Summary, but could not verify whether the weights had been obtained or documented as ordered. Another deficiency occurred in the monitoring and documentation of vital signs for a resident with hypertension, dementia, and a history of stroke who was receiving antihypertensive medication. The care plan directed staff to monitor vital signs as ordered, and a physician’s order required daily blood pressure and heart rate checks with provider notification for specific abnormal values. Record review showed that for 5 of 10 instances there was no documented blood pressure, and for 4 of 10 instances there was no documented heart rate with numerical values, even though the treatments were signed off as completed in the electronic Treatment Administration Record. Staff interviews confirmed that nurses were responsible for checking vital signs and that results should be documented in the Weights and Vitals Summary or treatment record; however, the LPN manager and DON both stated they could not verify that the blood pressure and heart rate had actually been obtained because the numerical results were not documented. A further deficiency was identified in the administration of oxygen therapy for a resident with congestive heart failure, COPD, and supplemental oxygen dependence. The care plan and Kardex indicated that oxygen was to be administered per medical orders and that staff should use oxygen as ordered and notify the provider if oxygen was not in use. During observation, the resident was in bed with a nasal cannula connected to an oxygen concentrator running at three liters per minute, but review of current medical orders revealed no physician’s order for continuous oxygen at that time. An order for supplemental oxygen via nasal cannula at three liters per minute was only obtained the following day. Nursing staff and the nurse practitioner stated that a provider order was required for oxygen, that oxygen is considered a medication, and that a medical order specifying the liter flow is needed because of the risk of over-oxygenation.
Neglect and Inadequate Care in LTC Facility
Penalty
Summary
The facility failed to protect residents from neglect, resulting in multiple instances of inadequate care. Six residents were identified as not receiving timely incontinence care, with some waiting up to 21 hours for assistance. This neglect was compounded by the failure to provide necessary wound care, as evidenced by residents with untreated wounds for several days, leading to soiled dressings and compromised rehabilitation sessions. The lack of response to call lights and the inability to provide basic care needs were prevalent, with residents left in soiled conditions for extended periods. Resident #350, with a history of diabetes and chronic venous ulcers, did not receive daily dressing changes as ordered, resulting in heavily soiled dressings and interrupted rehabilitation sessions. Similarly, Resident #65, who required wound care for a right thigh injury, had dressing changes missed on multiple occasions, and was found in a saturated brief with a strong odor of urine. Resident #48, dependent on staff for toileting, was left in a soaked brief for hours, with family members reporting the neglect to staff. The facility's staffing issues were highlighted by staff interviews, where CNAs and LPNs reported being unable to complete all required care due to short staffing. This was corroborated by observations of residents left without necessary assistance, such as Resident #73, who was left in a wheelchair for 15 hours without incontinence care, and Resident #76, who waited 21 hours for assistance. The administration was aware of these grievances but failed to address the underlying staffing problems, leading to a declaration of Immediate Jeopardy by the New York State Department of Health.
Removal Plan
- A QAPI meeting was held with all members present to discuss Immediate Jeopardy issues.
- 100% of staff working the previous three shifts, including staff on-site at the time of Immediate Jeopardy removal, received education on Abuse, Neglect, Mistreatment; Call Bells; Activities of Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly implemented shift-to-shift report.
- Interviews completed with multiple staff, including direct care staff and licensed nursing staff on two of two resident care units, revealed appropriate knowledge of the Abuse, Neglect and Mistreatment; call light response and accessibility; incontinence care; wound prevention and wound care; shift-to-shift report; and grievance process.
- Observations of random call bells on two of two units revealed call bells in working order. Two resident call bells on Unit 3 were not in reach of the resident. Observations of the two rooms were made with Administration present. Both residents will be evaluated by therapy for ability to use call bell and call bell placement.
- Approximately 30/40 total active nursing staff, including licensed nurses and Certified Nursing Assistants, were educated on Abuse, Neglect, and Mistreatment; call light response; Activities of Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly implemented shift-to-shift report.
- Five per diem staff members and four staff members who are on vacation and/or sick leave have been notified and will be educated prior to their next scheduled shift.
- Four of four leadership staff, including Administrator, Director of Nursing, Assistant Director of Nursing and Director of Social Work, were educated on the grievance process.
- A weekly on-call rotation for clinical leadership was implemented.
- A full house skin sweep audit was completed, newly identified wounds had treatments ordered and were scheduled for wound rounds.
