River Ridge Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Amsterdam, New York.
- Location
- 100 Sandy Drive, Amsterdam, New York 12010
- CMS Provider Number
- 335422
- Inspections on file
- 19
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at River Ridge Living Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a pest-free environment in two private resident shower rooms and two main shower rooms, where dead and live ants and water bugs were observed on the floors. Housekeeping staff reported cleaning private showers every other day and notifying maintenance when pests were seen, but one aide acknowledged not cleaning a private shower because it was not used and they had only recently learned it existed. The Director of Maintenance described ants as an ongoing issue, stated that a pest control vendor provided monthly treatments, and reported that water in the two private showers was run weekly, while a maintenance staff member stated they ran water monthly and that it had last been run about six weeks earlier, relying on the Director of Maintenance to contact the pest control vendor when pests appeared.
The facility failed to uphold residents' dignity and care standards. A resident was given plastic utensils due to a shortage, another was left in distress without access to a call bell after dialysis, and a third did not consistently receive adaptive utensils. Staff on C Wing entered rooms without knocking, violating privacy. These actions compromised the quality of life for the residents.
A resident with end-stage renal disease, atrial fibrillation, and type 2 diabetes mellitus experienced issues with the facility's laundry process, resulting in missing personal clothing and a cell phone. The resident was unaware of the grievance process, and staff interviews revealed that resident laundry was often mishandled, leading to items not being returned. The facility's policy on personal property was not effectively implemented, contributing to the deficiency.
The facility did not ensure residents were aware of the grievance process, as grievance forms were not readily available, and residents could not file grievances anonymously. During a Resident Council meeting, residents reported they were unaware of the grievance process and did not know the Grievance Officer. Staff interviews revealed that grievance forms were not easily accessible, and there was no option for anonymous filing, indicating a lack of effective communication and training on the grievance policy.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with respiratory issues did not consistently receive prescribed oxygen therapy. Another resident's abuse allegation was not investigated or documented, and no care plan was implemented to address potential abuse. A third resident requiring dialysis lacked a care plan for managing their condition. These oversights highlight significant gaps in care management.
The facility failed to update the care plans for two residents, leading to deficiencies in care. One resident's care plan for respiratory therapy was not revised despite their refusal to use a C-pap machine, and another resident's care plan for musculoskeletal disorder was not updated after they consistently removed a positioning wedge. Staff interviews revealed a lack of awareness and communication regarding these issues, resulting in a failure to provide appropriate care.
The facility failed to prevent an elopement and improperly stored medication. A resident with dementia eloped due to inadequate door security and response to alarms. Another resident had discontinued medication left accessible in their room, contrary to policy. Staff did not follow procedures for alarm response and medication storage.
The facility failed to provide continuous oxygen therapy as ordered for several residents with respiratory conditions. One resident was observed without oxygen due to inadequate equipment setup, another received oxygen at a lower rate than prescribed, and a third was found without their oxygen supply in a common area. Staff interviews revealed inconsistencies in monitoring and ensuring proper oxygen administration.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. Observations and interviews revealed that staffing levels were often below the required minimum, leading to long wait times for assistance. Residents and staff reported frequent short-staffing, with staff having to perform additional duties and work extra hours. The administration acknowledged the staffing challenges and efforts to recruit and retain staff, but these were not always sufficient to meet residents' needs.
The facility's policy for drug regimen reviews lacked specific time frames for notifying the facility and physician of irregularities, as well as for physician response and nursing intervention. The DON was unaware of these deficiencies in the policy provided by the pharmacy.
A facility's medication error rate exceeded 5% due to improper administration by staff. One resident's medication was given to a family member to administer without supervision, and another resident received insulin without proper priming of the pen. Staff interviews confirmed these actions were against facility policy.
The facility failed to properly label and store medications, with insulin pens, vials, inhalers, and eye drops lacking open or expiration dates. A Novolog Kwik insulin pen was incorrectly stored, and discontinued medications were not disposed of according to policy. Staff interviews revealed confusion about medication management responsibilities.
