Putnam Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Brewster, New York.
- Location
- 46 Mt Ebo Road North, Brewster, New York 10509
- CMS Provider Number
- 335824
- Inspections on file
- 20
- Latest survey
- September 29, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Putnam Ridge during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and high fall risk were not provided with the required level of supervision and assistance, resulting in one resident sustaining multiple injuries from a fall after being assisted by only one staff member instead of two, and another resident experiencing an unwitnessed fall due to missed hourly safety checks and lack of supervision in the day room. Staff interviews confirmed lapses in following care plans and documentation.
The facility did not ensure comprehensive, measurable care plans were developed or implemented for multiple residents, resulting in failures such as a resident receiving one-person assistance instead of two, lack of documented care plans for restraints and positioning devices, and missing or unimplemented care plans for activities and safety checks. Staff were often unaware of required interventions due to absent or incomplete documentation.
Two residents with severe cognitive impairment and behavioral needs did not receive activities tailored to their preferences and abilities. One resident wandered without engagement or a documented activity care plan, while another missed an off-unit event due to lack of staff available to assist with transfer from a walker to a wheelchair. Staff interviews revealed missing care plans in the new EMR and insufficient coordination between activities and nursing staff.
A resident with dementia, schizophrenia, and depression was not consistently monitored or redirected as required by their care plan, resulting in frequent unsupervised wandering and inappropriate toileting behaviors. Staff failed to complete and document thirty-minute safety checks, and interviews revealed inconsistent staffing and supervision, leading to repeated incidents of the resident entering other rooms and public areas without proper oversight.
A resident with severe cognitive impairment and total dependence on staff had a representative request that a specific CNA not provide care. Despite this, the CNA continued to care for the resident, and staff interviews confirmed the request had been communicated to relevant personnel, but the assignment was not changed.
A resident with severe cognitive impairment was found with unexplained bruising to the right eye and arm. Although the injuries were assessed by an LPN and Nurse Practitioner and an investigation was initiated, the incident was not reported to the state agency within the required two-hour window. The report was delayed until late in the evening, contrary to facility policy and regulatory requirements.
The facility did not monitor or document resident room temperatures during an air conditioning outage on one unit, relying only on hallway temperature checks despite a report of discomfort from a resident's family member. The facility's policy required monitoring of all occupied areas, but only hallway temperatures were checked until air conditioning was restored.
The facility did not consistently meet its own minimum staffing guidelines, resulting in repeated occasions where there were not enough CNAs on duty to provide timely care. Staff reported delays in feeding, toileting, and showers, with some responsible for up to 20 residents each. These staffing shortages led to increased complaints from families and contributed to issues such as more frequent UTIs and skin breakdowns, as confirmed by staff and management interviews.
Two residents experienced significant medication errors when one received a double dose of Baclofen for several days due to duplicate orders, and another was given crushed Nifedipine ER against warnings and did not receive a prescribed dose of guaifenesin, with the LPN documenting administration regardless. Staff failed to clarify orders, follow medication administration protocols, and adhere to facility policy.
A resident with severe cognitive impairment and special dietary needs was fed by a Unit Assistant who had not completed the required State-approved feeding assistant training. Facility staff and leadership confirmed that Unit Assistants received only in-house training and were unaware of the need for State-approved certification, resulting in the resident being assisted by unqualified personnel.
Staff failed to follow infection prevention protocols, including not using PPE or performing hand hygiene when entering isolation rooms for residents with RSV, and handled food items inappropriately by placing thumbs inside milk cartons without gloves or hand hygiene. Additionally, a resident with RSV was allowed to walk unmasked in common areas and sit near others during meals without staff intervention.
Residents were served meals in hallways due to a dining room closure following a respiratory virus outbreak, resulting in long waits for eating assistance because of staff and tray table shortages. Staff, including an LPN and activities leader, referred to residents needing help with eating as "feeders" in front of others, demonstrating a lack of awareness about respectful language and failing to maintain resident dignity.
Two residents with significant care needs did not receive timely assistance with toileting and feeding due to inadequate staffing. One resident waited extended periods for toileting help, with documentation missing for key shifts, while another dependent resident was left over an hour without being fed after meal delivery, and meal intake records were incomplete. Staff interviews confirmed that low staffing levels contributed to these delays and lapses in care documentation.
A resident with a seizure disorder was admitted with a hospital order for Diazepam nasal spray for active seizures, but this medication was not transcribed into the electronic medical record during admission. When the resident experienced a prolonged seizure, the medication was unavailable, resulting in transfer to the hospital. Staff interviews indicated uncertainty about why the order was omitted.
The facility failed to ensure proper identification of residents on the Apple unit, a dementia unit, as 12 out of 39 residents were observed without identification bands. This deficiency was noted during medication administration, where an LPN had to rely on other staff or electronic records for resident identification. The DON acknowledged the issue, highlighting the need for regular checks due to residents frequently removing their bands.
The facility failed to maintain adequate staffing levels on Unit A, as outlined in their nursing coverage plan. Staffing schedules for several months showed that the number of CNAs was consistently below the required levels, leading to inadequate care for residents needing total care. Interviews with CNAs and the DON confirmed the staffing shortages, with CNAs often caring for more residents than feasible. Despite efforts to hire more staff, the facility's reluctance to use agency workers exacerbated the issue.
Three residents experienced medication administration deficiencies, including late administration and lack of physician notification. A resident with a seizure disorder received Depakote late, while another with Parkinson's disease had Carbidopa-Levodopa administered outside the regulated timeframe. A third resident refused insomnia medications without physician notification. LPNs cited documentation errors and system glitches.
The facility did not conduct a comprehensive facility-wide assessment to determine necessary resources for resident care. The assessment lacked a detailed staffing plan specifying staff requirements per unit or shift. The Administrator, new to the role, acknowledged the omission during a survey.
Two residents experienced multiple falls due to inadequate supervision and lack of updated interventions. Despite having care plans in place, the facility failed to implement new strategies following each incident, contributing to ongoing fall risks. The DON and Administrator acknowledged the issues but did not provide evidence of effective follow-up actions.
A resident with severe cognitive impairment and incontinence was diagnosed with urinary tract infections due to inadequate incontinence care. The facility's policy requires regular checks and changes, but documentation showed numerous lapses in care over several months. Staff interviews revealed a lack of awareness of these omissions, and the DON acknowledged potential documentation issues.
The facility failed to ensure that seven Training Nurse Aides (TNAs) working for more than 4 months were certified, violating CMS requirements. The Director of Human Resources and the DON acknowledged the issue, citing staffing problems and misinterpretation of waiver expiration dates.
The facility failed to ensure that CNAs received the required twelve hours of in-service education per year and annual performance evaluations. Four CNAs were found to be deficient in training hours and had not received timely evaluations, with the last evaluations dating back several years. The lack of training was attributed to the pandemic, and the DON acknowledged the backlog in evaluations.
