Pine Forest Care Center For Rehab & Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Huntington, New York.
- Location
- 9 Hilaire Drive, Huntington, New York 11743
- CMS Provider Number
- 335040
- Inspections on file
- 16
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Pine Forest Care Center For Rehab & Healthcare during CMS and state inspections, most recent first.
A resident with dementia and mental illness, who exhibited increased wandering and emotional distress after a close companion's discharge, did not receive timely psychosocial assessment or appropriate follow-up after significant emotional changes and repeated medication refusals. The lack of assessment persisted even after the resident sustained serious injuries from exiting through a window and was readmitted with a diagnosis of suicide attempt.
A resident with dementia and a history of wandering was found outside after falling from a third-story window and was sent to the hospital. Although a nurse documented that the Medical Director was informed, the physician reported not being notified until the resident returned with multiple fractures. The nurse had sent a message via a messaging app but did not confirm receipt, and there was no documentation of the message. Facility staff confirmed that the physician should have been notified of the change in condition, but the required consultation did not occur.
Two residents with cognitive and medical impairments were involved in separate incidents where the facility failed to notify the Department of Health within the required timeframe after one incident of elopement and another involving a fall from a window with serious injuries. The facility also lacked documentation of capacity assessments, physician orders, and care plans for outings, and did not notify police when the residents did not return as scheduled.
A resident with dementia and behavioral issues repeatedly refused prescribed antipsychotic medication, but the psychiatric nurse practitioner did not implement an intervention plan or notify the primary care physician. The primary care physician was unaware of the extent of missed doses, and no changes were made to the medication regimen, resulting in a lack of appropriate medical supervision as required.
Surveyors found a treatment cart with a broken lock left unlocked and unattended in a hallway, with medications visible and accessible. An RN admitted to accepting and using the cart despite the broken lock, and the DON confirmed that carts should always be locked or under staff supervision.
A resident with a MRSA foot wound was placed on contact precautions requiring PPE use, but staff were observed providing care without proper PPE and failing to perform hand hygiene, despite clear signage and facility policy. Staff interviews confirmed the breach of infection control protocols, and the DON acknowledged the expectation for PPE use in such cases.
A resident with dementia and diabetes experienced significant unplanned weight loss over one month, with no documented nutritional interventions or changes to the care plan by the dietician despite facility policy requiring action. Staff were aware the resident was not eating full meals, but no calorie count or new interventions were initiated.
A resident with dementia and memory loss was found with a bottle of isopropyl alcohol and over 30 multivitamin tablets accessible at the bedside. The resident could not identify the items, and staff confirmed there was no care plan or order for self-administration. Both the LPN and DON stated these items should not have been accessible in the dementia unit.
The facility was cited for deficiencies in means of egress, including a non-compliant ramp slope on the second floor and a corridor on the first floor that was narrower than required. The ramp had a slope exceeding the permissible limit, and the corridor width was reduced to 40 inches, below the required 48 inches. Emergency exits were not arranged to prevent simultaneous blockage. Despite a CMS Time Limited Waiver, the facility showed no substantial progress in addressing these issues.
The facility's West building was found to be non-compliant with NFPA 101 construction standards during a Life Safety Code survey. The building, a two-story Type V (000) construction, did not meet the required Type V (111) standards. Despite a CMS Time Limited Waiver expiring soon, necessary permits were not obtained, and construction had not started. The facility's Plan of Correction included reconfiguring a corridor ramp and constructing an addition, but no milestones were completed at the time of the survey.
The facility did not conduct fire drills at unexpected times or under varying conditions, as required by NFPA 101 standards. Six out of twelve fire drills lacked documentation of the simulated conditions, and drills were conducted at similar times across shifts. This deficiency was acknowledged by the facility's Administrator and owner.
A resident reported being scratched by a CNA during care, but the facility failed to initiate a timely investigation. Despite the resident's complaints, no immediate action was taken, and the incident was only addressed two days later when reported by the resident's representative. The staff involved did not document the incident or initiate an investigation as required by facility policy.
A resident with a history of mental health disorders and substance abuse was hospitalized for an opioid overdose. Upon readmission, the LTC facility failed to create a comprehensive care plan to prevent further overdoses, despite having policies for Naloxone use. Interviews indicated that the responsibility for initiating such a care plan lay with the MDS Coordinator, with RN Supervisors as a backup.
A resident receiving Heparin injections did not have their injection sites rotated as required, leading to repeated injections in the same area and resulting in bruising. The facility's policy mandates site rotation to prevent tissue damage, but this was not followed, as confirmed by staff interviews and medical records.
A resident received Heparin injections without rotating the subcutaneous injection sites, contrary to professional standards and facility policy. This led to bruising on the resident's abdomen. The nursing staff and DON acknowledged the failure to rotate sites, which is necessary to prevent tissue damage.
