Renaissance Rehabilitation And Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Staatsburg, New York.
- Location
- 4975 Albany Post Road, Staatsburg, New York 12580
- CMS Provider Number
- 335404
- Inspections on file
- 18
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Renaissance Rehabilitation And Nursing Care Center during CMS and state inspections, most recent first.
The facility did not meet its own minimum CNA staffing requirements for day, evening, and night shifts over a two-month period, resulting in unsupervised residents, foul odors, and delays in care such as feeding, showers, and medication administration. Staff and residents reported long wait times, incomplete care, and difficulty performing necessary tasks due to inadequate staffing. Facility leadership acknowledged ongoing recruitment challenges and a lack of understanding regarding the use of the Facility Assessment to determine staffing needs.
The facility did not ensure RN coverage for at least 8 consecutive hours daily on multiple weekends, resulting in periods with no RN present. During these times, two residents experienced falls and another sustained a burn, none of whom were assessed by qualified staff until days later. LPNs contacted the DON by phone for guidance, but there was no documentation of in-person RN assessment or presence.
Three residents did not receive timely assessment by an RN after significant incidents, including open wounds and unwitnessed falls with injury or complaints of pain. In each case, LPNs documented the events and notified physicians, but there was no evidence of RN assessment or documentation prior to residents being moved or treated, and staffing records confirmed the absence of RNs during these critical periods.
A resident with cognitive impairment and poor safety awareness experienced two separate burn injuries from hot beverages due to inadequate supervision and lack of timely interventions. After the first incident, only resident education was provided, and no root cause analysis or comprehensive investigation was conducted. The second burn occurred months later, with delayed implementation of safety measures such as a lidded mug and cupholder, and these interventions were not promptly added to the care plan or communicated to staff. Both incidents were not reported to the state health department as required, and staff interviews revealed gaps in awareness and follow-through on accident prevention protocols.
A resident with cerebrovascular disease, dysarthria, and asthma, who was dependent on staff for bathing, did not consistently receive scheduled showers as outlined in their care plan and personal preference. Documentation and interviews confirmed missed showers, with accountability records showing fewer showers provided than required, and staff acknowledging lapses in both care delivery and documentation.
A resident with occasional urinary and bowel incontinence was not provided with a toileting program or individualized continence care, despite having intact cognition and expressing a preference to use the toilet rather than wear adult briefs. Staff did not update the care plan or trial a toileting program, and the resident's incontinence episodes increased. Interviews revealed that the resident was capable of being toileted with assistance, but staff cited insufficient staffing and did not implement appropriate interventions.
A resident with insomnia and other medical conditions did not receive six doses of a prescribed sleep medication due to delays in obtaining prior insurance authorization and failures in staff communication and medication management. The LPN did not notify the provider or pharmacy when the medication was unavailable, and the DON and pharmacy had unclear responsibilities regarding insurance approval, resulting in the resident's needs not being met.
The facility's governing body failed to implement effective policies to manage a prolonged outage of the large elevator, impacting meal delivery and evacuation processes. Despite awareness of the issue, no Quality Assurance Performance Improvement plan was documented to address the problem. The facility owner/operator was uncertain if the issue was discussed in meetings and believed alternative measures were in place, although no documentation supported this.
The facility failed to maintain a safe and functional environment due to a large elevator being out of order since spring 2024. This led to disruptions in meal delivery, with food temperatures falling into the danger zone, as un-insulated linen carts were used instead of the large, insulated meal truck. The facility's administration and maintenance staff were aware of the issue but faced delays in obtaining parts for repair, affecting resident activities and overall service provision.
The facility did not maintain a clean and homelike environment, with observations of sticky floors, overflowing garbage, and soiled briefs in resident rooms. Staff reported being overwhelmed due to understaffing, impacting their ability to complete tasks. The administrator noted the need for additional training and oversight for housekeeping staff.
The facility failed to maintain an effective infection prevention and control program, lacking a current Water Management Plan, failing to implement COVID-19 precautions, and breaching infection control during medication administration. Staff were unaware of Enhanced Barrier Precautions, leading to inadequate protective measures for residents with urinary catheters.
The facility did not implement an antibiotic stewardship program, failing to track and monitor antibiotic use as required. The RN Unit Manager was unaware of the term 'antibiotic stewardship' and did not track antibiotic use for residents. The DON/Infection Preventionist admitted responsibility but acknowledged that tracking was not being done, and the Administrator confirmed the Nursing Department's responsibility for monitoring antibiotic use.
The facility did not ensure the designated Infection Preventionist, the DON, completed specialized training in infection prevention and control before starting their role. The DON only completed a 4-hour mandatory training certificate, with no additional specialized training documented. This was confirmed during a survey and an interview with the DON.
The facility failed to prevent accident hazards and provide adequate supervision, resulting in multiple incidents involving residents. One resident on anticoagulants experienced falls without documented neuro-checks or hospital evaluation. Another resident had a non-functional enabler rail for over a month, affecting mobility. A third resident fell and fractured a hip, with no updated care plan interventions. Additionally, a fourth resident had multiple falls with major injuries, but their care plan was not updated. These incidents highlight systemic issues in fall prevention and care plan management.
The facility experienced chronic staffing shortages, leading to delays in resident care and unmet needs. Residents reported long wait times for assistance, and observations revealed soiled conditions and strong odors in rooms. Staff interviews confirmed the overwhelming workload due to understaffing, with management acknowledging recruitment challenges and the frequent use of overtime incentives.
The facility failed to ensure a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required by regulations. This deficiency was identified during a recertification survey, revealing that no RN was present on specific dates. The facility's Staffing Coordinator, Director of Nursing, and Administrator acknowledged staffing challenges and confirmed that emergencies were managed by contacting the on-call Nurse Practitioner or Director of Nursing.
The facility did not conduct annual performance reviews for CNAs, as required. The DON, responsible for these reviews, had not completed them since the aides' employment began. Interviews confirmed the lack of recent appraisals, and the facility is recruiting an Assistant DON to address this issue.
The facility failed to maintain proper food safety standards, with observations of improper food temperatures and expired items. Staff interviews revealed a lack of adherence to protocols, and improper transport methods may have contributed to the issue.
The facility failed to develop and implement a QAPI plan to address issues from a large elevator outage, affecting food safety, resident dining arrangements, and live music activities. The elevator had been malfunctioning since spring 2024 and was shut down by mid-July, leading to operational challenges. Staff interviews revealed a lack of documentation and planning in QAPI meetings, with no documented plans for safe resident transport, food safety, or alternative activities.