The facility failed to ensure food was stored, prepared, distributed, and served according to professional standards. Surveyors found multiple unlabeled and undated food items in the walk-in and cook's refrigerators, and wet pans on a rack designated for dry pans. The AFSD and FSD confirmed that all food items should be labeled and dated, and any food older than three days should be discarded.
The facility failed to ensure proper storage and labeling of medications on the Cedar and Apple units. Observations revealed multiple undated and expired medications, as well as excessive debris and sticky residue in the medication carts. Staff confirmed that nurses were responsible for cleaning the carts and removing expired medications, but these tasks were not performed as required.
A resident with a history of stroke, Parkinson's, and dementia reported an unwitnessed fall and a broken arm, which the facility did not thoroughly investigate or report to the NYSDOH. The investigation was incomplete, lacking an assessment of environmental factors and interviews with other staff or residents, and the determination regarding abuse or neglect was not made.
The facility failed to ensure a resident with severe cognitive impairment received necessary ADL care, resulting in the resident being observed multiple times with urine-soaked pants and not being out of bed as required by their care plan. Staff interviews revealed a lack of adherence to the resident's toileting schedule and care plan.
The facility failed to administer medications correctly and coordinate appointments for three residents. One resident received an incorrect dose of Clonazepam, another was sent to an appointment without an aide and was not seen, and a third was given crushed medications without a physician's order.
A resident missed an orthopedic appointment due to the facility's failure to notify the family and provide a required nurse aide escort. The Unit Secretary did not complete the necessary documentation, and the DON was unaware of the missed appointment.
A resident with a history of vertebra fracture, diabetes, and congestive heart failure had a care plan for non-compliance with a TLSO back brace that lacked documented goals and interventions. Staff interviews revealed that the care plan was initiated by the MDS coordinator due to a busy unit, but the Unit Manager failed to add necessary interventions.
A resident's dignity was compromised as their urinary catheter bag was left unconcealed, visible to others from the hallway. Despite facility policy requiring privacy, staff failed to cover the bag, and the issue persisted despite previous instructions from the Director of Nursing.
The facility failed to ensure that call bells were accessible for seven residents, despite care plans specifying their accessibility. Observations and staff interviews confirmed that call bells were often placed on the wall out of residents' reach, compromising their ability to call for assistance.
A facility failed to provide adequate supervision for a high-risk resident with multiple diagnoses, including dementia and a cervical vertebra fracture. The resident was observed attempting to stand up from their wheelchair without staff assistance or redirection on multiple occasions, despite being in a supervised area. Staff interviews revealed communication barriers and role limitations contributed to the lack of intervention.
The facility failed to maintain a medication error rate below 5%, with errors including crushing an extended-release tablet for a resident with dementia and not flushing a feeding tube between medications for another resident. The errors were not in compliance with physician orders and professional standards.
Failure to Prevent Accidents Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for two residents, resulting in actual harm to one. One resident, with a history of cerebral infarction, pulmonary embolism, and severe cognitive impairment, required total assistance for activities of daily living and specifically needed two staff members for bed mobility and transfers. Despite this, a certified nurse aide provided care alone during incontinence care, which led to the resident falling from bed. The resident was later found with multiple injuries, including a contusion to the right face, right elbow, a forehead laceration, and was subsequently diagnosed at the hospital with an acute intertrochanteric right femur fracture. The investigation confirmed that the fall occurred when only one staff member assisted the resident, contrary to the care plan and documented requirements. Another resident, diagnosed with Alzheimer's disease, diabetes, and dementia, was identified as being at high risk for falls and had a care plan requiring one-hour safety checks and supervision. On the day of the incident, there was no documented evidence that hourly safety checks were performed during a specific shift, and the resident was found on the floor after an unwitnessed fall from their wheelchair. Observations also revealed that the resident was left unsupervised in the day room, sliding forward in their wheelchair with the chair alarm activated, while no staff were present to supervise due to other duties or absences. Interviews with staff confirmed lapses in following the care plans, including failure to perform and document required safety checks and lack of clarity regarding supervision responsibilities in the day room. Staff acknowledged awareness of the residents' high fall risk but did not consistently implement or document the required interventions. The Director of Nursing was unaware of the incomplete safety check log at the time of the incident, and staff involved in the incidents either failed to follow established protocols or did not ensure proper documentation and supervision.
Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for several residents, as required by policy. For one resident with a history of cerebral infarction and severe cognitive impairment, the care plan and aide Kardex specified the need for two-person assistance with bed mobility and transfers. However, a certified nurse aide provided care alone, resulting in the resident falling from bed and sustaining injuries, including bruising and a laceration. The incident was documented by the Director of Nursing, and it was confirmed that the required two-person assist was not provided. Another resident with dementia, a femur fracture, and repeated falls had a physician order for a velcro alarm seatbelt in the wheelchair, with instructions for scheduled release and monitoring of the resident's ability to self-release. There was no evidence in the care plan addressing the use or release schedule of the lap/seat belt, and staff were unaware of the order or procedures related to the restraint. Observations showed the resident wearing the seatbelt for extended periods and being unable to remove it on command, with staff confirming the lack of guidance in the care plan or Kardex. A third resident with Alzheimer's disease, contractures, and muscle weakness had physician orders for a knee abductor roll and rolled gauze hand protectors. The care plan did not address these devices, and observations revealed the resident without the prescribed supports. Staff interviews indicated that therapy recommendations were not incorporated into the care plan, and the nurse manager could not locate documentation for these interventions, attributing the omission to a transition between electronic medical records. Additionally, care plans for activities and safety checks were missing or not implemented for other residents reviewed.
Failure to Provide Activities Meeting Residents' Needs Due to Care Planning and Staffing Issues
Penalty
Summary
The facility failed to ensure that activities were available and designed to meet the interests and support the well-being of all residents, specifically for two residents with cognitive impairments and behavioral needs. One resident with diagnoses including dementia, schizophrenia, and depression was observed multiple times wandering the hallways and not participating in activities, despite documented preferences for music and religious activities. There was no documented activity care plan for this resident in the current electronic medical record, and staff relied on verbal communication to share preferences. Observations showed the resident was often not engaged by staff and did not participate in ongoing activities, even when redirected. Another resident with Alzheimer's disease, anxiety, and depression missed an off-unit activity because the activities staff were unable to transfer the resident from an enclosed frame walker to a wheelchair, and nursing staff were not available to assist with the transfer. This resident's care plan indicated a need for transport assistance to attend off-unit events, but the lack of coordination between activities and nursing staff resulted in the resident remaining on the unit and not participating in the scheduled activity. Interviews with staff confirmed that the transition to a new electronic medical record system led to missing care plans and that activities staff could not perform necessary transfers without nursing assistance.