The facility failed to store, prepare, and serve food according to professional standards, with issues such as improper labeling, dirty storage areas, and cold food items stored above 41°F. Staff did not routinely measure cold food temperatures, and a broken cooler was not replaced. The Administrator was unaware of these lapses, violating facility policies and state regulations.
The facility's kitchen was found to have sanitary deficiencies, including a heavily dusted compressor, a leaking compressor in the walk-in refrigerator, and food debris on the floor. Uncovered milk cartons were stored under the leaking compressor, and there were no cleaning logs to verify daily cleaning of walk-in boxes. The facility's policies require clean and contaminant-free food storage, but these were not adhered to, leading to the observed deficiencies.
The facility did not ensure electrical safety as required by NFPA 70, with surveyors observing live electrical cables hanging in resident areas and stored improperly in the basement. These deficiencies indicate a failure to maintain electrical installations in a neat and workmanlike manner, posing potential safety hazards.
The facility failed to maintain its sprinkler system as per NFPA 25 standards, with gauges not tested or replaced within the required five-year interval and missing documentation for an annual antifreeze test. An antifreeze test indicated an incorrect freeze point in the emergency stairwell system, but no corrective actions were documented.
The facility was cited for not maintaining a comfortable and sanitary environment, with issues such as peeling paint, non-functional exhaust fans, and unsecured handrails observed in two nurse units. The Director of Maintenance noted daily cleaning and walkthroughs, but these were not recorded. The facility acknowledged the findings and plans to address them, though no timeline was set.
Failure to Provide Timely Psychosocial Assessment and Services After Significant Emotional Change
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, mental illness, and homelessness, who was assessed as having wandering and exit-seeking behaviors, did not receive appropriate treatment and services following a significant emotional event. After the discharge of a close companion from the facility, the resident exhibited increased wandering, emotional distress, and refusal of medications. Despite these changes, there was no documented evidence that a psychosocial assessment was completed to address the resident's altered mental and psychosocial state. The resident's care plan identified risks related to cognitive impairment and adjustment issues, and interventions included monitoring medication effectiveness and providing support for psychosocial wellbeing. However, the resident frequently refused prescribed antipsychotic medication, and the high rate of missed doses was not communicated to medical practitioners. Additionally, after the resident returned from an unauthorized absence and following the discharge of their companion, staff did not assess the resident's mood or risk for depression or suicide, despite facility policies requiring such assessments after significant emotional changes. The situation escalated when the resident was found on the ground outside the facility after removing an air conditioner from a window, resulting in multiple fractures and hospitalization. Upon readmission with a new diagnosis of suicide attempt, there was still no documented assessment for depression or suicide risk until several days later. Interviews with staff and medical personnel confirmed that the resident's emotional state should have been assessed after both the companion's discharge and the resident's readmission, but these assessments were not completed in a timely manner.
Failure to Notify Physician After Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's physician was properly consulted following a significant change in the resident's physical status. The resident, who had diagnoses including dementia, strange and inexplicable behavior, and a history of homelessness, was at risk for wandering and had moderate cognitive impairment. The resident was found outside on the ground at the back of the building after falling from a third-story window and was subsequently sent to the hospital via 911. Facility policy required prompt notification and consultation with the resident's physician in the event of an accident resulting in injury or with the potential to require physician intervention. Although a nursing progress note indicated that the Medical Director was made aware of the incident, the Medical Director later stated they were not informed of the resident's transfer to the hospital until the resident was readmitted with multiple fractures. The nurse supervisor reported sending a message via a messaging application but did not follow up to confirm receipt, and there was no documented evidence of the message due to the application's message retention policy. Interviews with facility staff, including the Director of Nursing Services, confirmed that the physician should have been informed of the change in the resident's condition. The Medical Director stated that staff were instructed to call if a message was not acknowledged, but this protocol was not followed. As a result, the required physician consultation did not occur at the time of the significant change in the resident's status.
Failure to Timely Report Alleged Abuse, Neglect, and Serious Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the New York State Department of Health as required by federal and state regulations. Two residents, both with significant medical and cognitive conditions, were involved in separate incidents where the facility did not notify the appropriate authorities within the mandated timeframes. In the first incident, two residents went out on pass and did not return at the expected time. The facility did not report their absence to the Department of Health until several hours after they were located, exceeding the required two-hour reporting window. There was also no documented evidence that the police were notified when the residents did not return as scheduled. In the second incident, one of the same residents, who had dementia and a history of wandering, exited the building through a third-story window after removing an air conditioner and sustained multiple injuries requiring hospitalization. The facility did not report this serious incident to the Department of Health within the two-hour timeframe, as required for events involving serious bodily injury. The delay was attributed to the staff managing emergency services and conducting internal interviews, as well as lack of immediate computer access for reporting. Additionally, the facility lacked documentation showing that either resident was assessed for capacity to go out on pass, had a physician's order for the pass, or had a comprehensive care plan addressing outings. Interviews with the DON and Administrator confirmed awareness of the reporting requirements but acknowledged the incidents were not reported within the required timeframes. The facility's own policies required prompt notification to authorities, but these were not followed in the cited events.