- Full house treatment completion audit conducted with no wound care treatments identified as missing or incomplete.
- Full house call bell audit completed with three call bells replaced.
- Full house incontinence rounding completed with incontinence care provided as needed.
- Audits to be continued each shift for wound treatment completion, call light accessibility and function, and incontinence care.
Insufficient Staffing Leads to Resident Neglect
Penalty
Summary
The facility was found to have insufficient staffing levels during an Extended Recertification Survey, which took place from January 21, 2025, to January 31, 2025. Observations and interviews revealed that the facility did not provide adequate nursing services to meet the needs of residents, resulting in psychosocial harm to several residents. Specifically, residents were observed to be incontinent of bladder or bowel for extended periods, and some reported going weeks without showers, leading to unkempt appearances and unclean hair. The facility's staffing plan did not specify a direct care staff-to-resident ratio, and the minimum staffing pattern was not consistently met, particularly during shifts with high call-ins. On the second-floor resident unit, which had a census of 46, there were only two Certified Nursing Assistants (CNAs) on duty due to nine call-ins. Residents reported long wait times for care, with one resident stating they had not received assistance since 5:00 AM, resulting in a saturated brief and a strong odor of urine. Another resident mentioned that they had to wait hours for care, including incontinence care and dressing changes. On the third-floor unit, with a census of 49, similar issues were observed, with residents reporting that they had not been changed or showered for extended periods. One resident was visibly incontinent of stool and had been waiting for hours to be changed. Interviews with staff, including CNAs and Licensed Practical Nurses (LPNs), confirmed the ongoing staffing issues. Staff reported that they were unable to provide adequate care due to the low number of staff on duty, leading to missed showers, infrequent rounds, and delayed wound care. The Director of Nursing and other administrative staff acknowledged the staffing challenges, citing high call-in rates and difficulties in retaining newly hired staff. Despite efforts to address the issue, such as using agency staff, the facility continued to struggle with maintaining sufficient staffing levels to meet the needs of its residents.
Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, several residents did not receive timely incontinence care or assistance with toileting, leading to situations where they were left soiled for extended periods. Resident #48, who was cognitively intact and dependent on staff for toileting, was found multiple times with urine-soaked clothing and linens, and reported feeling dehumanized by the lack of care. Similarly, Resident #28, also cognitively intact, experienced delays in receiving incontinence care and had not been showered for four weeks, leading to feelings of embarrassment and neglect. Resident #8, with moderately impaired cognition and a history of antibiotic-resistant infection, reported waiting for hours to be cleaned after incontinence and sometimes having to urinate on themselves due to a full urinal. The resident expressed frustration with the lack of timely assistance, which sometimes forced them to eat meals while soiled. Resident #350, who was cognitively intact and required assistance for toileting, also experienced issues with their urinal not being emptied in a timely manner, leading to spillage and further discomfort. Interviews with staff, including Certified Nursing Assistants and Nurse Managers, revealed that incontinence care and urinal emptying were not consistently performed every two to four hours as required. The Director of Nursing and Medical Director acknowledged that such neglect could have negative psychological effects on residents, making them feel anxious, frustrated, or upset. The report highlights a systemic issue in the facility's ability to provide timely and adequate care to its residents, impacting their dignity and quality of life.
Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility was found to be deficient in several areas during an Extended Recertification Survey and complaints investigation. The administration failed to ensure that residents were free from neglect, as evidenced by multiple instances where residents did not receive timely incontinence care, wound care, or assistance with toileting. Specific cases included residents being left in soiled conditions for extended periods, with one resident waiting approximately 21 hours for incontinence care and another left in a wheelchair for 14 hours without care. These failures resulted in the likelihood of serious injury, harm, or death for the residents, leading to an Immediate Jeopardy situation. The facility also failed to maintain resident rights, as some residents did not receive timely emptying of urinals, leading to unsanitary conditions. Additionally, residents reported going weeks without showers, and some were observed with unclean hair, indicating a lack of sufficient nursing staff to provide necessary care. Interviews with staff, including the Director of Nursing, confirmed that there were not enough staff to meet the residents' needs, and requests for additional staff had been made to the Administrator. Furthermore, the facility did not properly maintain the nurse call system, with issues such as non-functioning central panels and audible components. Grievances filed by residents regarding care issues were not thoroughly investigated or followed up on by the administration. Despite awareness of these concerns, the facility's Quality Assurance and Performance Improvement committee had not effectively addressed the issues, contributing to the overall deficiency in care and services provided to the residents.