Failure to Provide Adequate Supervision and Behavioral Health Support
Penalty
Summary
The facility failed to ensure sufficient staff with the necessary competencies and skills to meet the behavioral health needs of a resident with a history of dementia, schizophrenia, and depression. The resident exhibited behaviors such as wandering, entering other residents' rooms, and urinating or defecating in inappropriate places. The individualized care plan required ongoing monitoring, redirection, and thirty-minute safety checks, but these interventions were not consistently implemented. Documentation revealed that thirty-minute checks were missing for entire shifts on most days within a one-month period, and staff interviews confirmed that these checks were not always completed or signed for as required. Multiple observations showed the resident wandering unsupervised in hallways and other residents' rooms, including entering a room under contact precautions and defecating in a public area. Staff were not consistently present to redirect or supervise the resident, and on several occasions, the resident was only redirected after being observed by staff who were exiting other rooms. Family members and other residents' visitors reported witnessing the resident engaging in inappropriate toileting behaviors and wandering without supervision, sometimes having to call for staff assistance themselves. Interviews with staff and management indicated that while there were expectations for regular monitoring and redirection, staffing levels and the availability of unit assistants were inconsistent. Staff acknowledged that the required thirty-minute checks were not always performed, and that unit assistants, who provided additional supervision and engagement, were not present every day. The lack of consistent supervision and incomplete documentation of required checks contributed to the facility's failure to maintain the resident's highest practicable physical, mental, and psychosocial well-being as outlined in the care plan.
Resident Choice Not Honored in Assignment of Care Provider
Penalty
Summary
A deficiency occurred when a resident's right to choose their health care provider was not honored. The resident, who had diagnoses including dementia, anxiety, and major depressive disorder, was dependent on staff for all activities of daily living and had severely impaired cognition. The resident's representative had formally requested that a specific Certified Nurse Aide (CNA) not be assigned to provide care for the resident. Despite this request, the CNA continued to provide care to the resident, as observed by the resident's son. Interviews with facility staff confirmed that the request was communicated to the appropriate personnel, including the Director of Nursing, Staffing Coordinator, floor nurses, and the CNA in question. However, the CNA was still assigned to and provided care for the resident after the request was made. Staff members interviewed were unable to explain why the CNA continued to provide care despite the documented preference and communication, indicating a failure in the facility's process to ensure resident choice regarding care providers.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, specifically injuries of unknown origin, were reported to the state survey agency within the required two-hour timeframe. On the morning of 08/26/2025, a resident with severe cognitive impairment and total dependence for activities of daily living was observed with a bruise to the right eye and right arm. The initial observation was made by an LPN, who notified another LPN and the Nurse Practitioner. The Nurse Practitioner assessed the resident, noted additional swelling and bruising, and determined the injuries were consistent with a fall. The Assistant Director of Nursing was informed and began an investigation into the cause of the injuries. Despite the facility's policy requiring immediate reporting of suspected abuse or injuries of unknown origin, the incident was not reported to the state agency until 11:05 PM, well beyond the two-hour requirement. Interviews with the DON, Administrator, and Assistant DON confirmed awareness of the policy and the event, but the report was delayed until after a CNA provided a statement late in the evening. The deficiency was cited for failure to report the incident in a timely manner as required by regulation.
Failure to Monitor Resident Room Temperatures During Air Conditioning Outage
Penalty
Summary
The facility failed to ensure that comfortable and safe temperature levels were maintained in all resident rooms during a heat emergency when the air conditioning unit on one unit (Dogwood) was not functional. During the breakdown of the air-conditioning system, the facility did not check or document resident room temperatures, as the policy only required monitoring hallway temperatures. Although hallway temperatures were within regulatory limits, there was no evidence that resident rooms were checked for adequate or comfortable temperatures during the period the air-conditioning was out of service. The facility's policy required the Maintenance Department to monitor and document temperatures in all occupied areas, including resident rooms, and for the Administrator to review these logs during periods of high heat, but this was not done. A resident's spouse reported discomfort with the temperature on the affected unit, but a grievance report was not completed, and the issue was considered resolved after an air-conditioning unit was installed in the dining area. Nursing staff and the DON did not check resident room temperatures, and the Director of Maintenance confirmed that only hallway temperatures were monitored. The air-conditioning was restored to the affected unit the following day, but there was no documentation or evidence that resident rooms were checked for temperature compliance during the outage.
Failure to Maintain Minimum Nursing Staff Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple occasions where staffing levels fell below the facility's own minimum guidelines across several shifts and units. Record reviews of staffing schedules for February, March, and April 2025 revealed repeated instances where the number of Certified Nurse Aides (CNAs) on duty was less than required for both day, evening, and night shifts. The facility's staffing plan outlined specific minimums, but these were not consistently met, resulting in periods where only two CNAs were present on units that required three, and similar shortfalls on other shifts. Interviews with CNAs and nursing staff confirmed that these staffing shortages led to delays in resident care, such as longer wait times for toileting, feeding, and showers. Staff reported being unable to complete all scheduled showers and having to postpone care tasks to later shifts or days. CNAs described increased workloads, with some responsible for up to 20 residents each, and noted that residents and their families frequently complained about the delays in care. Staff also reported that the lack of adequate staffing contributed to issues such as increased urinary tract infections and skin breakdowns due to delayed incontinence care. The staffing coordinator and DON acknowledged the ongoing challenges in maintaining adequate staffing, despite efforts to use agency staff and incentive programs. Staff interviews indicated that the use of agency staff did not always resolve the issue, and regular staff were often asked to work extra shifts, leading to physical exhaustion. The administrator, newly in position, stated they were working to improve staffing numbers. The deficiency was cited under 10NYCRR 415.13(a)(1)(i-iii) for failing to ensure sufficient nursing staff to meet resident needs.
Significant Medication Errors Due to Duplicate Orders and Improper Administration
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration and order management. One resident with Alzheimer's disease, dementia, and depression, who was severely cognitively impaired and dependent on staff, received a double dose of Baclofen for three consecutive days. This occurred after duplicate physician orders for Baclofen 2.5 mg once daily were entered on consecutive days, resulting in the medication being administered twice daily instead of once. The error was not identified or questioned by the LPN administering the medication, who assumed the dosage had been increased and did not seek clarification, leading to the resident receiving 5 mg daily instead of the prescribed 2.5 mg. Another resident with Alzheimer's disease, ataxia, and hypertension, who also had severe cognitive impairment and required supervision for meals, was administered Nifedipine ER 30 mg in a crushed form, despite a clear warning on the medication packaging not to crush the extended-release tablet. The nurse did not have a physician order to crush the medication and was unaware of the warning. Additionally, the same nurse failed to administer a prescribed dose of guaifenesin cough syrup but documented in the Medication Administration Record that it had been given. Interviews with nursing staff and management confirmed that proper procedures were not followed in both cases. Duplicate orders were not clarified or discontinued, and medications were administered and documented incorrectly. The facility's policy required physician orders for crushing medications and proper administration techniques, which were not adhered to in these instances.