The facility failed to provide annual training on resident abuse prevention as required by its policy. The Director of Nursing could not produce documentation for three out of five sampled CNAs, and staff interviews revealed uncertainty about when the training occurred.
The facility did not provide timely notification to a resident's designated representative regarding the termination of Medicare Part A services. The representative was informed via telephone only one day before the last covered day, instead of the required two-day notice. This deficiency was identified during a recertification survey.
The facility did not provide written notification to two residents and their representatives regarding hospital transfers, as required. One resident was transferred twice due to medical issues, and another was transferred after presenting with bruising and pain. Facility staff were unclear about who was responsible for providing these notifications.
A facility failed to notify a resident and their representative in writing about the bed hold policy during hospital transfers, as required by their policy and state regulations. The resident, with conditions including a urinary tract infection and type 2 diabetes, was transferred to the hospital twice without receiving the necessary written information. Interviews revealed a lack of responsibility and procedure for providing these notifications.
Two residents experienced falls without subsequent updates to their care plans. One resident, with a history of falls and conditions like dementia, fell twice in February without new interventions added. Another resident, identified as a high fall risk, fell in August, resulting in a hip fracture, yet their care plan remained unchanged. Staff interviews revealed a lack of consistent care plan updates and communication gaps among the facility's nursing staff.
Three residents with severe cognitive impairments did not receive timely personal hygiene care due to staffing shortages. Observations revealed residents in soiled briefs and rooms with strong odors, indicating a lack of necessary services. Staff interviews confirmed that staffing challenges affected the timeliness of care.
A resident with cognitive impairment and other health issues was observed with open red areas on their skin, which were not assessed or reported to medical staff. Despite having a care plan for skin care, facility staff failed to communicate the resident's skin changes, leading to a deficiency in care.
A resident at risk for pressure ulcers did not receive proper care as their heels were not offloaded while in bed, despite physician orders. Staff were unaware of the order due to poor communication and documentation in the electronic medical record system. The DON acknowledged delays in entering care plans, contributing to the deficiency.
Expired IV Vancomycin bags were found in a medication room, with expiration dates ranging from July to August. An LPN was unsure if the facility intended to return them to the pharmacy, while an RN Unit Manager confirmed they should have been discarded. The DON noted that multi-dose insulin vials are no longer used, and the LPN should not have administered insulin from an open vial labeled for another resident.
A facility failed to document a medication irregularity review for a resident receiving Enoxaparin. The pharmacist recommended a review for a stop date, but the provider did not document the plan in the medical record. The Nurse Practitioner later acknowledged the oversight, citing workload challenges.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications, specifically the anticoagulant Enoxaparin. Despite a pharmacy recommendation to discontinue the medication, it continued to be administered without proper documentation or a care plan. The oversight was attributed to communication lapses and an overlap in Nurse Practitioners, with the new NP not intending to discontinue the medication due to the resident's condition.
The facility did not store drugs and biologicals according to professional standards, as expired 22-gauge insyte autogaurd needles were found on a medication cart. An LPN stated that these needles should have been discarded, and the facility's policy lacked guidelines for storing such medical supplies.
A facility failed to ensure a resident's right to formulate advance directives due to inadequate assessment of the resident's cognitive capacity. The resident, with fluctuating cognition, had a MOLST form updated without a signed confirmation or involvement of a health care proxy. Conflicting cognitive assessments and lack of physician documentation on capacity contributed to the deficiency.
A resident with declining cognition was not promptly communicated about changes in their advance directives, including a Do Not Hospitalize order. The facility failed to inform the resident's representative of these changes and the resident's deteriorating condition, leading to confusion and distress after the resident's death.
A resident with a history of aggression physically assaulted another resident, and the facility failed to implement 30-minute safety checks as required. Despite the facility's policy on abuse prevention, there was no physician's order for monitoring, and no evidence of such monitoring being conducted. The DON admitted to not entering the order, and both an LPN and RN confirmed the lack of documentation, leading to a deficiency in protecting residents from abuse.
A resident alleged abuse during a vascular appointment, but the facility failed to investigate or report the incident to the state health department. The resident, with a history of delusional disorders, had a bruise attributed to a fall. Staff interviews revealed a lack of communication and documentation, and the facility administrator was unaware of the allegation until contacted by the Attorney General.
A facility failed to create a comprehensive care plan for a resident dependent on hemodialysis, despite having a physician order and documentation for dialysis procedures. Interviews revealed that nursing staff were responsible for care plan updates, but due to workload, the care plan was not completed, violating facility policy.
The facility failed to provide appropriate dialysis care for two residents. One resident lacked a dialysis communication book, and necessary assessments before and after dialysis were not consistently performed. Another resident had no comprehensive care plan for hemodialysis, and communication sheets were missing for several treatment dates. These deficiencies indicate a failure to adhere to professional standards of practice for dialysis care.
Three residents in an LTC facility received medications earlier than prescribed due to an LPN administering 5:00 PM medications between 2:23 PM and 2:31 PM. The LPN stated they were instructed by the DON to do so due to a lack of relief. The RN Unit Manager and Nurse Practitioner were unaware of the early administration, and the DON confirmed it was a medication error.
The facility failed to provide CNAs with the required 12 hours of annual training, including dementia care and abuse prevention. Documentation showed incomplete training hours, and interviews confirmed a lack of recent in-services. The Director of Nursing cited staffing issues as a reason for the shortfall.
Failure to Maintain Minimum CNA Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff, specifically Certified Nurse Aides (CNAs), to meet the needs of residents on all shifts over a two-month period. Staffing schedules for July and August 2025 showed that the facility did not meet its own minimum staffing requirements for CNAs on any day or evening shift and was below the minimum on most night shifts. The facility's staffing policy and assessment required a minimum of 11 CNAs for day and evening shifts and 6 for night shifts, but these levels were not achieved. Observations revealed unsupervised residents, foul odors, and strong smells of urine in resident areas, indicating lapses in care and supervision due to inadequate staffing. Interviews with residents and staff confirmed the impact of insufficient staffing. Residents reported long wait times for call bells, cold meals, irregular showers, and delays in receiving medications. CNAs described being unable to complete assigned tasks, such as getting residents out of bed, providing showers, and supervising common areas. They also reported difficulty in feeding residents and performing necessary transfers, especially when staffing dropped to three or fewer CNAs per shift. Registered Nurses (RNs) indicated that they were unable to complete medication passes and assessments on time due to the need to assist CNAs with basic care tasks. Facility leadership, including the Staffing Coordinator, DON, and Administrator, acknowledged ongoing staffing challenges and difficulties in recruitment and retention. The Staffing Coordinator noted that agency staff were unreliable and that the facility often relied on staff working double shifts. The Administrator admitted to being unaware of the role of the Facility Assessment in determining staffing needs. The Corporate Administrator stated that the Facility Assessment was intended to guide staffing decisions, but it was not reviewed with the new administrator. These actions and inactions led to the facility's failure to ensure adequate staffing to maintain the well-being of each resident.