Two residents experienced issues with meal service, receiving cold and incorrect meals that did not match their dietary tickets. Staff shortages and lack of communication led to unappealing and unappetizing food, with residents not being informed of substitutions. Complaints about cold food were common, and staff failed to verify meal accuracy.
A resident with dementia and other conditions did not consistently receive adaptive eating utensils as required by their care plan. Observations showed the resident lacked a built-up fork, and staff interviews revealed a shortage of adaptive utensils in the kitchen, leading to the deficiency.
The facility failed to maintain food safety and sanitation standards in the main kitchen and two kitchenettes. Observations revealed soiled equipment and surfaces, improper sanitizing solution testing, and maintenance issues such as scraped walls and duct-taped freezer panels. The administrator acknowledged the deficiencies and planned to address them with relevant staff.
The facility did not ensure proper labeling of food brought by family or visitors for residents on the A-Wing Unit. During a survey, it was found that two restaurant entrees in the kitchenette refrigerators were not labeled with the resident's name, date received, and use-by date, as required by the facility's policy. This was confirmed by an administrator who acknowledged the oversight.
The facility failed to maintain an effective infection prevention and control program, with deficiencies observed in dressing changes for two residents and isolation precautions for COVID-19 positive residents. LPNs did not adhere to proper hand hygiene and glove-changing protocols, leading to potential wound contamination. Additionally, isolation room doors were left open, and a water system assessment for Legionella was not completed.
A fly infestation was observed in a resident unit, with flies found in corridors and around a resident with a feeding tube. Staff and family members reported ongoing issues despite pest control efforts. The Administrator acknowledged the problem and noted recent pest control treatment.
A resident with chronic health conditions was observed self-administering nebulized medication without an assessment or physician's order, contrary to facility policy. Despite being cognitively intact, the resident had not been evaluated for their ability to safely self-administer medication, and nursing staff routinely allowed this practice without the required interdisciplinary assessment.
Two residents in an LTC facility were not given the opportunity to make choices about their care, leading to deficiencies. One resident, with sleep apnea, was not allowed to choose when to use their C-PAP machine, while another, returning from dialysis, was left waiting to be put to bed despite expressing exhaustion. Both cases showed a lack of communication and documentation of resident preferences, resulting in unmet needs and dissatisfaction.
A resident with severe cognitive impairment fell and sustained injuries due to neglect in a facility. A CNA, unfamiliar with the care plan, provided care alone instead of the required two-person assist, and floor mats were not in place as planned. This resulted in the resident rolling out of bed and suffering facial bruising and a laceration.
The facility failed to report allegations of abuse involving two residents within the required timeframe. One resident fell out of bed due to a CNA not following the care plan, and the incident was reported two days late. Another resident reported rough handling by an agency nurse, resulting in facial marks, but the incident was not reported to the state. The facility's policy requires immediate reporting of such incidents, which was not followed.
The facility failed to monitor the nutritional status and conduct necessary assessments for two residents, leading to unaddressed weight changes and lack of comprehensive care plans. One resident experienced significant weight loss without proper monitoring or dietary assessment, while another lacked a nutrition care plan and had outdated assessments. The transition to a new RD contributed to these oversights.
A resident with multiple medical conditions reported that an agency nurse was rough when applying a C-Pap mask, resulting in facial marks. The incident was communicated to a CNA, an LPN, and administration, but no investigation or required reporting to the Department of Health was conducted. The DON and administrator were aware of the allegation but did not document, investigate, or take further action, and the incident was only discovered during a survey review.