Unqualified Staff Fed Resident Without State-Approved Training
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, dementia, and abnormal weight loss, who was dependent on staff for all activities of daily living including eating, was fed by a Unit Assistant who had not completed a State-approved feeding assistant training course. The resident required a mechanically altered diet with aspiration precautions, and the care plan specified that staff should feed and assist the resident to complete meals. During observation, the Unit Assistant was seen feeding the resident puree food, and both the Unit Assistant and facility leadership confirmed that the assistant had only received in-house training and was unaware of the requirement for State-approved training. Interviews with the Director of Human Resources and the Director of Nursing revealed that Unit Assistants routinely feed residents after receiving facility-based training, but none had completed the required State-approved eight-hour course. Documentation supporting completion of State-approved training for feeding assistants was not available, and facility leadership was not aware of the regulatory requirement for such training. This resulted in the resident being fed by unqualified staff, contrary to regulatory requirements.
Failure to Maintain Infection Control and PPE Protocols
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Staff members, including an activities leader, dietary aide, certified nurse aide, and nurse practitioner, entered and exited a room under contact and droplet isolation precautions for a resident with respiratory syncytial virus (RSV) without donning or doffing personal protective equipment (PPE) or performing hand hygiene. These staff members also failed to change masks, wear required face shields or goggles, and did not close the door as required. Some staff stated they did not notice the precaution signs or were unaware of the PPE requirements, despite the presence of posted signage and facility policy outlining these protocols. Additional deficiencies were observed during meal service, where staff, including an activities leader and an LPN, were seen placing their thumbs inside milk cartons while assisting residents, without wearing gloves or performing hand hygiene. The staff involved acknowledged that this was not appropriate practice, though one LPN claimed to have performed hand hygiene prior to the observation. These actions occurred during direct resident care and food handling, increasing the risk of contamination. A resident who tested positive for RSV was observed walking unmasked in the hallway and sitting in close proximity to other residents during meal times, with no staff intervention to encourage mask use or redirect the resident. The unit manager confirmed the resident's positive status and stated that attempts to have the resident wear a mask were unsuccessful. The facility's infection preventionist confirmed that all staff should use PPE when entering rooms under contact and droplet precautions, including when interacting with non-infected roommates.
Failure to Maintain Resident Dignity and Timely Assistance During Meals
Penalty
Summary
The facility failed to maintain residents' dignity and provide timely assistance with eating during meal services on the Apple unit. Due to an outbreak of respiratory syncytial virus, the unit dining room was closed, and residents were served meals in the hallways. Observations revealed that residents waited extended periods for assistance with eating because of a shortage of tray tables and insufficient staff. For example, one resident who was dependent for eating waited approximately 25 minutes before being assisted, while another resident with severe cognitive impairment and requiring supervision or assistance was left with an uneaten tray for over an hour before receiving minimal help. Another resident requiring setup assistance had their tray delivered but not set up for nearly an hour. Staff interviews confirmed that the dining room closure led to meals being served in hallways for supervision purposes, not infection control. The unit was short-staffed, with only two CNAs present instead of the minimum three, resulting in residents waiting a long time for assistance. Staff, including activities and rehabilitation personnel, were required to help during meals due to the high number of residents needing eating assistance. The unit manager acknowledged that the administration and DON were aware of the staffing challenges and the heavy assistance needs on the unit. Additionally, staff members referred to residents requiring eating assistance as "feeders" in the presence of other residents and a family member. Both the activities leader and a CNA admitted they were unaware that using the term "feeder" was inappropriate. These actions and language choices failed to uphold the residents' right to dignity and respect as outlined in the facility's Resident Rights policy.
Failure to Provide Timely Assistance with ADLs and Nutrition Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good nutrition and personal hygiene. For one resident with diagnoses including non-Alzheimer's dementia, arthritis, and depression, documentation showed they required substantial to maximal assistance for toileting and transfers. On a specific date, there was no documented evidence that this resident was toileted during the day or evening shifts, with only night shift documentation present. Interviews with staff revealed that residents sometimes waited up to 45 minutes for toileting assistance, especially when staffing levels were low, and that the resident's family had complained about long wait times for care. Staff also indicated that the resident required a two-person assist for transfers and that delays occurred when a second staff member was not immediately available. Another resident, who was dependent on staff for all ADLs due to conditions such as seizures, diabetes, dysphagia, and a deep tissue injury, experienced a significant delay in receiving assistance with eating. Observations showed that the resident's lunch tray was delivered and left at the bedside, but the resident was not fed for over an hour. Documentation of meal intake was also incomplete for this resident, with many days left blank. Staff interviews confirmed that feeding could be delayed when there were only two aides on the unit, as showers and other care tasks took priority, and that documentation sometimes lapsed due to insufficient staffing.
Failure to Transcribe and Provide Immediate-Use Seizure Medication
Penalty
Summary
A resident with a history of seizure disorder, Lennox-Gastaut syndrome, and intellectual disabilities was admitted to the facility with a hospital discharge summary that included an order for Diazepam nasal spray as an immediate-use medication for active seizures. Upon admission, the medication reconciliation process conducted by a registered nurse and a nurse practitioner failed to transcribe the Diazepam nasal spray order into the resident's electronic medical record. As a result, the medication was not available in the facility. Subsequently, the resident experienced a prolonged seizure episode during which staff were unable to administer any oral medications due to the resident's condition. Emergency services were called, and the resident was transferred to the hospital for treatment. Interviews with the admitting nurse and nurse practitioner revealed uncertainty and lack of recall regarding the omission of the Diazepam nasal spray order during the admission process. The facility's policy required two nurses to review all medication entries, but this process did not ensure the inclusion of the necessary seizure medication.
Identification Band Deficiency on Dementia Unit
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by the absence of identification bands on 12 out of 39 residents observed on the Apple unit. The facility's Medication Administration policy requires nurses to verify a resident's identification by checking their identification band before administering medication. However, during an observation, it was noted that these residents did not have identification bands in place, which is a critical step in ensuring the correct administration of medications. Interviews with staff revealed that Licensed Practical Nurse #1 had to rely on other staff members or the electronic medical record system to identify residents during medication administration due to the lack of identification bands. Registered Nurse #1 acknowledged the issue and stated that they conduct audits to replace missing bands, but residents on the Apple unit, which is a dementia unit, frequently remove their bands. The Director of Nursing confirmed the ongoing issue and emphasized the need for regular checks to ensure identification bands are in place, particularly on the dementia unit where residents are prone to removing them.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 Plan for Affected Resident: All 12 Residents affected were given new wrist bands. Plan to identify other potentially affected residents: All residents’ wrist bands were checked on each unit. All residents had wristbands in place. Plan for system changes and measures to prevent occurrence: The facility medication administration policy was reviewed. The policy was updated. All nursing staff were educated with emphasis on verification of residents by checking the residents’ name and medical record number on their wrist bands. If a resident does not have a wristband, they can verify via EMAR picture and continue their medication administration. The LPN is to create a wristband for any resident without a wristband by the end of the shift. All LPNs including nurse 1, were re-educated on the facility medication administration policy with emphasis on resident identification bands. Plan for monitoring correction action: Weekly audits will occur for one month on 15 residents per unit by the ADON/Unit Managers/Designee to ensure that all residents are wearing an identification band. After one month the wristbands will be audited biweekly for an additional two months. After two additional months wristband audits will be conducted monthly. All results will be reported at the quarterly quality measure meeting.