Failure to Provide Required RN Coverage and Resident Assessment
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, for four out of nine weekends reviewed, there was no RN present in the building for periods ranging from 36 to 48 hours. During these times, the facility relied on Licensed Practical Nurses (LPNs) who would contact the Director of Nursing (DON) by phone for guidance, but there was no documentation that the DON or any other RN was physically present or had assessed residents during these periods. The facility's staffing policy and assessment indicated the expectation of having sufficient RN coverage, including the DON as a full-time RN and additional RN managers and supervisors, but these staffing goals were not met. During the periods when no RN was present, several incidents occurred involving residents. Two residents fell out of bed, with one sustaining a bloody nose and another complaining of hip pain, but neither was assessed by an RN. Another resident sustained a burn on the thigh and was not assessed by qualified staff until two days later by a wound care physician. Interviews with the staffing coordinator and DON confirmed that there were times when no RN was scheduled, and the DON would only provide guidance remotely without documentation of being on duty or assessing residents in person. The administrator acknowledged awareness of the RN staffing gaps, particularly on weekends and night shifts.
Failure to Ensure Timely RN Assessment and Documentation After Resident Incidents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of quality, as evidenced by the lack of timely assessment by a registered nurse (RN) following significant incidents involving three residents. In the first case, a resident with paranoid schizophrenia and neurocognitive disorder was found with three open wounds on the left hip, reportedly caused by a coffee burn. There was no documented evidence that an RN assessed the wounds in a timely manner after discovery, and staffing records confirmed that no RN was present in the facility for over 36 hours during the period when the wounds were identified and reported. Communication about the incident occurred via group text, but no RN assessment was documented until after the wound care physician evaluated the resident days later. In the second case, a resident with metabolic encephalopathy, dysphagia, and lupus experienced an unwitnessed fall and complained of hip pain. The incident was documented by an LPN, and the physician was notified with x-rays ordered. However, there was no documentation of an RN assessment following the fall, and staffing records indicated that no RN was on duty at the time. Interviews with staff revealed uncertainty about whether an RN assessment occurred, and the Director of Nursing could not recall the event or confirm that an RN had evaluated the resident prior to their transfer from the floor to the bed. The third case involved a resident with dementia, depression, and anxiety who was found on the floor with a bloody nose after an unwitnessed fall. The resident was assisted back to bed by LPNs without documented RN assessment prior to the move. There was also no evidence of 72-hour post-fall monitoring or treatment for the bloody nose. Staffing records again showed no RN on duty at the time, and interviews with staff and the Director of Nursing confirmed that the expected process of RN assessment and documentation was not followed. The Director of Nursing acknowledged being the backup when no RN was present but did not come to the facility or document any assessment.
Failure to Prevent and Investigate Recurrent Resident Burns from Hot Beverages
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and poor safety awareness, resulting in two separate burn incidents from hot beverages. The first incident occurred when the resident spilled hot chocolate on their thigh, which was not reported to staff until the following day. Documentation shows that the only intervention after this incident was resident education, and there was no thorough investigation or root cause analysis conducted to determine how the accident occurred or to prevent recurrence. The care plan was updated to address wound care but did not include specific interventions for hot beverage safety or increased supervision. A second burn incident occurred several months later when the same resident sustained second-degree burns after placing a hot cup of coffee next to their thigh while self-propelling in a wheelchair. Again, the facility did not conduct a root cause analysis or a comprehensive investigation to determine if the accident was avoidable. The only new interventions at the time were the provision of a lidded coffee mug and cupholder, but these were not promptly added to the resident's care plan or communicated to all relevant staff. The care plan update focused on wound care and supervision during meals but did not address burn prevention or hot beverage management until much later. Both burn incidents were not reported to the New York State Department of Health as required. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness regarding the need for a root cause analysis and timely reporting. There was also a delay in updating care plans and staff instructions to reflect necessary interventions for hot beverage safety, despite recommendations from the dietary team and discussions in morning reports.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for bathing did not consistently receive showers as specified in their care plan and personal preference. The facility's policy required individualized care to maintain residents' quality of life, including honoring preferences for bathing routines. Documentation showed that the resident was to receive showers twice weekly, specifically on Tuesday and Friday evenings. However, review of Certified Nurse Aide accountability records revealed that the resident received only 5 out of 9 scheduled showers in one month and only 3 showers in the following month. During interviews and observations, the resident confirmed that showers were not always provided as scheduled, and staff corroborated that there were occasions when the resident did not receive their shower on the assigned shift. The Staff Development LPN stated the resident did not refuse showers, and the DON acknowledged a pattern of incomplete documentation by CNAs on certain shifts. The resident's medical history included cerebrovascular disease, dysarthria, and asthma, and they were cognitively intact at the time of the deficiency.
Failure to Provide Individualized Continence Care and Toileting Program
Penalty
Summary
A deficiency was identified when a resident with occasional urinary and bowel incontinence was not provided with appropriate services to maintain or improve continence. The resident was admitted with intact cognition and required staff assistance for toileting, hygiene, and transfers. The care plan indicated the resident should be maintained on a toileting program to promote dignity and prevent skin breakdown, with interventions such as monitoring for skin issues and using easily removable clothing. However, there were no updates to the care plan after the initial entry, and documentation showed that a toileting program trial had not been attempted, despite the resident's increasing incontinence episodes. Observations and interviews revealed that the resident expressed a clear preference not to wear adult briefs and requested assistance to use the toilet. The resident reported that staff did not respond to their calls for help, resulting in episodes of incontinence. The family member confirmed that the resident was able to use the toilet when out with family and that wearing briefs was not good for the resident's skin. Staff interviews indicated that the resident was capable of being toileted with assistance, but a toileting program was not implemented, and staff cited insufficient staffing as a barrier to providing this care. Further interviews with clinical and rehabilitation staff confirmed that the resident had not been placed on a toileting program, and there was no recommendation against toileting from the rehabilitation team. The nurse practitioner stated that the resident should be trialed with voiding if they were aware of their need to use the bathroom, and the DON stated the resident was not on a voiding program due to requiring two-person assistance for transfers. The lack of individualized continence care and failure to honor the resident's preferences led to the deficiency.