Deficient Nurse Call System Maintenance
Penalty
Summary
The facility failed to maintain a properly functioning nurse call system across all three resident use floors, as observed during the Extended Recertification Survey. The central nurse call system panels were either not present or not functioning properly, and the audible component of the call system was not operational. There was also no documented testing of nurse call devices on the first floor. Observations revealed that the nurse call panel on the third floor was unplugged and not operational, and the second-floor panel had been removed five months prior due to being unfixable. The Director of Facilities admitted to being unaware of the reasons for these issues and the meanings of different colored lights on the overhead call lights. During testing, the nurse call buttons in several resident rooms failed to produce an audible tone, and the overhead corridor lights remained on even after the activation was canceled. In one instance, a resident was unable to reach their tray table and pressed their call light button, which did not light up or make a sound. A Certified Nursing Assistant (CNA) confirmed the malfunction after being alerted by the surveyor. Another CNA mentioned that the call button would only make a noise if pressed repeatedly, indicating a lack of consistent functionality. Interviews with staff, including the Administrator and Corporate Administrator, revealed that the call bell system was installed in 2018 and was intended to have both visual and audible alerts. However, staff were expected to visually check for call lights in the hallways due to the absence of operational panels. The facility's records showed incomplete testing logs, with no documentation of testing in common bathrooms and shower areas on the first floor, and no mention of the annunciator panels being tested or needing repairs. The manufacturer's manual specified the intended use and installation requirements for the system, which were not being met, as evidenced by the lack of power and network connections for the tablets.
Infection Control Deficiencies in PPE Use and Masking Policy
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the improper use of Personal Protective Equipment (PPE) by nursing staff during high-contact care for residents on Enhanced Barrier Precautions. Resident #350, who had multiple venous and arterial ulcers, was observed receiving wound care from a Nurse Practitioner and a Registered Nurse, both of whom wore gloves but not gowns, despite the Enhanced Barrier Precautions sign indicating the need for both. The Registered Nurse admitted to not being aware of the precautions for Resident #350 and not recalling any education on Enhanced Barrier Precautions at the facility. Similarly, Resident #65, who had a skin impairment and was on Enhanced Barrier Precautions, received wound care from a Licensed Practical Nurse who wore gloves but not a gown. The nurse acknowledged the oversight and stated that they should have worn a gown. Resident #351, with an indwelling urinary catheter, was also on Enhanced Barrier Precautions, yet a Licensed Practical Nurse was observed handling the catheter drainage bag without wearing a gown. The nurse admitted to the error and recognized the need for a gown during such procedures. Additionally, the facility did not enforce its policy requiring unvaccinated staff to wear masks during the influenza season. Observations revealed that staff members without the influenza vaccine, identifiable by the absence of a purple sticker on their ID badges, were not wearing masks in resident care areas. This included a Licensed Practical Nurse and the Director of Maintenance, both of whom admitted to not receiving the flu vaccine and acknowledged the requirement to wear masks. The facility administrator was aware of the non-compliance with the masking policy as mandated by the state Department of Health.
Failure to Resolve Resident Grievances Promptly and Thoroughly
Penalty
Summary
The facility failed to ensure thorough and prompt resolution of grievances for two residents, leading to deficiencies in addressing their concerns. Resident #88, who had diagnoses including bipolar disorder, diabetes, and anxiety, filed multiple grievances regarding inadequate incontinence care during overnight shifts. Despite the facility's policy requiring investigations and follow-ups, there was no documented evidence of staff interviews or actions taken to address the resident's dissatisfaction. The resident continued to experience the same issues, indicating a lack of effective resolution. Resident #350, with diagnoses including diabetes and chronic venous ulcers, reported a grievance about not having their wound dressing changed. The facility's documentation lacked evidence of a thorough investigation, including ruling out abuse or neglect, and there was no indication that the resident was informed of any actions taken. The facility's failure to document a complete investigation and follow-up with the resident highlights a deficiency in handling grievances related to care concerns. Interviews with facility staff, including the Director of Social Work and the Director of Nursing, revealed inconsistencies in the grievance investigation process. The Director of Nursing acknowledged receiving grievances about inadequate assistance with activities of daily living and stated that staffing levels were reviewed. However, the investigations did not consistently include obtaining staff statements or ruling out abuse or neglect. The Regional Director of Clinical Services confirmed that the investigations were incomplete and lacked follow-up, further emphasizing the facility's failure to adhere to its grievance policy.