Failure to Maintain Pest-Free Conditions in Resident and Main Shower Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a pest-free environment and an effective pest control program in multiple shower areas, including two private resident shower rooms and two main shower rooms. During observations on 3/17/2026, dead and live insects, including ants and water bugs, were found in the private shower room of one resident room, and dead ants were found on the floor of another resident room’s private shower. Additional observations the same day revealed little black ants crawling on the floors of the Unit A and Unit C main shower rooms located across from specified resident rooms. These findings showed the presence of pests in resident shower areas that should have been maintained free of infestation. Interviews with staff revealed gaps in cleaning and maintenance practices related to these shower rooms. Housekeeping staff reported that private showers were cleaned every other day and that they notified maintenance when pests were seen, but one housekeeping aide stated they had been employed for about three months and only learned of one private shower a week prior, and had not cleaned it because it was not used. The Director of Maintenance stated that ants had been an ongoing problem attributed to residents dropping food, and that a pest control vendor provided monthly treatments, including a visit on the morning of 3/17/2025. The Director of Maintenance also stated that water in the two private showers was run weekly, while a maintenance staff member reported that they ran water in those showers monthly and that the last time water was run was about a month and a half earlier. Maintenance staff also indicated they relied on the Director of Maintenance to contact the pest control vendor when pests were observed, as they were not permitted to use spraying chemicals themselves.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promotes their quality of life. Resident #19 was provided with plastic utensils for their meal due to a shortage of silverware, which was acknowledged by the Kitchen Supervisor. The supervisor mentioned that the facility had run out of spoons and was unsure when new ones would arrive, leading to residents not receiving proper utensils for their meals. Resident #34, who was cognitively intact and required assistance for activities of daily living, was left in their wheelchair without access to a call bell after returning from an early morning dialysis appointment. The resident expressed distress and helplessness as they were unable to reach the call bell to request assistance to return to bed. Despite being aware of the resident's needs, staff failed to provide timely assistance, leaving the resident in discomfort for over an hour. Resident #38, who required adaptive utensils for meals, was not consistently provided with the necessary equipment. Observations revealed that the resident sometimes received the adaptive utensils and sometimes did not, depending on the kitchen's inventory. Additionally, staff on C Wing were observed entering residents' rooms without knocking, violating residents' rights to privacy and dignity. This behavior was noted among both nursing and housekeeping staff, indicating a systemic issue within the facility.
Failure to Maintain Resident's Personal Belongings
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, as evidenced by the mishandling of the resident's personal clothing and belongings. The resident, who was admitted with end-stage renal disease, atrial fibrillation, and type 2 diabetes mellitus, reported that their personal clothing was not laundered and returned in a timely manner. Specifically, the resident stated that they originally had 15 pairs of pants, but only 3 pairs were returned after laundry. Additionally, the resident reported a missing cell phone, which had not been found or returned. The resident was not informed about the grievance process and was unaware that they could file a grievance regarding their missing items. Interviews with facility staff revealed that the facility's laundry process involved sending linens to an outside company, and there was a system in place to differentiate between resident clothing and linens. However, staff often placed resident laundry in the wrong bags, resulting in items being sent out and sometimes not returned. The Director of Nursing acknowledged the issue and stated that the facility was attempting to move all laundry in-house. The Social Worker was unaware of the resident's missing items and stated that grievance forms were available, but the resident's complaint had not been brought to their attention. The facility's policy on personal property emphasized respect for resident belongings, but the inventory of personal items was not documented upon the resident's admission, contributing to the deficiency in maintaining a homelike environment.
Deficiency in Resident Grievance Process Awareness
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, as evidenced by the lack of readily available grievance forms and the inability for residents to file grievances anonymously. During a Resident Council meeting, all seven residents present reported they were unaware of the grievance filing process and did not know who the Grievance Officer was. Instead, residents typically brought their concerns to the Unit Manager, but felt these concerns were not always addressed. The facility's policy required quarterly education on the grievance process, but this was not effectively communicated to the residents. Interviews with facility staff revealed further issues with the grievance process. The Director of Social Work, who served as the Grievance Officer, acknowledged that grievance forms were not easily accessible to residents and that there was no option for anonymous filing. Although forms were kept in specific locations, residents had to request them, which posed a barrier. The Director of Nursing also confirmed the lack of an anonymous filing option and was unaware of the grievance process details, indicating a lack of staff training and communication regarding the grievance policy.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident #24, who was diagnosed with chronic obstructive pulmonary disease, emphysema, and acute respiratory failure with hypoxia, was not consistently provided with the prescribed continuous oxygen therapy. Observations revealed that the resident was often without supplemental oxygen, despite a physician's order for continuous oxygen delivery via nasal cannula. Interviews with staff indicated a lack of understanding and adherence to the oxygen therapy order, contributing to the deficiency. Resident #32, who had osteomyelitis, obstructive sleep apnea, and a wound infection, reported an allegation of abuse that was not investigated or documented by the facility. The resident experienced rough handling by a staff member while using a C-PAP machine, resulting in a red mark on their nose. Despite the resident's report and visible evidence of the incident, the facility failed to address the allegation, involve social work, or implement a care plan to protect the resident from potential abuse. Resident #73, diagnosed with end-stage renal disease requiring dialysis, dysphagia, and anemia, did not have a comprehensive care plan for dialysis management. The resident's care plan lacked goals and interventions related to dialysis, which is critical for managing their kidney disease and fluid balance. The absence of a structured care plan for dialysis was acknowledged by the nursing staff, highlighting a significant oversight in the resident's care management.