Failure to Provide Timely Pharmaceutical Services Due to Lapses in Communication and Medication Management
Penalty
Summary
Pharmaceutical services failed to meet the needs of a resident who was prescribed eszopiclone for insomnia. The resident, who had diagnoses including bipolar disorder, Lupus anticoagulation syndrome, and insomnia, did not receive six consecutive doses of the medication. Documentation showed the medication was not administered over several days, with some days marked as unavailable and others lacking any documentation. The facility's medication administration policy required staff to check overflow supplies, emergency boxes, and to notify the medical provider and pharmacy if a medication was unavailable, but these steps were not consistently followed. The nurse did not contact the medical provider or pharmacy to obtain the medication or an alternative, and there was no documentation in the nurse progress notes regarding the missed doses or unavailability of the medication. The delay in administration was due to the need for prior insurance authorization, which was not obtained until after multiple missed doses. The resident reported the issue through a grievance, and interviews revealed that staff, including the LPN and DON, were aware of the medication's unavailability but did not take all required actions to resolve the issue or communicate with the medical provider in a timely manner. The pharmacy also indicated that prior authorization was necessary, but there was confusion about who was responsible for obtaining it and notifying the facility. The physician and nurse practitioner were not promptly informed of the missed doses, which delayed the possibility of ordering an alternative medication.
Failure to Address Elevator Outage in Facility
Penalty
Summary
The governing body of the facility failed to establish and implement effective policies for managing and operating the facility, specifically regarding the consistent operation of the large elevator. Since the spring of 2024, the large elevator was not functioning consistently, impacting meal delivery, evacuation processes, and the movement of larger items. Despite being aware of the issue, the facility did not ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to address the elevator's downtime. The facility's policy on 'Elevator Breakdown-Single Car Operation' was not effectively executed, as there was no documentation of interventions or plans to mitigate the impact of the elevator outage on residents and staff. During interviews, the facility owner/operator acknowledged awareness of the broken elevator but was uncertain if it was discussed in QAPI meetings, as they did not attend these meetings. They believed that staff maintained food temperatures and provided alternative activities during the elevator's downtime. The owner/operator also mentioned that the elevator had issues for several months, with repair delays due to unavailable parts and staffing problems at the elevator technician company. Despite these challenges, the facility owner/operator did not believe the broken elevator negatively impacted residents' safety or health.
Elevator Malfunction Leads to Unsafe Environment and Meal Delivery Issues
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the large elevator being out of order since the spring of 2024. This deficiency was observed during the recertification and abbreviated surveys conducted from September 5 to September 13, 2024. The facility's policy on 'Elevator Breakdown-Single Car Operation' was not effectively implemented, leading to significant disruptions in meal delivery, evacuation processes, and the movement of larger items. The large elevator's downtime impacted the quality of life and convenience for residents, as well as the provision of services. The breakdown of the large elevator resulted in meal trays being transported on un-insulated linen carts, which could not maintain safe food temperatures. This issue was confirmed by interviews with Activity Aides and the Food Service Director, who acknowledged that food temperatures were within the danger zone. The facility's inability to use the large, insulated meal truck due to the elevator's size constraints further exacerbated the problem. The Food Service Director and Supervisor admitted to not checking food temperatures on the units since the elevator shutdown, prioritizing speed over safety in meal delivery. The facility's administration and maintenance staff were aware of the elevator's issues but faced challenges in obtaining the necessary parts for repair. The Director of Maintenance documented multiple attempts to follow up with the elevator repair company, which was experiencing staffing problems and delays in part availability. The elevator's malfunction also affected resident activities, with several concert activities canceled due to the elevator's shutdown. Despite being aware of the situation, the facility owner/operator and Administrator did not have a clear timeline for the elevator's repair, contributing to the ongoing deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as observed during the recertification survey. On Unit 2, resident rooms were found with sticky floors, overflowing garbage receptacles, garbage strewn on the floor, and soiled adult briefs lying on the floor. On Unit 1, the floor near the nursing station and in front of the elevator was littered with garbage and appeared stained. Additionally, the Unit 1 dining room floor had dried spills of coffee, and breakfast trays were left on tables well past meal completion time. Interviews revealed that the facility was chronically understaffed, contributing to the inability to maintain cleanliness. A Certified Nurse Aide reported being overwhelmed with the responsibility of providing morning care, feeding, and assisting with housekeeping for 30 residents, which hindered the completion of all tasks. The facility's administrator acknowledged the need for additional training and oversight for housekeeping staff, despite having sufficient staff available during two shifts.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Firstly, the facility did not have a current Water Management Plan to address potential Legionella risks. Although a Facility Risk Assessment was provided, it lacked a comprehensive Water Management Plan detailing the water management team, flow diagrams, and control measures. This plan was not made available until several days into the survey. Additionally, the facility did not properly implement infection control precautions for residents with COVID-19. In one instance, a resident who tested positive for COVID-19 did not have appropriate signage on their door to indicate necessary precautions. The Director of Nursing acknowledged that signs should have been posted immediately upon receiving a positive test result, but this was not done. Furthermore, there was a breach in infection control practices during medication administration. An LPN was observed using a glucometer on multiple residents without sanitizing it between uses. The LPN admitted that the glucometer should be sanitized between residents, and the Unit Manager confirmed that nurses are responsible for this task. Additionally, the facility failed to implement Enhanced Barrier Precautions, as staff were not aware of these requirements. A resident with a urinary catheter did not have signage indicating Enhanced Barrier Precautions, and staff were not using appropriate personal protective equipment during care.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required, which led to a deficiency in monitoring antibiotic use. The undated Antibiotic Stewardship Policy stated that the facility should promote appropriate antibiotic use and track infections to reduce adverse events. However, during the recertification survey, it was found that the facility did not have documentation of tracking antibiotic use, including the appropriate use and duration of antibiotic treatment. Interviews revealed that the Registered Nurse Unit Manager was unaware of the term 'antibiotic stewardship' and did not track or report antibiotic use for residents in July and August 2024. The Director of Nursing/Infection Preventionist acknowledged their responsibility to track antibiotic use but admitted that it was not being done, and there was no list of infections or antibiotic use being maintained. The Administrator confirmed that the Nursing Department was responsible for monitoring antibiotic use, but this was not being completed.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist, who was the Director of Nursing, completed specialized training in infection prevention and control prior to assuming their role. During a recertification survey conducted from September 5 to September 13, 2024, it was found that the Director of Nursing only completed a 4-hour New York State Infection Control Mandatory Training Certificate on October 15, 2023. There was no documented evidence of any additional specialized training in infection control. On September 6, 2024, a request was made to review the documentation of the Infection Preventionist's specialized training. The review revealed the lack of further specialized training beyond the mandatory certificate. In an interview on September 9, 2024, the Director of Nursing confirmed that they did not have any other specialized training in infection control.