Failure to Ensure Physician Oversight After Repeated Medication Refusals
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, behavioral issues, and homelessness repeatedly refused their prescribed antipsychotic medication, Quetiapine (Seroquel). Despite these refusals, there was no documented evidence that the psychiatric nurse practitioner, who prescribed the medication, implemented an intervention plan or notified the primary care physician about the ongoing refusals. The resident's medication administration records showed a significant number of missed doses over several months, with refusals increasing over time. The facility's policies required that a physician, physician assistant, nurse practitioner, or clinical nurse specialist provide orders for the resident's immediate care and needs, and that the physician take an active role in supervising resident care. However, the psychiatric progress notes only indicated that the resident should continue the current medication regimen, with no mention of the refusals or any plan to address them. The psychiatric nurse practitioner acknowledged being aware of the resident's inconsistent medication intake but did not know the exact number of refusals and did not take further action. Interviews revealed that the primary care physician was unaware of the extent of the missed doses and stated that the medication would not be effective with so many missed doses, potentially impacting the resident's judgment. The psychiatric nurse practitioner confirmed that no changes were made to the medication regimen, citing the resident's right to refuse medication. The lack of communication and intervention regarding the resident's repeated medication refusals led to the finding that the facility did not ensure the resident was under appropriate medical supervision as required by regulation.
Unlocked Treatment Cart with Broken Lock Found Unattended
Penalty
Summary
Surveyors identified that the facility failed to ensure all drugs and biologicals were stored in a locked compartment and accurately labeled, as required by facility policy and regulation. During an observation, a treatment cart on the first floor was found unlocked with the second drawer open and treatment medications visible, while no staff were present. The facility's policy states that all drugs and biologicals must be stored in locked compartments and only authorized personnel should have access to the keys. During a medication pass, medications must be under the direct observation of the administering staff or locked in the storage area or cart. A registered nurse acknowledged that the treatment cart's lock was broken and admitted to accepting the cart in that condition at the start of their shift, despite knowing it should not have been used without a functioning lock. The Director of Nursing Services confirmed that all treatment carts should be locked and, if the lock is not working, the cart should not be in use. The deficiency was identified for one of two facility treatment carts, specifically the one observed outside a resident's room.
Failure to Adhere to Contact Precautions for Resident with MRSA Infection
Penalty
Summary
A deficiency was identified when the facility failed to maintain an effective infection prevention and control program as required by federal regulations. Specifically, a resident with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) infection in a foot wound was placed on contact precautions, as documented in the care plan and supported by multiple physician orders. The orders specified the use of enhanced barrier precautions, including the use of personal protective equipment (PPE) such as gloves, gowns, and face masks during resident care activities. The facility's policies also required staff to adhere to these precautions and to report any breaches in infection control practices. Despite these requirements, observations revealed that staff did not consistently follow the prescribed infection control measures. During one observation, a registered nurse supervisor exited the resident's room wearing only a mask, which was then improperly disposed of by crumpling it and placing it in a pocket, without performing hand hygiene. Additionally, the same nurse was observed providing care to another resident without wearing any PPE. Interviews with the staff involved confirmed that they were not wearing gowns while providing wound care to the resident on contact precautions, and acknowledged that this was a breach of protocol that could lead to contamination. The Director of Nursing Services confirmed that signage was present on the resident's door indicating the required PPE for contact precautions, and stated that all staff should wear appropriate PPE before entering rooms of residents on contact precautions. However, there was no documented evidence of a physician's order to discontinue contact precautions for the resident, and the required infection control practices were not followed during the observed care activities. This failure to adhere to established infection prevention and control protocols resulted in a deficiency citation for the facility.
Failure to Address Significant Unplanned Weight Loss
Penalty
Summary
A deficiency was identified when a resident experienced a significant, unplanned weight loss, dropping from 190 pounds in July to 168 pounds in August, representing an 11.5% loss in one month. This exceeded the CMS guideline for significant weight loss, yet there was no documented evidence that the dietician implemented new nutritional interventions to address the decline prior to the survey. The facility's policy required specific actions when significant weight loss is detected, such as weekly and monthly weights, review of food intake, initiation of a 3-day caloric count, and identification of possible causes, but these steps were not documented as completed. The resident, who had diagnoses including dementia, anxiety disorder, and type 2 diabetes, required supervision or assistance with eating and other activities of daily living. Despite a care plan goal to prevent significant weight changes and ensure adequate meal and supplement intake, records showed the resident was not consuming full meals and often only ate part of a sandwich when offered as an alternative. Staff interviews confirmed that the resident was not eating the hot meals provided and that this was known among staff, but there was no evidence of escalation or intervention by the dietician or nursing team. Documentation from the dietician and changes to the plan of care were absent during the period of weight loss. The DON stated that a calorie count was not initiated because meal intake records indicated the resident was eating 50% of meals, though direct observation and staff interviews contradicted this. The medical director indicated that, in cases of significant weight loss, a calorie count and further investigation would typically be pursued, but there was no evidence these steps were taken for this resident.