Failure to Update Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team for two residents, leading to deficiencies in care. For Resident #32, the care plan for respiratory therapy was not updated to reflect the resident's refusal to use their C-pap machine for severe sleep apnea. Despite multiple refusals documented in the Treatment Administration Record, there was no evidence in the care plan of these refusals or any physician notification. Observations revealed that the resident was using oxygen via a nasal cannula without a corresponding order or regular monitoring of oxygen saturation levels. Interviews with staff indicated a lack of awareness regarding the broken C-pap mask and the resident's refusal to use it, highlighting a communication gap and failure to update the care plan accordingly. For Resident #68, the care plan for musculoskeletal disorder was not revised after the resident consistently removed a wedge intended for positioning between their thighs. Observations and interviews with staff revealed that the resident frequently removed the wedge or pillow, and alternative interventions had been trialed unsuccessfully. Despite these challenges, the care plan was not updated to reflect the resident's refusal or the ineffectiveness of the intervention. The Director of Rehabilitation acknowledged that the care plan should have been updated when the intervention was deemed inappropriate. The facility's policies require that care plans be revised when there are changes in a resident's condition or when interventions are no longer effective. However, in both cases, the care plans were not updated to reflect the residents' refusals or changes in their care needs. This oversight resulted in a failure to provide appropriate and individualized care, as required by the facility's policies and regulations.
Deficiencies in Supervision and Medication Storage
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for two residents. Resident #58, who was cognitively impaired and had a history of wandering, was able to elope from the facility. The door alarm near the C wing was activated, but the responding LPN did not see anyone near the door and turned off the alarm without conducting a head count. Resident #58 was later found in the parking lot by two nurses returning from their break. The facility's elopement policy was not followed, as the side doors did not have the required 15-second egress delay, allowing the resident to exit the building. Resident #74 had a container of triamcinolone acetonide cream stored on their nightstand, which was accessible to the resident and others entering the room. The cream was no longer prescribed for the resident, as the order had been discontinued. Despite this, the cream was left in the resident's room instead of being stored in the medication cart, as required by facility policy. Interviews with staff revealed that the resident was not assessed to self-administer medication, and the cream should have been removed from the room once it was no longer in use. The facility's policies on accidents and incidents, as well as wandering and elopement, were not adequately implemented, leading to these deficiencies. Staff interviews indicated a lack of adherence to procedures, such as conducting head counts after alarms and ensuring medications are stored securely. These oversights contributed to the unsafe conditions observed during the survey.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards for four residents who required oxygen administration. Resident #24, diagnosed with chronic obstructive pulmonary disease, emphysema, and acute respiratory failure with hypoxia, was observed without supplemental oxygen on multiple occasions, despite a physician's order for continuous oxygen via nasal cannula. The resident reported that the oxygen tubing did not reach the bathroom, and staff did not ensure the use of a portable oxygen tank attached to the wheelchair, leading to periods without oxygen. Resident #34, with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia, was observed receiving oxygen at a lower rate than prescribed. The oxygen concentrator was set at 3.5 liters instead of the ordered 4 liters. The resident stated they were always on 4 liters of oxygen, but staff interviews revealed inconsistencies in monitoring and adjusting the oxygen levels, with some staff unaware of the correct settings. Resident #61, diagnosed with chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, was found without their prescribed oxygen while in a common area. The resident indicated they were supposed to be on oxygen continuously but did not have an oxygen bottle in their wheelchair holder. Staff interviews confirmed the resident should have been on continuous oxygen, but there was a lack of clarity and follow-through in ensuring the resident had access to the necessary equipment.