Deficiencies in Accident Hazard Prevention and Resident Supervision
Penalty
Summary
The facility failed to ensure that residents remained as free from accident hazards as possible, as evidenced by multiple incidents involving four residents. Resident #161 experienced falls on two occasions while on anticoagulant medication, yet there was no documented evidence of neuro-checks following these falls, nor was the resident sent to the hospital for evaluation. The facility's policy required neuro-checks and monitoring, but these were not documented in the resident's medical record. Additionally, the staff did not remind the physician of the resident's anticoagulant medication, which could have influenced the decision to send the resident to the hospital. Resident #35 had a loose and non-functional shepherd's hook/enabler rail for over a month, which affected their ability to perform daily bed mobility tasks. Despite the resident informing staff and maintenance about the issue, the repair was not completed. The maintenance team was aware that a full repair required the resident to be out of bed, but this was not coordinated, leading to prolonged inaction. The lack of communication between maintenance and nursing staff contributed to the delay in addressing the safety hazard. Resident #18 fell and sustained a hip fracture, yet their fall care plan was not updated with new interventions to prevent future falls. The resident reported that they attempted to go to the bathroom independently due to delays in staff response to call bells. The cluttered state of the resident's room and the lack of accessible call bells further contributed to the unsafe environment. Similarly, Resident #87 experienced multiple falls with major injuries, but their care plan was not updated with new interventions, indicating a systemic issue in the facility's approach to fall prevention and care plan management.
Chronic Staffing Shortages Impact Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of understaffing documented in the facility's records. The Facility-Wide Assessment indicated the necessary staffing levels, but the actual staffing sheets revealed that the facility was understaffed on numerous days across several months. This understaffing led to significant delays in resident care, with reports of residents waiting extended periods for assistance, such as waiting to be transferred out of bed or having their call bells answered. Residents and their family members reported various issues related to the staffing shortages. One resident mentioned waiting four hours for a response to their call bell, while another noted the absence of staff late at night. Observations during the survey revealed residents in soiled conditions and rooms with strong odors, indicating a lack of timely care. Interviews with residents and staff highlighted the chronic nature of the staffing issues, with staff being overwhelmed by the number of residents they were responsible for, leading to delays in care and incomplete tasks. The facility's management acknowledged the staffing challenges, citing difficulties in recruiting and retaining nursing staff. The Director of Nursing and the Administrator both noted that staffing shortages were a persistent issue, affecting the timeliness and quality of resident care. Despite efforts to recruit new staff and offer incentives for overtime, the facility continued to struggle with maintaining adequate staffing levels, impacting the overall well-being of the residents.
Deficiency in RN Staffing Requirements
Penalty
Summary
The facility failed to comply with the regulatory requirement of having a Registered Nurse (RN) on duty for at least eight consecutive hours per day, seven days a week. During the recertification survey conducted from September 5 to September 13, 2024, it was found that the facility did not have an RN on duty on specific dates, namely April 12, April 13, April 27, and May 18, 2024. This deficiency was identified through a review of nurse staffing reports and confirmed by interviews with the facility's Staffing, Human Resources and Payroll Coordinator, Director of Nursing, and Administrator. The Staffing Coordinator acknowledged the challenge of maintaining adequate staffing levels and stated that the facility does not use staffing agencies, relying instead on offering bonuses and incentives to staff for covering extra shifts. The Director of Nursing confirmed that there were instances when no RN was present in the building, and emergencies during such times would be managed by contacting the on-call Nurse Practitioner or the Director of Nursing. The Administrator also admitted uncertainty about the presence of an RN for the required hours and mentioned ongoing recruitment efforts for nursing staff.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that certified nursing aide performance reviews were completed at least once every 12 months for five certified nurse aides. During the recertification survey, it was found that the Director of Nursing/Staff Educator, who is responsible for documenting these reviews, had not completed annual performance appraisals for the aides since their employment began in November 2022. Interviews with the Director of Nursing and a certified nurse aide revealed that performance appraisals had not been conducted in recent years, despite the aides having been employed for over a year. The facility acknowledged the issue and mentioned ongoing recruitment for an Assistant Director of Nursing to assist in completing these reviews.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a dinner observation, the temperatures of meat, mashed potatoes, milk, and super shake were found to be outside the acceptable range for food safety. Additionally, perishable foods in the kitchen were not labeled and dated, and nonperishable foods were expired. The facility's policy required that food temperatures be taken before serving, but this was not adhered to, as evidenced by the improper temperatures recorded during the survey. Interviews with staff revealed a lack of awareness and adherence to food safety protocols. The Food Service Director acknowledged that consuming expired food could lead to food poisoning, and the Administrator was unaware that food was being served in the danger zone. The improper use of linen carts for transporting meal trays due to elevator size constraints further complicated the situation, potentially contributing to the temperature discrepancies. Expired food items, such as gravy mix, were also found in the emergency supply area, indicating a broader issue with food management and safety practices within the facility.
Failure to Address Elevator Outage in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to address the issues arising from the large elevator being out of service. The elevator had been malfunctioning since the spring of 2024 and was completely shut down by mid-July 2024. This led to several operational challenges, including the inability to maintain food at safe temperatures when served on the units, residents having to eat on disposable plastic plates, and approximately ten residents who previously ate lunch in the main dining room being unable to do so. Additionally, live music performances were halted for about two months due to the inability to transport equipment using the small elevator. Interviews with various staff members, including the Director of Activities, Director of Maintenance, and the Administrator, revealed that the broken elevator was not documented as a topic in QAPI meetings, nor was there a QAPI plan created to address the outage. The facility did not document any meetings or plans to ensure safe resident transport, maintain food safety, or provide alternative activities. The Director of Maintenance mentioned that Medsleds were put in place for emergency transport, but there was no documentation of this or any staff education on the matter. The facility also restricted admissions for residents who would be difficult to transport in an emergency, but again, this was not documented. The facility owner/operator was aware of the elevator issues but did not attend QAPI meetings and was unsure if the topic was discussed. They believed that food temperatures were maintained and were unaware of the cessation of live music performances. The Food Service Director admitted to not checking food temperatures on the units after the elevator shutdown, prioritizing quick delivery over safety checks. This lack of documentation and planning highlights the facility's failure to address the operational challenges posed by the elevator outage effectively.