Accessible Hazardous Substances and Medications in Dementia Unit
Penalty
Summary
Surveyors observed that on the second floor, a locked dementia care unit, a resident's bedside table contained a bottle of over 30 multivitamin tablets and a 16-ounce bottle of 91% isopropyl alcohol, both accessible to the resident. The resident, who has a diagnosis of dementia, anxiety disorder, and type 2 diabetes, was unable to identify the pills or the alcohol, mistaking the alcohol for water. The resident's care plan documented short and long-term memory loss and included interventions to ensure safety, but there was no care plan or physician order permitting self-administration of medication. Staff interviews confirmed that the LPN was unaware of how the items came to be at the bedside and stated that the resident should not have access to either the alcohol or the vitamins. The DON also confirmed that no medication or alcohol should be accessible to residents on the dementia unit. The presence of these items in the resident's room, without staff knowledge or appropriate care planning, constituted a failure to maintain an environment free of accident hazards.
Deficiencies in Means of Egress and Ramp Compliance
Penalty
Summary
The facility was found to have deficiencies related to the means of egress as per the NFPA 101 Life Safety Code, 2012 Edition. Specifically, a ramp located on the second floor between the Old Building and the New Wing did not comply with the dimensional criteria set forth in the code. The ramp had a slope of 15 inches in height over a length of 10.3 feet, which exceeds the permissible slope of 1 inch in 8 feet. At the time of the survey, no work had been observed to address this issue, despite a time-limited waiver being granted to correct it. Additionally, a corridor on the first floor, adjacent to the Administrator's office, was found to be reduced to 40 inches in clear width, which is below the required minimum of 48 inches for corridors serving as means of egress from patient sleeping rooms. This corridor served as exit access for five occupied resident sleeping rooms and one nurse office. The arrangement of emergency exits at the end of this corridor did not comply with the Life Safety Code requirements, as they were located opposite each other with a distance of approximately 28 feet between them, potentially allowing both exits to be blocked by a single fire or emergency condition. The facility had been granted a CMS Time Limited Waiver to address these issues, set to expire on July 1, 2025. However, at the time of the survey, the facility had not demonstrated substantial progress in addressing the deficiencies. The owner stated that plans were being drawn by an architect, but permits had not yet been obtained, and no construction work had commenced. The facility's Plan of Correction included contracting with an architectural firm to reconfigure the ramp and modify the corridor width, but there was no evidence of progress on these plans.
Plan Of Correction
Plan of Correction: Approved April 22, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. Pine(NAME) Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025. 3a. The facility will require a time limited waiver for three years, ending 2/7/2028, to complete construction to widen the corridor to 48 inches minimum. The facility is currently investigating means to widen the existing first floor corridor as it is located between a masonry chimney and apparent bearing wall. The existing LRA shall be updated accordingly to include this work. It’s anticipated that the LRA will be updated by 8/7/2025. Following LRA modification approval, construction drawings will be prepared by 2/7/2026. Local approvals are expected to be obtained by 8/7/2026. Construction is anticipated to be complete by 10/7/2027. Signoffs are anticipated to be complete by 2/7/2028. 3b. While the facility has a time limited waiver in place, upon further review of the existing conditions during production of construction drawings, the Architect determined that the existing ramp slope is compliant. An existing ramp is permitted to have a maximum slope of 1:8, or 12.5%. The existing ramp was recorded to measure 15 inches in height and 10.3 feet in length. The existing ramp slope is calculated to be 12.14%, which is less than 12.5% maximum permitted. 3c. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. fire watches 2. additional fire drills 3. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. provide additional extinguishers 7. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required. 8. During construction, facility will perform frequent observations of the work areas to monitor resident safety. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11. The Administrator is responsible for the correction of this deficiency by 4/1/2025.
Non-compliance with NFPA 101 Construction Standards
Penalty
Summary
The facility was found to be non-compliant with NFPA 101: 19.1.6.1 during a Life Safety Code recertification survey. The West building, referred to as the Old Building, was identified as a two-story, fully sprinklered Type V (000) construction, which does not meet the required Type V (111) construction standards. The facility had been granted a CMS Time Limited Waiver (TLW) to address this issue, which is set to expire on July 1, 2025. However, as of the survey date, the facility had not yet obtained the necessary permits from the local jurisdiction, and construction had not commenced. The architect was still in the process of drawing plans, and additional smoke detectors had been installed, but these actions were insufficient to bring the building into compliance. The facility's Plan of Correction for tag K161, cited during a previous Life Safety Code survey, included reconfiguring the existing second-floor corridor ramp to achieve a compliant slope and constructing an addition to accommodate the level change. Despite having a timeline for obtaining town approval, preparing final construction drawings, and completing construction, there was no evidence that any of these milestones had been achieved at the time of the survey. The facility had contracted with an architectural/engineering firm to conduct a Fire Safety Evaluation System (FSES) after the installation, but the construction phase had not yet begun, leaving the facility out of compliance with the required safety standards.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. Pine(NAME) Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025. 3a. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. Fire watches 2. Additional fire drills 3. Testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. Identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. Conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. Provide additional extinguishers 7. Properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required. 8. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11. The Administrator is responsible for the correction of this deficiency by 4/1/2025.