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of staffing levels falling below the minimum requirements from January 1, 2025, to March 17, 2025. Observations and interviews revealed that the facility was consistently understaffed, particularly during day and evening shifts. The staffing schedule showed that on several occasions, the number of Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides on duty did not meet the facility's assessed minimum staffing levels. This shortage led to delays in responding to call bells and prolonged wait times for residents needing care. Interviews with residents, family members, and staff highlighted the impact of insufficient staffing on resident care. Residents reported being placed on the back burner and experiencing long waits for assistance. Staff members, including Certified Nurse Aides and Registered Nurses, confirmed the frequent short-staffing, which required them to perform additional duties and work beyond their scheduled hours. The facility's administration acknowledged the staffing challenges and their efforts to recruit and retain staff through bonuses and agency use, yet these measures were not always sufficient to meet the residents' needs. The Director of Nursing also recognized the persistent staffing issues, particularly on weekends, which resulted in residents waiting for care.
Lack of Time Frames in Drug Regimen Review Policy
Penalty
Summary
The facility failed to ensure the development of comprehensive policies and procedures for the monthly drug regimen review process. Specifically, the policy titled 'Long Term Care Solutions, Drug Regimen Review' lacked defined time frames for critical steps in the process. These steps include the notification of the facility and physician by the pharmacist upon identifying irregularities, the time allowed for the physician to respond to the report, and the time frame for nursing staff to address issues requiring intervention. The absence of these time frames in the policy indicates a gap in the facility's protocol for managing drug regimen reviews. During the recertification survey, it was noted that the policy did not specify the time frames for when the pharmacist should notify the facility and physician of any irregularities, nor did it outline how long the physician had to respond or how long the nursing staff had to address identified issues. The Director of Nursing acknowledged during an interview that the policy was provided by the pharmacy and was unaware of its deficiencies. This oversight in policy development could potentially impact the timely and effective management of residents' medication regimens.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% during a recertification survey. This deficiency was observed in two residents. The first resident, diagnosed with Alzheimer Disease, osteoarthritis, and constipation, was involved in an incident where an LPN allowed the resident's wife to administer Metamucil powder without supervision, contrary to facility policy. The LPN then inaccurately documented that the medication had been administered. Interviews with other nursing staff and the Director of Nursing confirmed that family members are not permitted to administer medications without a proper assessment and physician order. The second resident, with diagnoses including diabetes mellitus type 1, chronic kidney disease, and hypertension, was involved in an incident where an LPN failed to prime an insulin Kwik Pen before administering the prescribed dose of Humalog. The LPN was unaware of the requirement to prime the pen with each use, indicating a gap in knowledge despite the facility's training protocols. The Director of Nursing confirmed that all nurses receive training on medication administration, including insulin, and are observed by a preceptor before administering medications independently.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that medication carts in A, B, and C Wings, as well as a medication room in C Wing, contained insulin pens, vials, inhalers, and eye drops without open or expiration dates. Additionally, a Novolog Kwik insulin pen was incorrectly stored in a bag labeled for Degludec insulin, and two bottles of Megace liquid were found to be discontinued. Furthermore, an opened bottle of Jevity Tube feed and a black extra-large ice pack belonging to a discharged resident were improperly stored in the medication room refrigerator. The facility's policies and procedures require that all drugs and biologicals be stored safely and securely, with expiration dates checked prior to administration. Insulin pens should be clearly labeled with the resident's name, and discontinued medications should be returned to the pharmacy or destroyed. However, observations revealed that these protocols were not consistently followed. Interviews with staff, including an LPN and the Director of Nursing, indicated a lack of clarity regarding the collection and disposal of discontinued medications, as well as the responsibility for ensuring medication carts are clean and orderly.