Inadequate Staffing Levels on Unit A
Penalty
Summary
The facility failed to ensure sufficient nursing staffing to meet the needs of residents on Unit A, as determined by their own nursing coverage plan. The facility's policy outlined a staffing plan to provide necessary services, but the actual staffing levels fell short of these guidelines. The staffing schedules for May, June, and July 2024 revealed that the number of Certified Nursing Assistants (CNAs) on various shifts was consistently below the required levels. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the facility often operated with fewer CNAs than needed, leading to inadequate care for residents who required total care. Interviews with CNAs highlighted the challenges faced due to insufficient staffing. CNAs reported that they were often required to care for more residents than the staffing plan allowed, with some shifts having only two CNAs for a unit of 41 residents. This situation was exacerbated on weekends when staffing levels were particularly low. CNAs expressed frustration that despite raising concerns with administration, no effective measures were taken to address the staffing shortages. The facility's reluctance to use agency staff further compounded the issue, as agency staff were sometimes turned away despite the need for additional help. The Director of Nursing acknowledged the staffing issues and stated that efforts were being made to hire more staff and reduce reliance on agency workers. However, the staffing coordinator indicated that the facility was expected to use ideal staffing levels rather than minimal ones, which were not being met. Despite claims of improvement, the facility's staffing levels remained inadequate, impacting the quality of care provided to residents on Unit A.
Plan Of Correction
Plan of Correction: Approved January 14, 2025 The Staffing Coordinator/designees will schedule sufficient staffing on all units and all shifts. The facility assessment was reviewed and updated to show current staffing resources. Plan for Monitoring Corrective Action: The facility has implemented a bi-weekly staffing meeting to go over new hires, retention, recruitment, incentives, and all other related staffing issues. The final staffing schedule will be reviewed on a weekly basis by the staffing coordinator/DON, and findings presented to the bi-weekly staffing meeting. The facility will seek additional contracts from staffing agencies as a staffing contingency plan. We will increase the frequency of our orientation to facilitate a quicker onboarding process, thereby increasing our staffing resources. Our facility assessment will be reviewed and updated annually or as needed to show current staffing resources. All findings from the bi-weekly staffing meeting will be monitored by the QAPI monthly x 6 by the staffing coordinator/designee.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered in accordance with the prescriber's order or professional standards for three residents. Resident #1, who has a seizure disorder, was administered Depakote Sprinkles outside the regulated time frame on multiple occasions in October and November 2024. There was no documented evidence that the physician was informed of these late administrations. Licensed Practical Nurses involved admitted to errors in documentation and timing but did not notify the physician as required. Resident #2, diagnosed with Parkinson's disease, received Carbidopa-Levodopa outside the regulated time frame on several occasions in August and September 2024. The medication administration record showed discrepancies in the timing of doses, and the involved LPNs did not notify the physician of the late administrations. Some LPNs claimed to have administered the medication on time but signed the records late due to system glitches or being short-staffed. Resident #3, who suffers from insomnia, refused Trazodone and Melatonin on multiple occasions in January 2024, and there was no evidence that the physician was informed of these refusals. Additionally, there was a lack of documentation for the administration of these medications on one occasion. The Director of Nursing acknowledged the need for proper documentation and physician notification when medications are administered late or refused.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F760- Plan for affected Residents: Residents #1 & #2 will have their medication given within the regulated time frame. Resident #3 MD/NP will be made aware when the resident refuses medication. Resident #1 [MEDICATION NAME] and [MEDICATION NAME] levels were drawn, and the levels were in normal limits with no adverse effects. Plan to identify other potentially affected residents: Each Nurse Manager will do a weekly audit on 10 residents on their unit to ensure the medication is being administered timely. In addition, the Nurse Manager will conduct weekly chart audits on medication administration documentation to ensure that MD was made aware if a resident refused medication. Plan for system changes and measures to prevent occurrences: The policy was reviewed. Nurse Educator/ADON will re-educate LPN/RN’s on medication administration policy highlighting medication administration time. MD/NP to be notified when a resident refuses medication and this should be documented in the progress note as well as the medication administration record. Weekly medication administration competency will be done on 10% of the licensed nurses by Nurse educator/designee. Plan for Monitoring Corrective action: Nurse managers will conduct weekly audits on 10% of the residents on their unit to ensure that medications are given at the time prescriber ordered or in accordance with professional standards. Additionally, weekly chart audits will be done by each nurse manager on 10% of residents on their unit to ensure that for those residents that refused medication the NP/MD was notified, and it’s documented in the medical record. The facility plans to monitor its performance to ensure solutions are sustained by nurse educator/designee conducting weekly medication administration competency on 10% of the licensed nurses. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2).
Incomplete Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to ensure a comprehensive facility-wide assessment was conducted and documented to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, last completed in August 2024 and reviewed in September 2023, lacked a detailed staffing plan that specified the number of staff required per unit or shift. During a survey conducted in November 2024, it was found that the assessment did not include individual staff assignments or systems for coordination and continuity of care. The Administrator, who had been working at the facility since mid-August 2024, acknowledged the omission and stated that completing the facility assessment was a new task for them.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 The facility assessment was updated to include an updated staffing plan, the requirements of number of staff allotted for each unit or per shift. Plan for system changes and measures to prevent recurrence: The facility assessment’s staffing plan will be reviewed on a quarterly basis to review what changes need to be made to the staffing plan. Any updates/changes and initiatives will be reviewed. Additional input will be requested from the team to see what other suggestions and ideas they might have. Plan for monitoring corrective action: Facility assessment will be reviewed on a quarterly basis and any changes/updates will be discussed at the QA meeting.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. Resident #2, with a history of falls and requiring moderate assistance for transfers, experienced multiple falls from their wheelchair over a two-month period. Despite these incidents, there was no documented evidence of new interventions being implemented to prevent further falls, and the resident's care plan was not updated accordingly. Resident #3, who was cognitively intact but had poor safety awareness, also experienced several unwitnessed falls, some resulting in minor injuries. The resident's care plan included interventions such as anti-skid socks and a well-lit environment, but there was no documentation of new interventions following each fall. The Director of Nursing acknowledged the resident's poor safety awareness and confusion but did not provide evidence of additional measures taken to prevent further falls. Interviews with the Director of Nursing and the Administrator revealed that while the facility held regular meetings to discuss fall risks and safety interventions, there was a lack of documented follow-up actions or new interventions for the residents involved. The facility's failure to update care plans and implement effective fall prevention strategies contributed to the ongoing risk of accidents for these residents.
