Regeis Care Center

Penalty

Inspection fine: $54,890

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse and to protect a resident from potential further abuse after the allegation was reported. The facility’s abuse policy required that all alleged or suspected incidents of abuse, neglect, mistreatment, or misappropriation of resident property be thoroughly investigated, with findings documented and reported, and that residents be protected from abuse. Resident #1, who had non-Alzheimer’s dementia, muscle weakness, difficulty walking, and severely impaired cognition per the most recent MDS, was the subject of the alleged abuse. Video surveillance from the unit on the date of the incident showed Resident #1 ambulating with an unsteady gait, using hallway handrails, and then rolling a cart with personal protective equipment into two residents’ rooms. Certified Nursing Assistant (CNA) #1, who was pushing another resident up the hallway, followed Resident #1 into a room, rolled the cart back into the hallway, and was then seen pulling Resident #1 by the arm into the hallway. CNA #1 held Resident #1 under the left armpit and pulled the resident up the hallway toward their wheelchair while the resident resisted. CNA #1 then seated Resident #1 on the edge of the wheelchair; as the resident resisted sitting, CNA #1 held the resident under the armpit and by the pants and dragged the resident fully back into the wheelchair. CNA #1 then pushed the resident’s upper body forward while their right hand moved back and forth at the resident’s lower back, appearing to hit the resident on the buttock, with the resident’s body jerking forward. A visitor for another resident was observed in a nearby doorway looking toward CNA #1 and Resident #1, and the visitor and CNA #1 appeared to exchange words and hand gestures. Later that day, the visitor reported the incident to the Director of Nursing (DON). The facility’s undated internal summary of the incident documented that the visitor demanded discipline for CNA #1 due to a verbal altercation and described hearing a commotion, coming out to observe, and asking CNA #1 what they were doing with Resident #1. The DON stated in interview that the visitor only reported rudeness by CNA #1 and did not report rough handling or hitting. The DON reviewed the video footage but stated they did not identify CNA #1’s actions as abusive or excessively rough and, based on CNA #1’s denial, did not further investigate the matter as abuse. CNA #1 was suspended for one day for poor customer service and then reassigned to another unit, but was not removed from resident care or access to residents in response to an abuse allegation, and no thorough abuse investigation was initiated at that time. Registered Nurse Supervisor #1 reported that the DON informed them that a family member had complained that CNA #1 was cursing at them after they questioned what CNA #1 was doing with Resident #1. The DON told the supervisor that video review showed CNA #1 attempting to put Resident #1 into their wheelchair and instructed the supervisor to perform a body assessment on Resident #1. The supervisor stated that they and the DON assessed Resident #1 and found no redness, discoloration, or visible injury, and that the resident was smiling and in good spirits with no complaints of pain or discomfort; however, this assessment was not documented in the resident’s chart, and the physician was not notified. There was no documented RN assessment of Resident #1 related to the alleged incident, and the attending physician later stated they were not made aware of any allegation of rough handling or abuse involving Resident #1 until more than a week after the event. The facility did not initiate a formal abuse investigation until after the state surveyor’s onsite visit, during which it was confirmed that CNA #1 had continued to work on other units after the date of the alleged abuse.

Removal Plan

• Certified Nursing Assistant #1 was removed.
• Resident #1 was assessed.
• Facility wide in-service was conducted.
• Administration rounding on all units was conducted.
• Resident #1's care plan was reviewed and updated.
• Audit log for Accident/Incidents was reviewed for the past 30 days.
• Facility reviewed and assessed 52 residents for abuse and mistreatment.
• Nurse Practitioner assessed Resident #1.
• The Director of Nursing and Assistant Director of Nursing received in-service on ensuring a thorough investigation of all allegations.
• Interdisciplinary Meeting was held.
• Facility investigation was reviewed.
• Facility reviewed Policy and Procedure on Abuse Prevention.