Deficiency in Meal Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for two residents. During a resident council meeting, one resident complained that meals were consistently cold, unappealing, and often arrived with incorrect or missing items. An observation confirmed that the resident received a meal that did not match their lunch ticket, and the food temperatures were below the expected levels. The kitchen supervisor admitted to being short-staffed and not having the requested items, leading to the resident receiving a regular meal without being informed of the substitution. Another resident also experienced issues with meal service, receiving a tray that did not match their dietary ticket. The resident's meal was cold, and the food was not as ordered, leading to the resident consuming only a small portion of the meal. The resident expressed that the food was often inedible, prompting their family to bring food from outside. A certified nurse aide confirmed that cold food was a common complaint and that substitutions were made without informing the residents. Interviews with staff revealed a lack of communication and verification processes regarding meal substitutions and tray accuracy. The registered dietician acknowledged the need for residents to be informed of substitutions and expressed unfamiliarity with the resident's preferences. The facility administrator noted ongoing staff changes and common food complaints, emphasizing the need for staff to verify meal tickets and address issues with cold or disliked food promptly.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident with dementia, hypertension, and type 2 diabetes, who required adaptive devices to eat independently. The resident's care plan specified the need for a built-up fork, knife, and spoon with meals, as recommended by physical and occupational therapy. However, during observations, the resident was found without the necessary adaptive fork and sometimes received a regular curved spoon instead of the required built-up utensils. The resident confirmed that they occasionally did not receive the adaptive fork. Interviews with staff revealed that the kitchen sometimes lacked the necessary adaptive utensils, and the kitchen supervisor acknowledged the shortage and uncertainty about when new items would arrive. A Certified Nurse Aide confirmed that the resident was supposed to have built-up utensils, but availability depended on the kitchen's stock. A Registered Nurse stated that staff should verify meal trays for accuracy and contact the kitchen if items were missing, but this procedure was not followed, leading to the deficiency.
Food Safety and Sanitation Deficiencies in Kitchen and Kitchenettes
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 the recertification survey, it was observed that the main kitchen and two of the three kitchenettes had several deficiencies. In the main kitchen, the test papers used to check the sanitizing solution did not have the correct graduation for measuring the quaternary ammonium compound, which is necessary to ensure the efficacy of the sanitizer. Additionally, various items such as bulk food containers, shelving, sheet pan racks, stoves, and the floor under cooking line equipment were found to be soiled with food particles. In the A-Wing and B-Wing kitchenettes, similar issues were noted. The microwave oven, refrigerator, and floors were soiled with food particles and dirt. The plastic panels in the freezer sections of the refrigerators were covered with white duct tape, and the walls were scraped with holes present. These observations indicate a lack of proper cleaning and maintenance in the food service areas, which could compromise food safety. During an interview, the administrator acknowledged these issues and mentioned plans to discuss them with the dietary, housekeeping, and maintenance staff.
Improper Labeling of Resident Food Brought by Family
Penalty
Summary
The facility failed to ensure that food brought for residents by family or visitors was stored safely and distinctly from facility food on the A-Wing Unit. During a recertification survey, it was observed that two restaurant entrees stored in the resident unit kitchenette refrigerators were not properly labeled with the resident's name, date received, and use-by date, as required by the facility's policy. This policy, documented in a document titled 'Food Brought by Family/Visitors' dated November 2024, mandates that all food brought to residents must be labeled accordingly. The deficiency was confirmed during an interview with Administrator #1, who acknowledged that the staff should have labeled the food and indicated that staff would be re-educated on this requirement.