Plan Of Correction
Plan of Correction: Approved January 29, 2025 Plan for affected Resident: Resident #2 continues wheelchair pad alarm and remains in supervised area for safety. All fall interventions will be documented on updated care plan at the time of fall and reviewed at the risk meeting weekly. Resident has not had any recent falls. Resident #3 is no longer at the facility. Plan to identify other potentially affected residents: All admissions and readmission fall risk assessments will be reviewed upon admission and each quarter to ensure the appropriate interventions are in place to aid in the prevention of falls based upon the resident risk category. Resident charts were audited from (MONTH) 1st 2024 to current for residents that are at risk for falls to ensure that appropriate interventions are in place. Plan for system changes and measures to prevent recurrence: The fall policy was reviewed and updated. The facility will take the following measures to ensure the problem does not reoccur: Nurse educator/designee will re-educate all licensed nursing staff on Fall Risk assessment and Fall Prevention. All CNA’s will be in-serviced on fall prevention by Staff Educator/designee. All new admissions/readmissions and any incident or accident that took place the day before will be reviewed at the morning IDT meeting to ensure that interventions are in place and properly documented. All new admission & re-admission resident charts will be audited weekly by ADON/Designee. Additionally, those residents who are at risk of falls will be in a supervised area for safety. Daily Environmental rounds will be conducted by nurse managers/supervisor and nurse educator to ensure the unit is free from accident hazards as is possible. Nursing staff will rotate supervised areas to ensure adequate supervision is being provided for residents that are at risk, as documented on the CNA assignment. Plan for monitoring corrective action: The facility plans to monitor its performance to make sure that solutions are substantiated by doing weekly audits that will be conducted by the nurse managers/designee to ensure all residents discussed at the at-risk meeting/admission and readmission have fall interventions with date in place. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2) thereafter.
Failure to Provide Adequate Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident with urinary and bowel incontinence received appropriate treatment and services to prevent urinary tract infections. This deficiency was identified during an abbreviated survey, where it was found that a resident, who was always incontinent and dependent on direct care staff, was diagnosed with urinary tract infections on two separate occasions. The facility's incontinence policy requires residents to be kept dry, clean, and comfortable, with checks and changes every two to four hours. However, documentation revealed numerous instances where direct care staff did not record providing necessary incontinence care over several months. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living. Despite having a care plan that included specific interventions to prevent urinary tract infections, such as applying barrier ointment and monitoring for symptoms, the facility's records showed significant lapses in documented care. Interviews with staff indicated a lack of awareness of these documentation omissions, and the Director of Nursing acknowledged that missing documentation could either be an omission or indicate that care was not provided. The deficiency was noted under 10 NYCRR 415.12(d)(1).
Plan Of Correction
Plan of Correction: Approved January 14, 2025 Plan for affected Resident: Resident #1 is being changed every 2-3 hours. Resident is on a UTI prevention protocol. Resident currently has no UTI. Incontinent care documentation is being done following incontinent care for bowel and bladder. Resident currently does not have a foley catheter. Plan to identify other potentially affected residents: Nurse Managers to do daily audits of CNA documentation for incontinent care bowel and bladder of each resident on their unit. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the charting has been done or is in progress for all incontinent residents. Plan for system changes and measures to prevent occurrences: The facility will take the following measure to ensure that the problem does not reoccur: The incontinent policy was reviewed and updated. Nursing Educator to re-educate CNA's and LPN's on peri care, Urinary tract infections and the incontinent policy. All incontinent residents are to be placed on a toileting schedule or changing schedule every 2-4 hours and PRN. Nurse Manager/Supervisor/designee to check that incontinent care is rendered to all incontinent residents on each unit per protocol every 2-4 hours. Nurse Manager/Supervisor to run report an hour before the end of each shift to ensure that the documentation has been done or is in progress after care is rendered for all incontinent residents. Residents readmitted with new foley catheter will be assessed by the RN for appropriateness of the foley and follow up with NP/MD for clinical necessity or foley will be removed if not indicated. Plan for Monitoring Corrective action: Nurse Manager/designee to do weekly audits on 10% of the residents per unit and patient resident observation to ensure that incontinent care is being provided timely and documentation is being done when incontinent care is provided. Findings will be reported to the QAPI committee monthly times three (3) and quarterly times two (2).
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility did not ensure that individuals working as nurse aides for more than 4 months were competent and certified to provide nursing and nursing-related services. Specifically, seven Training Nurse Aides (TNAs) were employed and functioned in the role of nurse aides for more than 4 months without receiving nurse aide certification. This was in violation of the Centers for Medicare and Medicaid Services (CMS) memorandum, which required facilities to ensure that anyone functioning as a nurse aide completed a state-approved nurse aide training program and passed an oral/written examination within 4 months of hire. The TNAs in question were hired on various dates and continued to work without certification beyond the allowed period. During interviews, the Director of Human Resources and the Director of Nursing (DON) acknowledged the issue. The Director of Human Resources stated that they believed the TNAs were permitted to work until a certain date and had been giving verbal reminders to the TNAs to complete their certification. The DON stated that they expected nurse aides to be competent and certified before performing care on residents and admitted to being aware of the non-certified nurse aides working due to staffing problems at the facility.