Deficiency in Conducting Fire Drills at Unexpected Times
Penalty
Summary
The facility failed to ensure that fire drills were conducted at unexpected times and under varying conditions, as required by the 2012 NFPA 101: Life Safety Code. Specifically, the document review revealed that in six out of twelve fire drills, the condition that caused the simulated fire drill and fire alarm activation was not documented. Additionally, the fire drills were conducted at similar times across different shifts, with three out of four morning shift drills occurring around 10:00 AM and all four night shift drills occurring between 11:00 PM and 6:15 AM. Furthermore, the fire drill logs from the past year did not include the scenarios simulated during the drills, making it impossible to determine if the drills were conducted under varying conditions. This lack of documentation and variation in drill timing was acknowledged by the facility's Administrator and owner during the exit interview. The failure to conduct fire drills at unexpected times and under varying conditions, as well as the lack of detailed documentation, constitutes a deficiency in compliance with the NFPA 101 standards.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Pine (NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The EVS Director will conduct fire drills along with scenarios for each fire drill on all three shifts and alternate the times within the shifts, as well as the dates within the month. 4. The Administrator will review with the EVS Director the proposed times and dates of the fire drill to ensure the randomization of the dates and times that the fire drills are being conducted. 5. The Administrator will review the fire drill log book on a quarterly basis to ensure fire drills have been scheduled/conducted on random times/dates. 6. The Administrator will report the findings of his quarterly fire drill audit at the quarterly QA/QAPI meeting. 7. The Administrator and EVS Director will be responsible for the correction of this deficiency.
Failure to Timely Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure a timely and thorough investigation of an alleged abuse incident involving a resident. On December 28, 2024, a resident reported being scratched by a Certified Nursing Assistant (CNA) during morning care. However, there was no documented evidence that an investigation was initiated until December 30, 2024, when the resident's representative reported the incident to the Director of Nursing Services. The facility's policy requires that all accidents or incidents involving residents be reported immediately and an Accident/Incident Report be completed on the shift in which the incident occurred, but this protocol was not followed. The resident involved had a history of Bipolar Disorder and Urinary Tract Infection and was assessed to have moderately impaired cognition. The resident required assistance with daily activities and had no functional limitations in the range of motion. On the day of the incident, the resident alleged that a CNA squeezed their fingers and scratched their buttocks during care. Despite the resident's complaints, the initial examination by a nurse found no visible injuries, and the resident's skin was noted to be intact. The resident continued to insist on being scratched, but no immediate investigation or documentation was made by the staff present at the time. Interviews with the staff involved revealed inconsistencies in the handling of the incident. The CNAs involved denied the allegations, and the Registered Nurse who assessed the resident failed to document their findings or initiate an investigation. The Director of Nursing Services was only made aware of the situation two days later, highlighting a significant delay in addressing the resident's allegations. This delay in response and lack of documentation contributed to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F610. SW met with resident #55 on 2/28/2025 and offered psychological and psychiatric services. Resident declined the services, and resident denied any emotional distress. RN #2 was re-educated on 3/01/2025 on the policy and procedure on initiating abuse/mistreatment/neglect investigation and reporting guidelines and on proper documentation. Certified Nurses Assistant #4 and #5 was re-educated on 2/26/2025 on the policy and procedure of abuse/mistreatment/neglect and exploitation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the alleged deficient practice. Facility did an audit/review on 2/25/2025 on investigations of allegations, and no potential reportable allegations of abuse were found. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Abuse Reporting and Investigating was reviewed by DNS, Admin, and Social Worker and no updates were made. All RN Supervisors were re-educated on 3/01/2025 on the Policy and Procedure for Abuse Reporting and Investigation Policy by the DON/designee. New hires will be trained during the onboarding process. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure allegations of abuse, neglect or mistreatment are investigated immediately as required. Any adverse findings will be immediately corrected accordingly. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.