Infection Control Deficiencies in Dressing Changes and Isolation Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a recertification and abbreviated survey. Specifically, the facility did not ensure proper infection control practices during dressing changes for two residents with pressure sores. For one resident, an LPN did not set up a clean field or perform proper hand hygiene during a dressing change, leading to contamination of the wound. The LPN failed to sanitize hands between glove changes and did not maintain a clean technique, which was acknowledged during an interview. Another resident experienced similar deficiencies during a dressing change performed by a different LPN. The LPN did not change gloves or sanitize hands after touching drainage and contents from inside the wound, leading to potential contamination. Despite recent training on infection control and dressing changes, the LPN did not adhere to the proper procedures, as confirmed by a registered nurse during an interview. Additionally, the facility did not maintain isolation precautions for residents who tested positive for COVID-19. Doors to isolation rooms were left open, contrary to droplet precaution protocols. Staff interviews revealed a lack of adherence to these precautions. Furthermore, the facility failed to complete a water system environmental assessment for Legionella within the past year, as confirmed by the facility administrator.
Fly Infestation in Resident Unit
Penalty
Summary
The facility failed to maintain a pest-free environment and an effective pest control program on one of its resident units, as evidenced by a small fly infestation. Observations on March 11, 2025, revealed little black flies in the corridors near several rooms and around a resident with a feeding tube on the C-Wing. The following day, flies were observed around staff serving meal trays. A family member reported that the infestation was severe enough to cover the television in a resident's room, noting that removing trash helped alleviate the issue. A Certified Nurse Aide mentioned that the black flying bugs had been present since their hiring, despite the facility having a pest control vendor. The Administrator acknowledged awareness of the fly problem and indicated that a pest control vendor had treated the issue the previous week.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that an interdisciplinary team assessed a resident's ability to safely self-administer medication when clinically appropriate. Specifically, a resident with chronic systolic congestive heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease was observed self-administering nebulized medication in the solarium without having been assessed for their ability to do so safely. The facility's policy required that residents could only self-administer medications if the attending physician and the interdisciplinary care planning team determined they had the decision-making capacity to do so safely. The resident was cognitively intact and understood the self-administration process, as evidenced by their ability to articulate the frequency and method of their medication administration. However, a previous assessment indicated the resident expressed no interest in the self-medication program, and no further evaluation was conducted. Despite this, nursing staff routinely handed the resident their medication for self-administration without a formal assessment or physician's order, contrary to the facility's policy. Interviews with nursing staff and the Director of Nursing confirmed that the resident did not have the necessary assessment or order to self-administer their medication.
Failure to Respect Resident Choice in Care Planning
Penalty
Summary
The facility failed to ensure resident self-determination and choice for two residents, leading to deficiencies in care. Resident #32, who was cognitively intact and had a history of heart failure, obstructive sleep apnea, and osteomyelitis, was not given the choice of when to use their C-PAP machine. The resident expressed that the mask was often offered too early, interfering with their evening activities, and was not offered again if initially refused. Despite the resident's repeated requests for a more suitable schedule, the care plan did not reflect their preferences, and staff were unaware of the resident's concerns until the survey. Resident #34, diagnosed with end-stage renal disease, COPD, and anxiety, was not allowed to return to bed after early morning dialysis sessions, despite expressing exhaustion and pain. The resident was left in a wheelchair without access to a call bell and had to wait for assistance to return to bed. The care plan did not document the resident's preference to rest after dialysis, and staff were unaware of the resident's needs, leading to delays in care and the resident feeling upset and helpless. Both cases highlight a lack of communication and documentation regarding resident preferences, resulting in unmet needs and dissatisfaction. The facility's failure to incorporate resident choices into care plans and schedules contributed to the deficiencies observed during the survey.