Penalty

Inspection fine: $54,890

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a resident from physical abuse and to respond appropriately to an abuse allegation. The facility had an Abuse Prohibition Policy and Protocol dated 09/11/2025 stating residents would be protected from abuse, neglect, and mistreatment, and that the facility had zero tolerance for any kind of abuse. Resident #1 had diagnoses including non-Alzheimer’s dementia, muscle weakness, and difficulty walking, with a quarterly MDS dated 01/02/2026 documenting severely impaired cognition and a need for partial/moderate assistance with functional abilities. Care plans documented that Resident #1 wandered into other residents’ rooms uninvited, placing the resident at risk for potential abuse, and that staff were to monitor the resident’s whereabouts and redirect as needed, as well as address the resident in a calm and gentle manner; however, there was no documented evidence of the frequency of monitoring. On 02/17/2026, surveillance video footage from approximately 4:34 PM showed Resident #1 getting up from a wheelchair and ambulating with an unsteady gait up the hallway while holding onto handrails. Resident #1 moved a cart stocked with personal protective equipment and rolled it into two residents’ rooms. Certified Nursing Assistant (CNA) #1, who was wheeling another resident up the hallway, stopped and went into one of the rooms behind Resident #1. The video showed CNA #1 rolling the cart back into the hallway, then standing in the doorway pulling Resident #1 by the arm and pulling the resident into the hallway. CNA #1 then held Resident #1 under the left armpit and pulled the resident up the hallway toward the wheelchair while Resident #1 continued to resist. CNA #1 placed Resident #1 on the edge of the wheelchair; as Resident #1 resisted sitting, CNA #1 held the resident under the left armpit, put a hand behind the resident holding them by the pants, and dragged Resident #1 back into the wheelchair, then pushed and held the resident’s upper body forward with one hand while the other hand moved back and forth at the resident’s lower back, with Resident #1’s body jerking forward. A visitor for Resident #2 was observed standing in a doorway looking in the direction of CNA #1 and Resident #1, and the visitor and CNA #1 appeared to be exchanging words and hand gestures. Later that day, Resident #2’s visitor reported to the Director of Nursing (DON) that they observed CNA #1 being rough handed and hitting Resident #1 on the buttocks. The facility’s Summary Investigation for the incident documented that the visitor went to the DON’s office demanding discipline for CNA #1, describing a verbal altercation and stating they heard a commotion and came out to see what was happening, then asked CNA #1 what they were doing with Resident #1. The DON and Assistant Administrator reported that they reviewed the surveillance video to see the interaction between CNA #1 and the visitor and stated they did not identify CNA #1’s actions as abusive or excessively rough, characterizing the transfer as an attempt to maintain safety. The DON instructed a Registered Nurse Supervisor to assess Resident #1; the RN Supervisor reported observing Resident #1 smiling, in good spirits, with no visible injury and no complaints of pain or discomfort, but did not document this assessment in the chart or notify the physician. Despite the visitor’s report that CNA #1 was rough handed and hit the resident, and the video evidence of forceful handling while the resident resisted, there was no documented evidence that the allegation of abuse was investigated as abuse or reported to the New York State Department of Health, constituting a failure to ensure the resident was free from physical abuse and that an abuse allegation was properly investigated and reported.

Penalty

Inspection fine: $54,890

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to immediately report an allegation of abuse to the New York State Department of Health as required by regulation and by its own Abuse Prohibition policy. The policy, last revised on 09/11/2025, states that all alleged violations involving abuse, neglect, exploitation, or resident property are to be reported immediately, but not later than two hours after the allegation is made. Despite this, an allegation that a certified nursing assistant (CNA) was rough handed and hit a resident on the buttock was not reported to the State Survey Agency or other required authorities. Resident #1 had diagnoses including non-Alzheimer’s dementia, muscle weakness, and difficulty walking, and a Minimum Data Set dated 01/02/2025 documented severely impaired cognition. On 02/17/2026, surveillance video showed Resident #1 ambulating with an unsteady gait, holding onto hallway handrails, then moving a personal protective equipment cart into other residents’ rooms. CNA #1, who had been wheeling another resident up the hallway, followed Resident #1 into a room, pulled the resident by the arm into the hallway, then held the resident under the left armpit and pulled them up the hallway toward their wheelchair while the resident resisted. CNA #1 then seated Resident #1 on the edge of the wheelchair; as the resident resisted, CNA #1 held the resident under the left armpit, placed a hand behind the resident holding them by the pants, dragged the resident back into the wheelchair, and pushed and held the resident’s upper body forward while moving a hand back and forth at the resident’s lower back, during which the resident’s body jerked forward. At approximately 5:30 PM that day, Resident #2’s visitor reported to the Director of Nursing that they had observed CNA #1 being rough handed and hitting Resident #1 on the buttock. The facility’s internal summary of the incident documented that the visitor came to the DON’s office demanding discipline for CNA #1 after a verbal altercation and reported hearing a commotion, then observing CNA #1 attending to Resident #1 and questioning what the CNA was doing. A registered nurse supervisor assessed Resident #1 the same day, noting the resident was smiling, in good spirits, had no visible injury, and reported no pain or discomfort. The Assistant Administrator later stated that, after reviewing the video, they concluded there was no harm and no allegation of rough handling or hitting, and therefore the incident was not treated as an abuse allegation and was not reported to the Department of Health, despite the visitor’s report and the facility’s policy requirements.