Failure to Provide Timely Incontinence Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically incontinence care and personal hygiene, for three residents. Resident #28, who has diagnoses including morbid obesity, diabetes, and heart failure, reported not receiving timely incontinence care and had not been given a shower or hair wash for four weeks. Observations confirmed the resident was heavily incontinent and had greasy hair, with staff citing an inability to complete all care tasks due to a high resident assignment. Resident #48, with a history of stroke, hemiplegia, and diabetes, was found to be soaked through with urine on multiple occasions, indicating a lack of timely incontinence care. Despite being dependent on staff for toileting, the resident was not checked or changed for extended periods, with staff attributing the oversight to the resident not calling for assistance and staffing shortages. Resident #65, diagnosed with a right leg fracture, Parkinson's disease, and malnutrition, was also not assisted with toileting, resulting in incontinence. The resident, who requires assistance for transfers and toileting, was found with a saturated brief and reported not receiving help to use the bathroom. Staff acknowledged the resident's need for assistance but failed to provide it, citing assumptions about the resident's ability to self-toilet.
Deficiencies in Wound Care and Diagnostic Follow-Up
Penalty
Summary
The facility failed to provide appropriate wound care for Resident #350, who had multiple diagnoses including diabetes, peripheral vascular disease, and chronic venous ulcers. The resident's physician orders required daily dressing changes for 12 different wounds on their lower extremities. However, observations revealed that the dressings were undated, heavily soiled, and not changed for several days. Interviews with the resident and nursing staff confirmed that the wound care was not completed as ordered due to staffing issues, and the Treatment Administration Records showed multiple instances where the wound care was not documented as completed. Resident #12, who had diagnoses including low back pain, osteopenia, and dementia, experienced a significant delay in receiving a lumbosacral spine x-ray that was ordered by a physician. Despite the order being placed, the x-ray was not performed until 15 days later. Interviews with the resident and staff indicated that the order was not properly communicated or followed up on, leading to the delay. The x-ray eventually revealed a compression fracture that was not identified in a previous study. The deficiencies in care for both residents were attributed to failures in communication, documentation, and adherence to physician orders. The facility's staff, including nurses and management, acknowledged the lapses in care and the impact of staffing shortages on the ability to provide timely and appropriate treatment. These deficiencies were identified during an Extended Recertification Survey and complaint investigation, highlighting the need for improved processes to ensure residents receive care according to professional standards of practice.
Failure to Provide Timely Incontinence Care and Pressure Ulcer Management
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure ulcer and prevent new ulcers from developing for Resident #65. The resident, who preferred to spend most of their time in bed, was not assisted with toileting and was left incontinent of urine for multiple hours. This neglect led to the development of a pressure ulcer on the resident's right buttock, which went untreated for several days. The facility's policy required staff to inspect the skin during personal care and address moisture causes, such as incontinence, to prevent pressure injuries. Resident #65 had a history of right leg fracture, Parkinson's disease, and malnutrition, and was assessed as being at moderate risk for pressure ulcers. Despite this, the resident was found sitting in bed with a saturated brief and a strong smell of urine, indicating a lack of timely incontinence care. The resident's care plan required assistance with toileting every two to four hours, but this was not adhered to, as evidenced by the resident's statement and the observations of the Certified Nursing Assistant (CNA) who had not provided care for six hours. The facility's failure to document and report the pressure ulcer was further highlighted when the Assistant Director of Nursing assessed the resident and found an open wound that was not documented in the medical record. The Director of Nursing confirmed that any new skin impairment should be reported immediately for assessment and treatment orders. The lack of timely incontinence care and failure to report and document the pressure ulcer contributed to the deficiency identified during the survey.