Deficiency in CNA In-Service Education and Performance Evaluations
Penalty
Summary
The facility did not ensure that each certified nurse aide (CNA) received the required twelve hours of in-service education per year based on their individual performance review. Specifically, CNA #8 lacked 6 hours of training, CNA #9 lacked 10 hours of training, CNA #10 lacked 8.5 hours of training, and CNA #11 lacked 7 hours of training. Additionally, all four CNAs did not receive an annual performance evaluation. The last performance evaluations for CNA #8, #9, #10, and #11 were completed on 12/12/20, 9/7/22, 2/12/20, and 7/2/21, respectively. The Infection Control Nurse/Educator (IP) confirmed that no additional documented in-services were provided for these CNAs, attributing the lack of training to the pandemic, which prevented in-person meetings at that time. Interviews with the CNAs and the Director of Nursing (DON) revealed that the facility was behind on conducting evaluations and providing in-service education. CNA #8 mentioned that their last evaluation was about 2-3 years ago, despite the requirement for annual evaluations. The DON acknowledged inheriting incomplete evaluations and stated that Nurse Managers were responsible for conducting them but were behind schedule. The DON also mentioned that efforts were being made to catch up on the in-service education and evaluations.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food safety. During an initial tour of the kitchen, surveyors observed multiple food items in the walk-in refrigerator and the cook's refrigerator that were unlabeled and undated. Specifically, a rack of bread with ten loaves had no receive date, a package of approximately ten slices of cheese was not labeled or dated, a small pan of applesauce was not labeled, and a small pan of yogurt was dated but not labeled. Additionally, the cook's refrigerator contained 16.9 ounces of red wine vinegar, approximately fifty slices of cheese, a 120-milliliter bottle of hot sauce, yellow liquid in small cups, cakes in a baking pan, and cookies in a baking pan, all of which were unlabeled and undated. Furthermore, a rack designated for dry pans contained wet pans. During interviews, the Assistant Food Service Director (AFSD) and the Food Service Director (FSD) confirmed that all food items were supposed to be labeled and dated according to the facility's policy. The AFSD stated that without proper labeling and dating, staff would not know when the food items expired or what the food items were, potentially leading to residents getting sick from expired food. The FSD reiterated that any food item older than three days should have been discarded and that the rack designated for dry pans should only contain dry pans.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional principles for two of four medication carts on the Cedar and Apple units. Specifically, during a medication storage observation, multiple undated and expired medications were found on the Cedar Unit medication cart, including tobramycin eye drops, olopatadine eye drops, bacitracin ophthalmic ointment, Latanoprost eye drops, a daily probiotic supplement, Geri-Lanta, Chlorohexidine Gluconate oral rinse solution, ferrous gluconate, and carbamazepine. Additionally, the cart contained excessive debris, including medication wrappers, mouth swabs, used medication packaging, multiple unpackaged and unlabeled pills, and sticky residue. RN #2 confirmed that nurses should be cleaning the medication carts weekly and that the facility's pharmacy consultant should have identified the expired and undated medications during their monthly visits. On the Apple Unit medication cart, an unidentifiable pill in an unlabeled pill-crusher sleeve, expired NUTRI-Stat bottles, opened and undated bottles of Chlorahexidine Gluconate oral rinse solution, polyvinyl alcohol lubricating eye drops, and artificial tears were found. The cart also had multiple unidentifiable sticky residues and debris. LPN #3 stated that nurses were responsible for cleaning the medication carts and removing expired and undated medications. The Director of Nursing (DON) confirmed that staff should be dating bottles when opened and cleaning the medication carts routinely, and that medications should be discarded 30 days after opening.
Failure to Investigate and Report Injuries of Unknown Origin
Penalty
Summary
The facility did not ensure all injuries of unknown origin were thoroughly investigated and reported to the New York State Department of Health (NYSDOH) for one resident reviewed for abuse. Specifically, Resident #449, who had a history of stroke, non-traumatic brain dysfunction, Parkinson's, and dementia, reported an unwitnessed fall and a broken arm that was not thoroughly investigated to rule out abuse. The resident was found with a skin tear below the left knee and a bruise/hematoma to the right arm, and upper arm and elbow pain. Despite the resident's report of falling out of bed during the night, the investigation did not determine if there was reasonable cause to believe that abuse, mistreatment, or neglect had occurred. The facility's Accident/Incident (A/I) Report and subsequent investigation were incomplete. The Director of Nursing (DON) acknowledged that the injuries were not further investigated based on the resident's and staff's statements. The investigation did not include an assessment of environmental factors that could have contributed to the fall or interviews with other staff or residents. Additionally, the determination on the A/I report regarding whether the incident could be considered abuse or neglect was not checked off, which the DON stated was an oversight. As a result, the incident was not reported to the NYSDOH.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that Resident #64, who was unable to carry out activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene. Resident #64, who had diagnoses including vascular dementia, hypothyroidism, muscle weakness, and orthostatic hypotension, was observed on multiple occasions with urine-soaked pants. Specifically, on 10/18/23, the resident was seen at 9:28 AM, 10:42 AM, and 10:55 AM in the hallway sitting in a Merri walker with urine-soaked pants. Interviews with staff revealed that the resident had not been changed since the start of the 7 AM shift and was scheduled to be provided care only after lunch. Additionally, the resident was supposed to be toileted every two hours and as needed, but this was not adhered to by the staff on duty. Further observations on 10/25/23 showed that Resident #64 was still in bed at 10:08 AM, contrary to the care plan that required the resident to be out of bed by the 11 PM-7 AM shift. Interviews with various CNAs and LPNs indicated a lack of awareness and adherence to the resident's care plan, with staff members unable to explain why the resident was not out of bed as required. The Director of Nursing confirmed that the night shift was aware of the care plan but failed to follow it. This lack of compliance with the care plan resulted in the resident not receiving timely toileting and personal hygiene care, as mandated by the facility's protocols.
Failure to Administer Medications and Coordinate Appointments Correctly
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with professional standards of practice for three residents. Resident #23, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and major depressive disorder, received an incorrect dose of Clonazepam. The prescribed dose was 0.25 mg, but the resident was administered 0.50 mg, which was the previous dosage before it was reduced due to lethargy. This error was acknowledged by the involved LPN and the Director of Nursing (DON), and a medication discipline warning notice was issued to the responsible nurse. Resident #299, admitted for short-term rehabilitation with diagnoses including vertebral fracture and congestive heart failure, was sent to an orthopedic consult appointment without an aide. The consultant physician refused to see the resident without an aide, and the Unit Secretary admitted to not completing the Out of House Appointment and Transportation Worksheet fully, which included failing to document the need for a CNA escort. The DON confirmed that the Unit Secretary was responsible for ensuring all necessary information and arrangements were made for outside appointments. Resident #105, with diagnoses including vascular dementia and generalized anxiety disorder, was administered crushed medications without a physician's order. The LPN responsible for administering the medications stated that the resident was given crushed medications due to a cough, but there were no orders to crush the medications. Both the LPN and the LPN unit manager acknowledged that a physician's order was required to crush medications, and the medical doctor confirmed that it was unacceptable to crush medications without such an order.
Failure to Notify Family and Provide Escort for Resident's Appointment
Penalty
Summary
The facility did not ensure that a resident's representative was informed about an orthopedic appointment, resulting in the resident missing the appointment due to the lack of an escort. Resident #299, who had diagnoses including a fracture of the thoracic spine, diabetes, and congestive heart failure, was scheduled for an orthopedic consult. The Out of House Appointment and Transportation Worksheet indicated that the resident was not seen because a nurse aide was required but not provided, and the family was not notified to accompany the resident. The form's checkboxes for family notification and the need for a CNA escort were left blank. Interviews revealed that the Unit Secretary was unaware that a nurse aide was needed for the appointment and did not complete the worksheet fully. The Director of Nursing stated that the Unit Secretary was responsible for obtaining and documenting all necessary information for outside appointments, including whether an escort was needed. The DON was not aware that the resident missed the appointment due to the lack of staff in attendance. The incomplete documentation and lack of communication led to the resident missing the scheduled orthopedic consult.