Penalty

Inspection fine: $54,890

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices to prevent accidents for a resident with an unsteady gait and high fall risk. The resident had diagnoses including non-Alzheimer’s dementia, muscle weakness, and difficulty walking, and a quarterly MDS documented severely impaired cognition. The MDS also showed the resident required partial/moderate assistance for walking 50 feet and for transfers from sitting to standing, and that the resident used a wheelchair for locomotion. The resident’s fall care plan included interventions such as keeping rooms and hallways well-lit, clean, and clutter free, ensuring the call bell was within reach, encouraging and reminding the resident to call for assistance, providing properly fitted footwear and gripper socks at night, and providing assistance with ADL care as needed. On the date of the incident, surveillance video from the unit showed that at approximately 4:38 PM the resident got up from their wheelchair and ambulated up the hallway with an unsteady gait while holding onto the handrails. The resident then walked across the hallway to a cart stocked with personal protective equipment and rolled the cart into two residents’ rooms. During this time, staff were observed going in and out of residents’ rooms, and there were three CNAs and one LPN assigned to that side of the unit. Staff interviews indicated that one CNA was monitoring residents in the dining room, another CNA was taking residents to their rooms for incontinence care before dinner, and the LPN was administering medications while also monitoring residents sitting in the hallway. The video further showed that when one CNA observed the resident entering a room with the cart, the CNA stopped, went into the room behind the resident, and rolled the cart back into the hallway. The CNA was then seen standing in the doorway pulling the resident by the arm, pulling the resident into the hallway, and holding the resident under the left armpit while pulling the resident up the hallway toward the wheelchair as the resident resisted. The CNA then placed the resident on the edge of the wheelchair; as the resident resisted sitting, the CNA held the resident under the armpit and by the pants and dragged the resident back into the wheelchair. The CNA pushed the resident’s upper body forward while their right hand moved back and forth at the resident’s lower back, appearing to hit the resident on the buttock, and the resident’s body jerked forward. Interviews with CNAs, the LPN, the RN Supervisor, and the DON confirmed that staff were expected to monitor residents in the hallway and dining room and that the resident was on hourly visual monitoring, but the resident was nonetheless able to ambulate unassisted and manipulate the cart in the hallway and other residents’ rooms.