Deficiency in Annual Abuse Prevention Training
Penalty
Summary
The facility was found deficient in providing annual training to staff on resident abuse prevention during the recertification and abbreviated surveys conducted from 9/5/24 to 9/13/24. The facility's policy mandates that employees receive training on abuse prevention upon employment and annually thereafter. However, the Director of Nursing was unable to provide documentation of such training for the past 12 months for three out of five sampled certified nurse aides. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, revealed that while they had been in-serviced on the facility's abuse protocol, they could not recall when the training occurred. This lack of documentation and uncertainty among staff indicates a failure to comply with the facility's policy and regulatory requirements.
Failure to Provide Timely Notification of Service Termination
Penalty
Summary
The facility failed to ensure that residents and/or their designated representatives were fully informed of their right to an expedited review of a service termination. Specifically, for residents receiving Medicare Part A services, the facility did not provide timely notification of the termination of services using the Notice to Medicare Provider Non-coverage form CMS-10123. This deficiency was identified during a recertification survey conducted from September 5, 2024, to September 13, 2024. The issue was evident in the case of one resident, who last received rehabilitative services on March 26, 2024. The resident's designated representative was informed of the service termination via telephone only one day prior to the last covered day, instead of the required two-day notification period. The social worker explained that the notice was given late because it was the day they received the notice to obtain the signature.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for hospital transfers, as required by regulations. Specifically, two residents were transferred to the hospital without receiving written notices. Resident #38, who had diagnoses including urinary tract infection and type 2 diabetes mellitus, was transferred to the hospital on two occasions, 5/17/24 and 5/29/24, due to medical issues such as altered mental status and minimal urine output. Despite these transfers, the facility did not provide written notification to the resident or their representative, as confirmed by the Director of Nursing, who stated that the facility does not provide such notifications. Similarly, Resident #18, with diagnoses including vascular dementia and chronic obstructive pulmonary disease, was transferred to the hospital on 8/3/2024 after presenting with bruising, nausea, and hip pain. Again, the facility failed to provide written notification to the resident or their representative about the transfer. Interviews with facility staff, including the Director of Social Work and the Director of Nursing, revealed a lack of clarity regarding responsibility for providing these notifications, with the Director of Social Work indicating that nursing staff were responsible, yet no written notifications were provided.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers, as required by their own policy and state regulations. Specifically, for one resident reviewed for hospitalization, there was no evidence that written notice of the bed hold policy was provided when the resident was transferred to the hospital on two separate occasions. The facility's policy mandates that residents and their representatives receive written information about the state's bed hold duration and payment amount before any transfer to a hospital or therapeutic leave. The resident involved had medical conditions including a urinary tract infection, retention of urine, and type 2 diabetes mellitus. The resident was discharged to the hospital twice, with discharge assessments documenting these transfers. Despite requests for documentation, the facility could not provide evidence of written notification of the bed hold policy for these transfers. Interviews with the Director of Social Work and the Director of Nursing revealed a lack of responsibility and procedure for providing such notifications, with the Director of Nursing stating that the facility does not provide written notification of the bed hold policy during hospital transfers.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive care plans with measurable objectives, time frames, and appropriate interventions for two residents who experienced falls. Resident #87, who had a history of falls and was at increased risk due to conditions such as dementia and depression, experienced falls on two occasions in February 2024. Despite these incidents, the fall care plan was not updated with new interventions to prevent further falls. Additionally, there was no documented evidence of an Accident/Incident Report for one of the falls, and the Director of Nursing was unable to locate the incident report for the fall on February 10, 2024. Resident #18, diagnosed with vascular dementia and other conditions, was identified as a high fall risk. This resident fell on August 2, 2024, resulting in a hip fracture. The fall care plan was not updated with new interventions following this incident, despite the resident's high fall risk status. The only new intervention noted at the time of the fall was to encourage the resident to call for assistance. However, the care plan itself did not reflect any changes or additions to address the increased risk of falls. Interviews with facility staff, including the Director of Nursing and a Registered Nurse Unit Manager, revealed a lack of consistent updates to care plans following falls. The Director of Nursing admitted to feeling overwhelmed and unable to consistently update care plans, while the Registered Nurse Unit Manager stated that new interventions should be added to care plans following falls. A Licensed Practical Nurse was unaware of recent falls and any new interventions for Resident #18, indicating a communication gap and lack of awareness among staff regarding the residents' care plans and fall prevention strategies.
Deficiency in Timely Personal Hygiene Care Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents received necessary services to maintain good personal hygiene, as observed during a recertification survey. Three residents, who required staff assistance for personal hygiene and toileting, did not receive morning care in a timely manner. Resident #45, with severe cognitive impairment and requiring assistance for personal hygiene and toileting, was observed in a soiled adult brief and pajama top, with morning care not yet provided due to short staffing. Resident #66, also with severe cognitive impairment, required assistance with toileting and was found with a soiled adult brief on the floor, and the room had a strong smell of urine. Morning care had not been completed for this resident either. Similarly, Resident #78, with severe cognitive deficits, was observed with feces on their hands and surrounding areas, indicating a lack of timely personal hygiene care. Interviews with staff, including the Director of Nursing and the Administrator, revealed that staffing shortages were a known issue, affecting the timeliness of resident care. The facility's policies emphasized the importance of providing necessary care to maintain residents' hygiene and dignity, but these were not adhered to due to insufficient staffing levels.
Failure to Assess and Report Skin Changes
Penalty
Summary
The facility failed to ensure that Resident #45 received treatment and care in accordance with professional standards of practice, specifically regarding the assessment and care planning for changes in the resident's skin condition. Resident #45, who has diagnoses including cognitive communication deficiency, chronic kidney disease, and generalized anxiety disorder, was observed with several open red areas on their skin, which were not assessed or reported to the Physician or Nurse Practitioner. The resident's care plan included interventions for skin care, but there was no documented evidence of assessment or notification of medical staff regarding the observed skin changes. Interviews with facility staff revealed that the resident's skin changes and itching were observed by multiple staff members, including a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), but were not reported to the appropriate medical personnel. The LPN admitted to observing the resident's scratching over a month ago and applying ointment without reporting it. The facility's Nurse Practitioner stated they were not informed of the resident's skin changes, and thus no assessment was conducted. The lack of communication and failure to follow the care plan's interventions led to the deficiency in providing appropriate treatment and care for Resident #45.