Non-compliance with TLSO Brace Care Plan
Penalty
Summary
The facility did not implement a person-centered care plan with measurable objectives, time frames, and appropriate interventions for a resident who was non-compliant with wearing a TLSO back brace. The resident, who had a history of a T9-T10 vertebra fracture, diabetes, and congestive heart failure, was admitted with a physician's order to wear the TLSO brace when out of bed. However, the care plan created for the resident's non-compliance with the brace lacked documented goals, interventions, and updates, despite the resident's refusal to wear the brace and the spouse's concerns. Interviews with the facility's staff revealed that the care plan was initiated by the MDS coordinator due to the unit being busy with admissions. The registered nurses involved were aware of the resident's non-compliance but did not ensure that appropriate interventions were documented. The Unit Manager, who was new to the position, was supposed to add the interventions but failed to do so. This lack of proper documentation and follow-through led to the deficiency noted in the survey.
Failure to Maintain Resident Dignity with Unconcealed Catheter Bag
Penalty
Summary
The facility did not ensure that care was provided in a manner to maintain the dignity of a resident with a urinary (Foley) catheter. Specifically, the catheter bag for a resident was not concealed, allowing it to be visible to other residents, staff, and visitors from the public hallway. This was observed on multiple occasions, and the facility's policy on urinary catheter care, which mandates privacy, was not followed. The resident in question had diagnoses including cerebral infarction, chronic kidney disease, and atrial fibrillation, and required extensive assistance for personal hygiene and toilet use. During interviews, a CNA expressed uncertainty about why the catheter bag was uncovered, and an RN indicated they would request dignity bags from the supply room. The Director of Nursing acknowledged that staff had been previously instructed on this issue, but it remained a recurring problem. The deficiency was noted during a recertification survey, highlighting a failure to maintain the resident's dignity as per the facility's policy and regulatory requirements.
Inaccessible Call Bells for Multiple Residents
Penalty
Summary
The facility did not ensure that the call bell system was accessible for seven residents reviewed for the environment. Observations revealed that the call bells for these residents were not within their reach, despite care plans specifying that call bells should be accessible. For instance, Resident #115, who has severe cognitive impairment and requires supervision with bed mobility and transfers, was observed with the call bell hanging on the wall out of reach. Similarly, Resident #60, who has severe dementia, was also found with the call bell not within reach while in bed. Other residents, including those with diagnoses such as vascular dementia, epilepsy, and Alzheimer's disease, were similarly observed with call bells placed on the wall and not within their reach. Interviews with staff, including CNAs and an LPN, confirmed that call bells should be within reach of all residents and that this requirement is documented in the CNA care guide. The Director of Nursing also stated that all staff should follow the care plans, which include ensuring call bells are accessible. Despite these guidelines, multiple residents were found without accessible call bells, indicating a failure to adhere to the care plans and ensure resident safety and communication needs.
Inadequate Supervision for High-Risk Resident
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for a resident assessed at high risk for falls. The resident, who had diagnoses including lack of coordination, a non-displaced fracture of the seventh cervical vertebra, and dementia without behavioral disturbance, was observed multiple times attempting to stand up from their wheelchair without staff assistance or redirection. Despite being in a supervised area as per their fall care plan, the resident was seen trying to stand up from their wheelchair in the TV room and dining room without staff intervention. On one occasion, the resident was seated at the edge of their wheelchair seat, and two staff members present did not redirect the resident. On another occasion, the resident was observed sleeping in their wheelchair with their feet positioned between the foot pedals and their body slid down in the wheelchair. Interviews with staff revealed that the Unit Assistant, who was present during one of the incidents, did not assist the resident because they did not understand English well and were not responsible for resident care. The training nurse aide stated that they would assist the resident if they saw them trying to get up from their wheelchair and that the Unit Assistant could not assist with cares. The resident was later provided with a seatbelt as a fall prevention measure. The facility's failure to provide adequate supervision and timely intervention for a high-risk resident led to the deficiency noted in the report.
Medication Administration Errors
Penalty
Summary
The facility did not ensure a medication error rate of no more than 5% during a medication administration observation, resulting in a 12% error rate. Specifically, Resident #132 was administered Metoprolol Extended Release Tablet crushed instead of whole, contrary to the physician's order and FDA guidelines. The LPN responsible for this error stated that they crush all pills for residents with dementia, regardless of their ability to swallow or the physician's order. This action was not in compliance with the facility's medication administration policy, which requires nurses to double-check and ensure all medications are administered as per the physician's order. Additionally, Resident #136 was administered medication through a feeding tube without flushing between two medications, as observed during a medication administration. The LPN involved could not provide a reason for not flushing the feeding tube between medications. The Director of Nursing confirmed that medications should be given according to professional standards and physician orders, which include not crushing extended-release medications and flushing feeding tubes between different medications.
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.
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.
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.
Surveyors found that the facility’s most recent assessment of its 140-bed operation, including rehab, stepdown medically complex, and LTC dementia/chronic illness units, did not adequately specify how necessary resources are maintained for resident care. The assessment lacked a breakdown of bed capacity per unit and, under its staffing plan, only generally stated that staffing is based on census and acuity and reviewed each shift, with additional RNs scheduled for multiple admissions. It failed to identify contingency planning for non-emergency events that could affect direct care nurse staffing or other care resources, and it did not describe any plan to maximize recruitment and retention of direct care staff, resulting in a deficiency under 10NYCRR S415.26.
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 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 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.
Inadequate Facility-Wide Assessment of Resources and Staffing Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document an adequate facility-wide assessment that determines what resources are necessary to care for residents competently during day-to-day operations and emergencies. During an Abbreviated Survey, record review of the most recent facility assessment, dated on an unspecified date and reviewed by the QAPI Committee on 09/04/2025, showed that the assessment did not sufficiently identify how the facility maintains necessary resources for resident care. The assessment described the facility as a 140-bed SNF with four nursing units (one rehabilitation unit, one stepdown medically complex unit, and two LTC units for residents with dementia and other chronic illnesses), but it did not provide a breakdown of bed capacity per unit. Under the staffing plan section, the assessment stated that staffing is based on resident census and acuity, is reviewed prior to each shift, and that the facility intends to assign the same staff to units and schedule additional RNs for multiple admissions. However, the assessment did not adequately identify contingency planning for events that do not trigger the formal emergency plan but could still affect resident care, such as issues with availability of direct care nurse staffing or other needed resources. Additionally, the assessment did not identify how the facility develops or maintains a plan to maximize recruitment and retention of direct care staff, as required by 10NYCRR S415.26.
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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