Penalty

Inspection fine: $54,890

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to administer operations in a way that ensured effective and efficient use of resources to support each resident’s highest practicable well-being, as required by its Administration-Management policy. The incident centers on a resident with non-Alzheimer’s dementia, muscle weakness, difficulty walking, and severely impaired cognition, who was observed on facility video surveillance ambulating with an unsteady gait, holding onto hallway handrails, and moving a PPE cart into other residents’ rooms. A CNA followed the resident into a room, then was seen on video pulling the resident by the arm into the hallway, holding the resident under the left armpit, and pulling the resident up the hallway toward the wheelchair while the resident resisted. The CNA then placed the resident on the edge of the wheelchair, continued to hold under the left armpit, grasped the resident by the pants, and dragged the resident fully into the wheelchair, pushing and holding the resident’s upper body forward while moving a hand back and forth at the resident’s lower back, causing the resident’s body to jerk forward. A visitor was seen in a nearby doorway observing and gesturing during this interaction. Later that day, the visitor reported to the DON that they had a verbal altercation with the CNA and that the CNA had been disrespectful, and also stated they heard a commotion and came out to see the CNA attending to the resident. The facility’s internal summary characterized the CNA’s actions as an immediate assistance back to the wheelchair using a compact pivot transfer to maintain safety. The DON and Assistant Administrator reviewed the surveillance footage but stated they did not identify the CNA’s actions as abusive, excessively rough, or causing harm, and the CNA denied abuse. The DON directed an RN Supervisor to assess the resident, who was found sitting on the bed smiling, in good spirits, with no visible injury and no complaints of pain or discomfort. Despite the visitor’s report and the video evidence of the CNA pulling, dragging, and forcefully repositioning the resident while the resident resisted, facility administration did not treat the situation as an allegation of abuse requiring immediate investigation and protection of residents from further potential abuse. The CNA was suspended for one day for poor customer service and reassigned to another unit, but the facility did not initiate an abuse investigation at that time and did not report an alleged abuse incident to the New York State Department of Health within two hours of the allegation. The formal investigation into the abuse allegation was not initiated until after a state surveyor went onsite, and the facility did not report the allegation to the Department of Health as required, constituting a failure to administer the facility in accordance with regulatory requirements and its own policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with Acute Sinusitis and prescribed antibiotics. Despite the facility's policy requiring individualized care plans to address medical, nursing, mental, and psychosocial needs, no care plan was created for the resident's condition and antibiotic use. The resident, who had a history of Anemia, Hypertension, and Asthma/Chronic Obstructive Pulmonary Disease, was observed with a non-productive cough and had been taking antibiotics for Sinusitis following a positive Influenza A diagnosis. The absence of a care plan was confirmed through interviews with the Unit Manager, Infection Control Prevention Registered Nurse, and Director of Nursing, who acknowledged the oversight. The deficiency was identified during a recertification survey, where it was noted that the resident's care plan lacked interventions for the diagnosis of Acute Sinusitis and antibiotic use. The resident had been hospitalized, and the medication administration record showed that antibiotics were administered until the hospitalization. Interviews with staff revealed that the responsibility for initiating the care plan fell on the nursing supervisor, Unit Manager, and Infection Control Registered Nurse, but the care plan was not initiated due to oversight. The Director of Nursing emphasized the importance of the care plan as a blueprint for resident care, highlighting the failure to adhere to the facility's policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, a resident with diagnoses of Diabetes Mellitus, Peripheral Vascular Disease, and Cancer had a physician's order to notify the physician when the resident's finger stick blood sugar was less than 200 mg/dL or more than 350 mg/dL. However, the licensed nurse did not notify the physician on seven occasions when the blood sugar was below 200 mg/dL and on three occasions when it was above 350 mg/dL. Additionally, the resident was administered Novolog insulin without a physician's order when the blood sugar was above 350 mg/dL. The facility's policy on Diabetes Management required blood sugar levels to be measured and the physician to be notified according to specific parameters. Despite this, the electronic Medication Administration Records showed instances where the physician was not notified, and insulin was administered without orders. Interviews with the LPN, Medical Doctor, and Director of Nursing confirmed that the physician's orders were not followed, leading to the deficiency in care for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food served to residents was maintained at appetizing temperatures, as evidenced by the experience of Resident #134. The resident, who has diagnoses of Diabetes Mellitus, Hyperlipidemia, and Hypertension, reported that their food was cold by the time it reached their room. Observations during the survey revealed that food temperatures were not consistently maintained at the required levels, with some items such as chicken and broccoli being served at temperatures below the facility's policy standards. The facility's policy requires hot foods to be held at 135 degrees Fahrenheit or higher, but during test tray evaluations, several food items were found to be below this temperature. The Food Service Director acknowledged that the issue had been identified previously and that a plan to improve meal service was initiated but only partially implemented due to equipment and staffing challenges. The Director of Nursing also confirmed that the food temperature issue had been recognized earlier, but the improvement plan was only applied to one unit, leaving other areas without the necessary changes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that survey results were posted in a location that was easily accessible and visible to residents, family members, and legal representatives. During the Recertification Survey conducted from January 13 to January 21, 2025, it was observed that the survey results were placed in an unlabeled plastic sleeve on a bulletin board across the Finance Department's office, which was not in plain view. This location was down the hall from the main entrance, making it difficult for residents and their families to access. Additionally, the survey results did not include complaint investigations from the preceding three years, which is a requirement. Interviews with residents during a Resident Council Meeting revealed that many were unaware of the location of the survey results. The Director of Nursing and the Administrator both stated that the survey results were temporarily relocated due to construction and redoing of wallpaper. They also mentioned that there were no complaint surveys to include in the results, which contradicts the requirement to have such information available. The lack of proper communication and visibility of the survey results led to the deficiency noted in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services Data System within the required 14-day period after completion. This deficiency was identified during a recertification survey, where it was found that three residents' assessments were not submitted on time. Specifically, the assessments for Residents #164, #152, and #64 were completed but not transmitted within the mandated timeframe. The facility's policy requires timely submission of MDS assessments, yet the submission report indicated that 17 assessments were submitted late. Interviews with facility staff revealed that the delay in submission was due to the absence of the MDS Coordinator, who was away from the facility for two weeks. During this period, the MDS Assessors did not have access to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, which is necessary for submitting the assessments. The Director of Nursing was unaware of the late submissions and stated that the MDS Coordinator is responsible for ensuring timely completion and submission of assessments. Despite the Assessors being trained on the submission process, the assessments were still submitted late, indicating a lapse in the facility's internal processes for managing MDS submissions.