Inadequate Catheter Care and Delayed Urinalysis Collection
Penalty
Summary
The facility failed to provide appropriate treatment and care to prevent urinary tract infections for two residents, as observed during the Extended Recertification Survey. Resident #20, who had a history of urinary tract infections and was dependent on staff for toileting hygiene, was found with their indwelling urinary catheter drainage bag lying uncovered on a soiled chair and above the level of the bladder. Additionally, a physician-ordered urinalysis for Resident #20 was not obtained in a timely manner, as the sample was never collected, leading to a delay in potential treatment. Resident #351, who had severe cognitive impairment and a history of urinary tract infections, was observed with their urinary catheter drainage bag placed at the level of the bladder and on the ground without a barrier on multiple occasions. Staff interviews revealed a lack of adherence to facility policy regarding the positioning of urinary drainage bags, which should be kept below the level of the bladder and off the floor to prevent infection. The facility's failure to adhere to its own catheter management guidelines, including maintaining the drainage bag below the bladder and ensuring timely collection of urinalysis samples, contributed to the deficiencies observed. Staff interviews indicated a lack of consistent practice in managing catheter care, which could potentially lead to increased risk of urinary tract infections for the residents involved.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with State and Federal Laws, specifically regarding the storage of controlled medications. During the survey, it was observed that the second-floor north medication cart contained controlled medications, including psychotropic, antianxiety, antidepressant, and opioid medications, which were not stored in a permanently affixed compartment as required by regulations. The medication cart was not affixed to the wall and was left unattended in the hallways, increasing the risk of diversion. Licensed Practical Nurse #2 confirmed that controlled medications were stored in the medication cart and not in the double locked cabinet in the medication room, as per facility policy. Additionally, the third-floor medication room was found to contain a narcotic cabinet with a pill box of approximately 80 undated and unlabeled pills. The Licensed Practical Nurse Manager was unaware of the pill box's ownership and stated that any resident pill boxes should be labeled with resident identifiers. The Director of Nursing acknowledged that controlled medications should be stored behind two locks in the secured double door cabinet in the medication room, except during shifts when they are in use. The failure to adhere to these storage protocols was identified as a deficiency during the survey.
Failure to Document and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that residents were educated and offered influenza and pneumococcal vaccinations, as required by their policies. During the Extended Recertification Survey, it was found that three out of five residents reviewed did not have documented evidence of being provided educational material or being offered, receiving, or declining the vaccines. Specifically, Resident #12, who had dementia and impaired cognition, had no documentation that their Health Care Proxy was informed about the vaccines. Resident #53, who was cognitively intact, had not received an updated pneumococcal vaccine since 2015. Resident #351, with severe cognitive impairment, had no record of receiving the influenza vaccine or any documentation that their Health Care Proxy was educated about the vaccines. Interviews with facility staff revealed a lack of awareness and documentation regarding the vaccination status of the residents. The newly hired Infection Preventionist was unaware of Resident #53's need for an updated pneumococcal vaccine and could not provide documentation for any of the residents' vaccination education or status. The facility's Administrator acknowledged the gaps in vaccination documentation and stated that the Quality Assurance Committee was aware of these issues. The deficiency was cited under 10 NYCRR 415.19(a)(3).
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide quarterly personal fund statements to a resident, identified as Resident #10, or their representative, as required by their policy. Resident #10, who was diagnosed with paranoid schizophrenia, high blood pressure, and diabetes, was cognitively intact according to a recent assessment. During an interview, the resident expressed that they had not received any quarterly statements and were unaware of the balance in their personal funds account, which was found to be $9,800.12. The facility's records showed that all quarterly statements had been signed by the facility as the representative payee, but there was no evidence that these statements were provided to the resident or their representative. The Business Office Manager indicated that statements were not sent to residents deemed not cognitively intact, and was unsure if Resident #10 had a representative. However, the Corporate Administrator clarified that both cognitively intact residents and representatives of those with fluctuating cognition should receive these statements. It was later confirmed that Resident #10's brother was their Health Care Proxy. This oversight was a violation of the facility's policy and regulatory requirements, as the facility did not ensure the resident or their representative received the necessary financial information.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to ensure that copies of residents' transfer and discharge notices were sent to a representative of the Office of the State Long Term Care Ombudsman, as required by regulations. This deficiency was identified during an Extended Recertification Survey conducted from January 21, 2025, to January 31, 2025, involving three residents. Resident #20, with diagnoses including urinary retention, benign prostatic hyperplasia, and chronic kidney disease, was transferred to the hospital multiple times between November and December 2024. Resident #76, who had bilateral below-knee amputations, a history of deep vein thrombosis, and anxiety, was transferred on November 28, 2024. Resident #248, diagnosed with a cerebral vascular accident, diabetes, and chronic obstructive pulmonary disease, was transferred on December 12, 2024. Interviews conducted during the survey revealed that the Ombudsman had not received any transfer or discharge notices from the facility for the past year. The Director of Social Work acknowledged that it was the responsibility of the Social Worker to send these notices, but they had not been sent since October 2024. The facility's Administrator was unaware of this lapse in communication. The facility was unable to provide documentation that the Ombudsman had been notified of the residents' transfers and discharges, as required by 10 NYCRR 415.3(i)(1)(iii)(a-c).