Failure to Prevent Pressure Ulcers Due to Inadequate Communication and Documentation
Penalty
Summary
The facility failed to ensure proper care to prevent pressure ulcers for a resident identified as being at risk. The resident, who had severe cognitive deficits and was at risk for pressure ulcers, had a physician's order to offload heels while in bed. However, during multiple observations, the resident's heels were found resting directly on the mattress without any offloading device or pillow, contrary to the care plan interventions and physician's recommendations. Interviews with staff revealed a lack of awareness and communication regarding the resident's care needs. Certified Nurse Aides and a Licensed Practical Nurse were unaware of the heel offloading order, and it was not discussed during morning rounds or change of shift rounds. Additionally, the electronic medical record system used by the staff did not display tasks related to heel offloading for the resident, and the Director of Nursing acknowledged delays in entering care plans into the system. This lack of communication and documentation contributed to the deficiency in care provided to the resident.
Expired Medications Not Removed Timely
Penalty
Summary
The facility failed to ensure the timely identification and removal of expired medications during a recertification survey. Specifically, several bags of IV Vancomycin with expiration dates ranging from July 17, 2024, to August 10, 2024, were found in the first-floor unit medication room. These expired medications were observed both in the refrigerator and on a shelf outside the refrigerator. The facility's policy, last revised in August 2023, mandates that discontinued drugs should be removed from the medication cart and disposed of according to the procedures outlined in the manual, and drugs should not be kept after their expiration date. During interviews, a Licensed Practical Nurse (LPN) expressed uncertainty about whether the facility intended to return the expired IV Vancomycin to the pharmacy. The LPN indicated that Registered Nurses (RNs) are responsible for checking expired IV medications. The Registered Nurse Unit Manager confirmed that the pharmacy was contacted to pick up the expired medications, but they were not collected, and acknowledged that the expired medications should have been discarded. Additionally, the Director of Nursing stated that the facility no longer uses multi-dose insulin vials and emphasized that the LPN should not have administered insulin from an open vial labeled for a different resident.
Failure to Document Medication Irregularity Review
Penalty
Summary
The facility failed to ensure that the attending provider documented in the resident's medical record that an identified medication irregularity had been reviewed and what actions, if any, had been taken to address it. This deficiency was identified during a recertification survey for a resident who was receiving Enoxaparin 40 mg injection. The consultant pharmacist recommended a review of the medication for a stop date and appropriate use based on diagnosis and patient mobility. Although the provider agreed with the recommendation and noted that the medication was discontinued, this was not documented in the resident's medical record. The Nurse Practitioner, who reviewed the drug regimen on a later date, stated that they did not discontinue the medication because it had already been discontinued and was necessary for the bed-bound resident. However, there was no documentation in the medical progress notes to reflect the provider's plan regarding the medication. The Nurse Practitioner acknowledged the oversight and the difficulty in documenting due to the large volume of work, but recognized the need to write a note in the patient's chart after reviewing and making changes.
Inadequate Monitoring of Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the anticoagulant Enoxaparin. The deficiency was identified during a recertification survey, where it was found that there was inadequate monitoring of the medication. The facility's policy requires a licensed pharmacist to review each resident's drug regimen at least once a month, with more frequent reviews depending on the resident's condition. However, for one resident, the medication regimen review recommendation from the pharmacy dated several months prior was not acted upon in a timely manner. The recommendation to discontinue the medication was signed by a Family Nurse Practitioner months later, but the medication continued to be administered without proper documentation or a care plan addressing potential side effects. Interviews with the Director of Nursing and the Nurse Practitioner revealed lapses in communication and documentation. The Director of Nursing acknowledged that the order should have been addressed and attributed the oversight to an overlap in Nurse Practitioners. The Nurse Practitioner, who started working at the facility after the initial recommendation, stated that they reviewed the recommendation but did not intend to discontinue the medication, as the resident was bed-bound and required it. Despite this, there was no documentation in the resident's medical record to reflect this decision, and the facility's process for updating medication orders was not followed, leading to the deficiency.
Expired Needles Found on Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored according to the manufacturer's specifications and professional standards of practice. During a recertification survey, it was observed that the 2nd floor unit south side medication cart contained expired 22-gauge insyte autogaurd needles, which are used for administering intravenous medications. The facility's policy on 'Storage of Drugs' did not include guidelines for the storage of medical supplies such as intravenous needles. On the specified date, three expired insyte autogaurd needles were found on the medication cart. A Licensed Practical Nurse (LPN) stated that these needles should not have been on the cart and should have been discarded. The LPN explained that the nurse responsible for starting an intravenous line should check the needle's expiration date, and the nurse with the medication cart keys should ensure all items in the cart are within their expiration range.
Failure to Ensure Resident's Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate advance directives, as evidenced by the handling of the Medical Orders for Life Sustaining Treatment (MOLST) for a resident with fluctuating cognitive abilities. The resident, who had a history of diabetes mellitus, a left above-knee amputation, osteomyelitis, and rheumatoid arthritis, initially completed a MOLST form indicating Do Not Resuscitate and Do Not Intubate orders, among other directives. However, the form was not signed, and there was no documentation confirming the physician's assessment of the resident's capacity to make such decisions at the time. Over time, the resident's cognitive status appeared to decline, as indicated by a Brief Interview for Mental Status score of 6, suggesting severely impaired cognition. Despite this, changes were made to the MOLST form, including the addition of comfort measures and a directive not to hospitalize, based on verbal consent witnessed by the social worker and psychiatric nurse practitioner. The resident's representative was not involved in these decisions, and there was no health care proxy in place to assist with care-related decisions. The situation was further complicated by conflicting assessments of the resident's cognitive abilities. While a psychologist noted the resident's inability to participate in psychological services due to cognitive deficits, the psychiatric nurse practitioner believed the resident was clear in expressing their wishes for comfort care. This discrepancy, along with the lack of a formal capacity assessment, contributed to the deficiency in ensuring the resident's right to formulate advance directives was upheld.
Failure to Notify Resident's Representative of Changes in Condition and Advance Directives
Penalty
Summary
The facility failed to promptly inform the designated representative of a resident about changes in the resident's condition and advance directives. The resident, who was admitted with diagnoses including metabolic encephalopathy, white matter disease, and delusional disorder, initially had intact cognition but later showed severely impaired cognition. Despite this, there was no documented evidence that the resident's representative was promptly informed of the change in the resident's advance directives to Do Not Hospitalize. The representative was not notified until after the resident's death, leading to confusion and distress as the representative was unaware of the resident's deteriorating condition and the decision not to hospitalize. The report highlights a communication breakdown within the facility, where the resident's representative was not adequately informed about critical changes in the resident's care plan. The Director of Social Work acknowledged that the Medical Orders for Life Sustaining Treatment were updated to comfort care and palliative care, but the representative was not informed in a timely manner. The representative expressed that they were not aware of the changes and had expected to be contacted for any necessary approvals. The facility's failure to ensure proper notification contributed to the representative's lack of awareness regarding the resident's condition and care decisions.