Neglect Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall and injury. A Certified Nurse Aide (CNA) provided care to a resident who was care planned to require a two-person assist for bed mobility and transfers. During the care, the CNA turned the resident, causing them to roll out of bed and fall to the floor. This incident led to the resident sustaining ecchymosis to the right facial area and a laceration above the right eye. The resident involved had a history of vascular dementia, epilepsy, and major depressive disorder, with severe cognitive impairment. The care plan for the resident included the use of floor mats on both sides of the bed to prevent falls, which were not in place at the time of the incident. The CNA involved was from a staffing agency and was not familiar with the resident's care plan, leading to a break in protocol. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, confirmed that the care plan was not followed. The CNA provided care alone, contrary to the requirement for a two-person assist, and the absence of floor mats further contributed to the resident's fall. The facility's failure to adhere to the care plan and ensure proper staffing and equipment placement resulted in the resident's injury.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe. For Resident #14, an incident occurred where a Certified Nurse Aide did not follow the care plan, resulting in the resident falling out of bed and sustaining injuries. This incident was not reported to the New York State Department of Health until two days later, despite the requirement to report such incidents within two hours. The Director of Nursing and the Administrator were not made aware of the incident until two days after it occurred, leading to a delay in reporting. Resident #32 reported an incident where an agency nurse was rough while placing a C-pap mask, resulting in marks on the resident's face. The resident informed a Certified Nurse Aide and a Licensed Practical Nurse about the incident, but it was not reported to the New York State Department of Health. The Administrator and Director of Nursing were aware of the incident but did not report it, as they believed the resident had not been abused. There was no documentation to support their decision not to report the incident. The facility's policy requires all allegations of abuse, neglect, or exploitation to be reported immediately to the appropriate authorities. However, in both cases, the facility failed to adhere to this policy, resulting in a deficiency. The lack of timely reporting and investigation of these incidents highlights a failure in the facility's processes for handling allegations of abuse.
Failure to Monitor Nutritional Status and Conduct Assessments
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and provide nutrition care and services consistent with the residents' comprehensive assessments for two residents. Resident #51, who was at risk for weight changes due to conditions such as Parkinson's Disease, lymphoma, and severe protein-calorie malnutrition, did not have their weight monitored as indicated in their care plan. The resident experienced significant weight loss, and a quarterly dietary assessment was not completed. Interviews revealed that the resident was a picky eater and often refused supplements, preferring a jelly sandwich instead. A scheduled interdisciplinary team meeting to address the resident's nutritional status was canceled due to a survey, and the transition to a new Registered Dietitian contributed to the oversight in completing the dietary assessment. Resident #64, diagnosed with chronic congestive heart failure, acute respiratory failure, and chronic kidney disease, also did not receive appropriate nutritional care. The resident's weight was not monitored as scheduled, and there was no comprehensive care plan regarding nutrition. The most recent nutrition assessment was from a year ago, and quarterly assessments were not conducted. Interviews indicated that the resident should have had a nutrition care plan, which was typically completed by the Registered Dietitian, but this was not in place. The facility's policy required nutritional assessments to be conducted upon admission, quarterly, and as needed based on changes in condition. However, these assessments were not completed for the residents in question, leading to a failure in recognizing, evaluating, and addressing their nutritional needs. The Director of Nursing acknowledged the oversight and attributed it to the transition to a new Registered Dietitian, who did not complete the necessary assessments despite repeated requests.
Failure to Investigate and Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was thoroughly investigated and reported in accordance with its own policy and regulatory requirements. The incident involved a resident with diagnoses including heart failure, obstructive sleep apnea, and osteomyelitis of the spine, who was cognitively intact and able to communicate. The resident reported that an agency nurse was rough when placing a C-Pap mask, causing the strap to hit their face and the mask to be applied too tightly, resulting in marks on the resident's face. The resident communicated this to a Certified Nurse Aide and later to an LPN, and the incident was also reported to administration. Despite the resident's report and visible marks, there was no documented evidence that the facility initiated an investigation or reported the incident to the Department of Health as required. The administrator and DON were both made aware of the allegation, but neither took steps to investigate, document, or report the incident. The DON acknowledged that an investigation should have been conducted and the accused staff member removed from resident care, but no such actions were taken. The agency nurse involved did not return to the facility, and the resident's family also raised concerns with a unit manager who was no longer employed at the facility. The facility's policy required immediate and thorough investigation of all abuse allegations, including documentation, staff interviews, and timely reporting to authorities. However, these procedures were not followed in this case, and the incident only came to light during a survey review, nearly two months after the alleged event. There was no documentation of any investigation, interviews, or findings related to the incident, and the required notifications to the Department of Health were not made within the mandated timeframe.
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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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