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality in medication administration for a resident with multiple diagnoses, including multiple sclerosis, epilepsy, and hypertension. The resident, who had moderately impaired cognition and impaired vision, was not assessed for the ability to self-administer medications. Despite this, medications were left unattended with the resident in a common area. The facility's policy requires licensed nurses to ensure all medications are administered and documented, but this was not adhered to in this instance. On the day of the observation, the resident was found in the dining room with a medication cup containing six pills, which were spilled. The pills were picked up by a Certified Nurse Aide and given to a Unit Clerk, who then passed them to a Licensed Practical Nurse. The nurse responsible for the resident admitted to not confirming that the resident had swallowed the medications. The Director of Nursing confirmed that the nurse should have stayed with the resident until the medications were swallowed and that medications should not have been left unattended with the resident.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified during an Abbreviated Survey for three residents. Resident #2, who was cognitively intact and had diagnoses including bacteremia and major depressive disorder, was transferred to the hospital but did not receive written notification of the bed hold policy. Similarly, Resident #3, with a below-the-knee amputation and benign prostatic hyperplasia, was transferred to the hospital twice without receiving the required notification. Resident #1, who had moderate cognitive impairment and diagnoses including acute cystitis and pancreatitis, was also transferred to the hospital without documented evidence of receiving the bed hold policy notification. Interviews with facility staff revealed a lack of understanding and communication regarding the bed hold policy. The Business Office Manager, in their position for two years, was unaware of the notification process for hospital transfers and believed the policy was only addressed upon admission. The Administrator stated that clinicians were responsible for providing the bed hold form at the time of transfer, but the Unit Manager, who started in March 2023, had never been involved in this process and did not know who was responsible. This lack of clarity and communication contributed to the facility's failure to comply with the regulatory requirement to notify residents or their representatives of the bed hold policy during hospital transfers.
Failure to Provide Necessary Personal Hygiene Services
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 grooming and personal hygiene. Specifically, Resident #11, who had diagnoses including rheumatoid arthritis, diabetes, and depression, did not receive assistance with shaving and washing their hair. Despite being scheduled for a shower, observations revealed that Resident #11's hair appeared unwashed, and they had thick, dark facial hair. The resident expressed that they were unable to care for their hair and facial hair on their own, and it bothered them. The facility's records indicated that Resident #11 required assistance with personal hygiene, but this assistance was not adequately provided as evidenced by their unshaven appearance and unwashed hair during multiple observations. Similarly, Resident #12, who had diagnoses including hemiplegia and hemiparesis following a stroke, did not receive assistance with shaving and nail care. Observations showed that Resident #12 had long facial hair and dirty fingernails with dark, brown debris underneath. Despite being given a shower, the Certified Nursing Assistant did not notice the need for shaving and nail care. The Director of Nursing acknowledged that grooming and hygiene should be completed as needed and during showers, and the Administrator noted that concerns about activities of daily living had been raised at resident council meetings. These deficiencies indicate a failure to provide necessary personal hygiene services to residents who are unable to perform these activities themselves.
Failure to Provide Adequate Assistance Devices for Resident Transfers
Penalty
Summary
The facility failed to ensure that Resident #12 received the appropriate assistance devices to prevent accidents. Resident #12, who had diagnoses including hemiplegia following a stroke, osteoarthritis, and heart failure, required the use of a Hoyer lift for safe transfers. However, during an observation, two Certified Nursing Assistants (CNAs) transferred the resident without using the mechanical lift, citing the unavailability of a Hoyer lift sling. The CNAs admitted to transferring the resident earlier that morning without the mechanical lift for the same reason. The facility's policy mandates the use of a Hoyer lift for such transfers, but this was not followed due to the lack of available slings. Further investigation revealed that the issue of insufficient Hoyer lift slings was known to the facility's management. The Laundry Supervisor confirmed that audits had been conducted due to staff complaints about the lack of slings, and no slings were available in the laundry or clean linen rooms during the survey. CNAs reported that they often had to leave residents in bed or use alternative methods due to the shortage of slings. The Director of Nursing and the Administrator were aware of the issue but had not conducted a thorough assessment or follow-up to resolve the problem. The Administrator mentioned that additional slings had been ordered but had not yet arrived.
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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