Failure to Develop Care Plan for Opioid Overdose
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident who experienced an opioid overdose. Resident #55, who had diagnoses including Delusional Disorder, Bi-Polar Disorder, and Alcohol Abuse, was transferred to the hospital due to unresponsiveness and was readmitted with a diagnosis of opioid overdose. Despite the facility's policy requiring Naloxone availability and standing orders for its administration, there was no documented evidence of a care plan with appropriate interventions to prevent further opioid overdoses. Interviews revealed that the Minimum Data Set Coordinator and the Director of Nursing Services acknowledged the absence of a care plan addressing the opioid overdose. The Minimum Data Set Coordinator stated that they or the admission nurse could have initiated such a care plan, and the Director of Nursing Services confirmed that the responsibility lay with the Minimum Data Set Coordinator, with Registered Nurse Supervisors as a backup. The lack of a care plan specifically addressing the opioid overdose was identified as a deficiency during the survey.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction to address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F656. Resident #55 care plan was updated on 2/10/2025 by MDS Coordinator to include [DIAGNOSES REDACTED]. All residents on opioids and/or have a history of opioid overdose have the potential to be affected by this alleged deficient practice. A full house audit was conducted on all residents by MDS Coordinator/DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that addresses their risk for opioid overdose and have appropriate goals and interventions to prevent potential opioid overdose. Any negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Comprehensive Care Plan was reviewed by MDS Coordinator/ DON/ Social Worker, Coordinator/DON/social worker. The DON/MDS Coordinator educated the nursing staff and IDT on 2/25/2025 about “Comprehensive Care Plans” with emphasis on developing a person-centered care plan for those residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression, with appropriate goals and interventions to prevent further potential opioid overdose. Care plans were immediately updated to reflect an accurate, person-centered plan of care for the residents based upon the residents assessed condition and needs, if required. Staff were reminded of the potential consequences to both the residents and staff if the policy is not followed. Any staff found responsible for the deficient practice will be referred to the DON for counseling. An audit was conducted on all residents by MDS Coordinator /DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that accurately reflects their physical and mental health needs and assures their needs are addressed and met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator /DON/Designee will audit 5 resident care plans x 4 weeks, then 5 resident care plans monthly x 3 months to ensure that residents with moderate to high risk index for opioid overdose or serious opioid-induced respiratory depression have a person-centered care plan addressing potential for opioid overdose with appropriate goals and interventions to prevent further potential opioid overdose. Any adverse findings will be immediately corrected. Audit findings will be presented to the QA Committee monthly meetings x 6 months. The results of these audits will be reviewed in the monthly QA Committee monthly meetings for 6 months or until 100% compliance is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5. The date for correction and the title of the person responsible for correction of each deficiency: DON is responsible for the compliance by 03/10/2025.
Failure to Rotate Injection Sites for Heparin Administration
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the improper administration of Heparin injections to a resident. The resident, who had a diagnosis of Functional Quadriplegia and an intact cognitive status, was receiving Heparin subcutaneously twice daily as a prophylactic measure. However, the nursing staff did not rotate the injection sites as required by the facility's policy, leading to repeated injections in the same area of the lower left abdomen. This was confirmed through a review of the Medication Administration Record, which showed multiple instances of consecutive injections in the same site over several days. During an observation, the resident was found to have a quarter-size ecchymosis on the lower left abdomen, indicating potential tissue damage from the repeated injections. Interviews with the nursing staff and the Director of Nursing Services confirmed that the injection sites were not rotated as per the policy, and the nurse responsible could not provide a reason for this oversight. The physician also acknowledged that failure to rotate injection sites could result in bleeding, pain, and tissue damage, further highlighting the deficiency in adhering to professional standards of care.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F658. Resident #20 was reassessed by RN supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated ON 2/26/2025 to include rotating sites with each administration. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON and no updates were made. All Nurses were re-educated on 3/01/2025 by DON/Designee on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months on all residents on [MEDICATION NAME] to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.
Failure to Rotate Injection Sites for Heparin Administration
Penalty
Summary
The facility failed to ensure pharmaceutical services met the needs of each resident by not adhering to professional standards of practice for administering medications. Specifically, Resident #21 was prescribed Heparin Sodium Injection Solution and the nursing staff did not rotate the subcutaneous injection sites as required. The facility's policy and procedure for injection site rotation, as well as professional guidelines, emphasize the importance of rotating injection sites to prevent complications such as bruising. Resident #20, who was admitted with functional quadriplegia and had an intact cognitive status, received Heparin injections to the same site on the lower left abdomen over multiple days. This was documented in the Medication Administration Record for January and February 2025. During an observation, a quarter-size bruise was noted on the resident's abdomen, and the resident confirmed they did not monitor the injection sites. Interviews with the nursing staff and the Director of Nursing Services revealed that the injection site was not rotated as required, which could lead to tissue damage and discomfort.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F755. Resident #20 was reassessed by the RN Supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated on 2/26/2025 to include rotating sites with each administration. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON/Designee and no updates were made. All Nurses were re-educated on 3/01/2025 by the DON on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The consultant pharmacist will monitor externally for appropriate site rotation based on administration records and will report negative findings to DON. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.