Failure to Implement Safety Checks for Aggressive Resident
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving Resident #14, who was known to have a history of physical and verbal aggression. On July 30, 2024, Resident #14 physically assaulted another resident by punching them in the stomach. Despite the facility's policy on abuse prevention, which includes monitoring and intervention strategies, the necessary 30-minute safety checks were not implemented to prevent further incidents. The facility's documentation and interviews revealed that there was no physician's order for the 30-minute monitoring, and no evidence was found that such monitoring was conducted. The deficiency was further highlighted by the lack of communication and follow-through among the facility's staff. The Director of Nursing admitted to not entering the order for the 30-minute monitoring, and both the Licensed Practical Nurse and Registered Nurse Unit Manager confirmed that the intervention was not documented in the physician's orders or the Medication Administration Record. This oversight in documentation and execution of safety measures contributed to the failure to protect the resident from further abuse, as required by the facility's policies and state regulations.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were thoroughly investigated and reported to the New York State Department of Health. This deficiency involved a resident who, during a vascular appointment, alleged abuse by a staff member after being questioned about a bruise on their forehead. The facility was informed of the allegation on the same day by the vascular provider, but the social worker and nurse practitioner attributed the bruise to a fall and did not investigate or document the allegation until over a week later. The resident, who had a history of delusional disorders, was admitted with multiple diagnoses including diabetes and rheumatoid arthritis. The resident was independent in cognition but dependent on assistance for transfers. The vascular clinic noted the resident had a large bruise on their forehead and was covered in feces. Despite the resident's insistence that they were attacked, the facility staff attributed the bruise to a fall that occurred days earlier, and no immediate investigation was conducted. Interviews with facility staff revealed a lack of communication and documentation regarding the alleged abuse. The Director of Nursing and other staff members believed the resident's confusion was due to a possible urinary tract infection and did not consider the allegation credible. The facility's administrator was unaware of the allegation until contacted by the Attorney General's office, and the facility did not report the incident to the state health department, believing it was unnecessary since the vascular nurse practitioner had already reported it.
Failure to Develop Comprehensive Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was dependent on hemodialysis. The deficiency was identified during a recertification and abbreviated survey, where it was found that the resident, who had a diagnosis of chronic kidney disease, diabetes, and obesity, did not have a care plan addressing their dialysis needs. Despite having a physician order for hemodialysis three times a week and documentation in a dialysis communication binder for vital signs to be taken before and after dialysis, there was no documented evidence of a care plan in the resident's medical health record. Interviews with the Director of Nursing and a Registered Nurse Unit Manager revealed that the responsibility for updating care plans lay with the nursing staff. However, the Director of Nursing acknowledged the absence of a care plan for the resident's dialysis dependency. The Registered Nurse Unit Manager admitted that due to frequent medication administration duties, they were sometimes unable to update care plans. This lack of a comprehensive care plan for the resident's dialysis needs was a violation of the facility's policy and regulatory requirements.
Inadequate Dialysis Care for Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents requiring such services, as identified during the recertification and abbreviated surveys. Resident #13, diagnosed with end-stage renal disease and dependent on renal dialysis, did not have a dialysis communication book available, which is essential for tracking vital signs and assessments before and after dialysis treatments. Despite the resident receiving hemodialysis at a community dialysis center three times a week, the necessary assessments were not consistently performed, as confirmed by the Registered Nurse Unit Manager and the Director of Nursing. The lack of consistent monitoring was attributed to potential staffing issues. Resident #162, who had diagnoses including kidney disease and type 2 diabetes, also did not receive adequate dialysis care. There was no comprehensive care plan documenting the required care related to hemodialysis treatments. Although the resident had a physician's order for hemodialysis three times a week, there were no communication sheets available for several dates when the resident was supposed to receive dialysis. The Clinical Manager of the Community Dialysis Center confirmed the resident's admission and discharge dates but could not recall if communication sheets were completed. This lack of documentation and oversight indicates a failure to adhere to professional standards of practice for dialysis care.
Medication Administration Errors Due to Early Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as observed during the recertification and abbreviated surveys. Three residents did not receive their medications in accordance with the prescriber's orders and accepted health standards. Specifically, medications such as antibiotics, antidiabetic pills, antihypertensives, inhalers for chronic obstructive pulmonary disease, and antipsychotics were not administered at the prescribed times. This occurred on a specific date when medications due at 5:00 PM were administered between 2:23 PM and 2:31 PM by a Licensed Practical Nurse (LPN). Resident #38, who had diagnoses including urinary tract infection and type 2 diabetes mellitus, was supposed to receive Methenamine Hippurate and Metformin at 5:00 PM, but these were administered early. Similarly, Resident #104, with conditions such as hypertensive heart failure and chronic obstructive pulmonary disease, was given medications like Carvedilol, Advair Diskus, Entresto, and Vitamin C earlier than prescribed. Resident #89, diagnosed with schizophrenia and dementia with agitation, received Olanzapine prematurely. The LPN responsible for these early administrations stated they did so because they needed to leave early and were instructed by the Director of Nursing to administer the medications before their shift ended. Interviews with the Registered Nurse Unit Manager and the Nurse Practitioner revealed that there was no authorization for early medication administration, and the situation was not communicated to the physician. The Director of Nursing confirmed that medications should not be given more than one hour before or after the ordered time and acknowledged that the early administration constituted medication errors. The facility's policy requires that any medication administration issues be reported and corrected, but this protocol was not followed in this instance.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of annual training, including education on dementia care management and resident abuse prevention. During a recertification survey, it was found that five CNAs did not complete the mandatory training hours. The Director of Nursing, responsible for documenting these in-services, could not provide sufficient evidence of the required training for the CNAs reviewed. Documentation provided showed only partial completion of the training hours, with some CNAs having as little as 30 minutes to 1 hour of training documented. Interviews conducted during the survey revealed that CNAs had not received recent in-services, although they had attended some in the past year. The Director of Nursing acknowledged the shortfall in training hours and attributed it to the current staffing situation, as the facility was in the process of hiring an Assistant Director of Nursing to help facilitate these in-services. The lack of adequate training was a violation of the New York State Department of Health requirements, which mandate at least 12 hours of annual training for CNAs.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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