Deficiency in Food Storage and Temperature Control
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a kitchen inspection, it was observed that several food items in the walk-in refrigerator and freezer were not properly labeled and dated. Additionally, multiple frozen food packages had ice and frost buildup inside, indicating improper sealing. The dry storage area contained a plastic container and milk crates that were dirty, and a plastic tub of beef soup base was observed with black dust on the lid. The Food Service Director acknowledged that the cooks were responsible for labeling and dating food and ensuring packages were sealed to prevent freezer burn. Cold food items, including yogurt, milk, chicken salad sandwiches, and egg salad, were found to be stored at temperatures above the required 41 degrees Fahrenheit. The facility's policy required daily recording of food temperatures to ensure compliance with food safety standards, but the Cook's Temperature Log Sheet did not show evidence of monitoring cold food temperatures. Interviews revealed that staff did not routinely measure the temperature of cold food items such as sandwiches, milk, and yogurt, and the cooler used to keep cold items was broken and not replaced. The Administrator was unaware that the kitchen was not following the food storage and temperature procedures. The Food Service Director admitted that they did not routinely measure the temperature of cold food items served to residents. The failure to maintain proper food storage and temperature standards was a violation of the facility's policies and procedures, as well as state regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 Pine (NAME) Center For Rehabilitation and Healthcare provides the Following Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F812. The Food Service Director ensured that all improperly labeled and dated food items were discarded immediately. The Food Service Director gave in-services to the cooks on 2/4/2025 on properly labeling and dating food items. The Food Service Director cleaned the edge of the lid immediately upon recognition. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this alleged deficient practice. The Food Service Director did a kitchen-wide tour on 2/03/2025 to ensure that the facility is in compliance with food storage procedures. All negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Administrator and Food Service Director reviewed the policy on Food Storage. No changes were made. They also reviewed the policy on Cleaning and Sanitation of Dining and Food Service Areas and the policy on Food Temperatures, and no changes were made. Kitchen staff were in-serviced on 2/04/2024 on the policies with specific focus on proper labeling of food packages, disposing of freezer-burned food, and on the cleanliness of the food storage areas. They were also in-serviced on Cold Food temperatures, with specific focus on keeping all cold food items on ice during preparation to adhere to the regulations. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility has implemented tray line temperature audits to ensure the facility is in cold food temperature compliance. Audits will be done weekly for the first 4 weeks and then monthly for the following 5 months. The facility has implemented audits on proper labeling/dating as well as cleanliness to ensure staff are adhering to state and federal regulations and will be done weekly for the first 4 weeks and then monthly for the following 5 months following. Audits will be discussed at the QA meeting to monitor for compliance. 5. The date for correction and the title of the person responsible for correction of each deficiency. The Administrator will be responsible for implementation and compliance by 03/10/2025.
Sanitary Deficiencies in Kitchen and Food Storage
Penalty
Summary
The facility was found to have deficiencies in maintaining sanitary conditions in its kitchen, which serves food to residents. During a survey, it was observed that the compressor above the chest freezers was heavily dusted, and the mesh cover of the compressor in the walk-in refrigerator was dusty and in disrepair. Additionally, the compressor was leaking directly onto the floor of the walk-in refrigerator, where uncovered crates of milk cartons were stored directly underneath, and a puddle of standing water was present nearby. Further observations revealed that food debris was present on the floor under the racks storing food for resident consumption in the walk-in refrigerator. The Director of Food Services mentioned that the walk-in boxes are cleaned daily in the afternoon, but there were no cleaning logs to verify this, and the cleaning was part of the kitchen staff's job description. The Director of Maintenance acknowledged responsibility for the maintenance of the compressor fans and indicated plans to repair and clean them. The facility's policies and procedures, effective from October 2024, state that food should be stored in clean, dry areas free from contaminants and that refrigerated units should be kept clean and in good working condition. Additionally, a comprehensive cleaning schedule should be maintained, with tasks being initialed upon completion. However, the lack of adherence to these policies contributed to the observed deficiencies in food storage and equipment maintenance.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Pine (NAME) Center For Rehabilitation and Healthcare provides the following Plan Of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The food service director immediately moved the milk crates to a different location in the fridge. 4. The compressor above the chest freezer has been cleaned and will be checked weekly to ensure no dust build-up. 5. The walk-in fridge has been swept and cleaned. 6. The food service director inserviced all staff on filling out the cleaning logs. 7. The EVS Director reached out to the vendor who will be replacing the fan mesh cover and fixing the leak. The vendor came on site, and the facility received and approved the quote. The vendor will be onsite 3/12/2025 to complete the work. 8. The food service director will conduct daily checks of the walk-in fridge until it is repaired and report all findings to the administrator/EVS Director. 9. The food service director will conduct daily checks of the walk-in fridge to ensure it has been swept and cleaned. 10. The EVS Director/designee will present any findings at the quarterly QA/QAPI meetings. 11. The EVS Director/designee will be responsible to correct this deficiency.
Electrical Safety Deficiencies in Facility
Penalty
Summary
The facility failed to ensure that live parts of electrical equipment were adequately guarded against accidental contact, as required by NFPA 70: National Electrical Code. During a Life Safety Code recertification survey, surveyors observed several deficiencies related to electrical installations. On the second floor, electrical cables were found hanging by the wall near a ramp in a resident-occupied area. In the basement's former rehabilitation room, live electrical cables were stored in a plastic bucket and left out in the open, and additional cables were seen hanging from the ceiling. These observations indicate a failure to maintain electrical installations in a neat and workmanlike manner, as well as a failure to guard live parts against accidental contact, posing potential safety hazards to residents and staff.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan Of Correction. 1. No Residents were affected by this deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The electrical cables by the ramp have been covered and the facility will have the vendor onsite to discuss removing the cables. 4. The cables in the former Rehabilitation room have all been removed or covered up. 5. The EVS Director/designee will conduct an audit around the facility to identify any additional wiring that needs to be covered up. 6. The EVS Director will audit the facility every week for the first 4 weeks and then monthly for 3 months and then quarterly for up to a year to ensure all live electrical cables are covered. 7. The EVS Director/designee will present any findings in the quarterly QA/QAPI meetings. 8. The EVS Director/designee will be responsible to correct this deficiency.
Deficiency in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, as evidenced by the lack of testing or replacement of sprinkler system gauges within the required five-year interval. During the Life Safety Code recertification survey, it was noted that the gauges had not been replaced or tested since December 23, 2019, which exceeded the five-year requirement. Additionally, the facility did not provide documentation of an antifreeze test for the sprinkler system, which is required annually to ensure the correct freeze point of the antifreeze solution. Further investigation revealed that the antifreeze test conducted on February 29, 2024, indicated an incorrect freeze point in the emergency stairwell system, with a recommendation to drain and replenish the system. However, there was no evidence provided to confirm that corrective actions were taken following this recommendation. The facility's failure to maintain proper records and perform necessary maintenance actions led to the deficiency noted in the survey.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Pine (NAME) Center for Rehabilitation and Healthcare provides the following Plan of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The facility has a signed quote for the gauge testing/replacement; the vendor will be onsite to perform the 5 year/gauge inspection/replacement. 4. The Administrator will coordinate with the EVS Director/vendor to conduct retesting of the emergency stairwell freeze point and drain and replenish if needed. 5. The vendor will be onsite 3/20/2025 to conduct all necessary testing/replacements. 6. The facility has created an alert in our maintenance portal to alert when the facility is due for testing. 7. The EVS Director/designee will coordinate with the vendor to schedule/conduct any further required testing. 8. The EVS Director/designee will call the vendor and have them come down to inspect the emergency stairwell system, and they will perform any necessary work and retest once the work is completed. 9. The EVS Director/designee will report any findings at the quarterly QA/QAPI meetings. 10. The EVS Director/designee are responsible to correct this deficiency.
Facility Deficiencies in Environmental Maintenance
Penalty
Summary
The facility was found to have deficiencies in maintaining a comfortable and sanitary environment for residents, as required by regulations. Observations revealed that in two of the four nurse units, there were issues such as peeling paint on corridor walls and around door frames, non-functional exhaust fans in a nurse station's toilet and a resident's room, and unsecured handrails by a ramp. Additionally, a resident's room on the first floor had peeling paint around the window frame and stained ceiling tiles. These deficiencies were noted during a survey conducted over two days, with the Director of Maintenance and the Administrator present during the observations. The Director of Maintenance stated that housekeeping staff clean residents' rooms, toilets, and floors daily, but these activities are not recorded. The Director also mentioned that daily walkthroughs are conducted to identify issues needing repair, such as peeling paint, and that environmental staff receive training every three months. Despite these measures, the facility acknowledged the findings and indicated plans to repaint and renovate the affected areas, although no definitive timeline was provided for these actions.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center For Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. The toilet in room [ROOM NUMBER] has been repaired by the maintenance team. 4. The maintenance team has started plastering/repainting/repairing the entire second floor. 5. The handrail by the ramp has been readjusted and tightened to ensure it is firmly secured. 6. Room [ROOM NUMBER] has been plastered and repainted, and stained ceiling tiles have been replaced. 7. An exhaust fan for the second floor bathroom was purchased and installed by the maintenance team. 8. The EVS Director inserviced all his staff on the facility's policy on high dusting. 9. Audits will be conducted every week for the first 4 weeks and monthly for the next 3 months to ensure high dusting is completed. 10. The EVS Director/designee will ensure any items put into the facility's maintenance system are immediately addressed. 11. The EVS Director will report any findings at the quarterly QA/QAPI Meetings. 12. The EVS Director will be responsible for the correction of this deficiency.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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