Ross Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Brentwood, New York.
- Location
- 839 Suffolk Avenue, Brentwood, New York 11717
- CMS Provider Number
- 335159
- Inspections on file
- 19
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Ross Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple fractures and intact cognition reported to an LPN during the night shift that a staff member from the prior shift had verbally threatened to further injure the resident’s already injured arm. The LPN immediately informed the RN supervisor, who interviewed the resident and initiated an incident report but did not promptly notify the DON or ADON. Administration was not informed until the next morning, and the allegation was not reported to the state health department until the following day, exceeding the required two-hour reporting timeframe. The facility’s abuse policy lacked specific reporting timeframes, and interviews with the DON, ADON, Administrator, and Medical Director showed they were unaware that all alleged abuse must be reported to state authorities within two hours, regardless of injury, and the allegation was not documented in the resident’s medical record.
Three LPNs failed to follow Enhanced Barrier Precautions during medication administration and wound care, leading to infection control deficiencies. One LPN did not wear a gown while administering IV medications to a resident with a central catheter, another did not wear a gown for a resident with a Gastrostomy tube, and a third did not maintain a clean field or perform hand hygiene during wound care. These actions were contrary to the facility's infection control policies.
The facility failed to ensure the Medical Director's participation in quarterly QAPI meetings, as required by policy. The Medical Director did not sign attendance sheets for any 2024 meetings, and interviews revealed discrepancies in their involvement. The Director of Nursing stated the Medical Director only attends quarterly meetings, while the Administrator confirmed they do not physically attend but are briefed afterward.
The facility did not ensure that corridor doors were smoke-resistant, as required by NFPA standards. During a survey, it was found that the double doors to the Electrical Closet had a manual bolt, preventing proper latching and smoke resistance. This issue was present on all resident floors, and the Director of Maintenance acknowledged the problem.
A survey found that electrical receptacles in resident areas on the 6th Floor had not been inspected annually as required, with inspection stickers dated January 2023. Additionally, an outdoor outlet near the Physical Therapy Room was damaged. The Director of Maintenance acknowledged these issues.
The facility did not ensure full protection by an approved sprinkler system, as required by NFPA 101 standards. Observations revealed missing escutcheons, concealed caps, and ill-fitting or missing ceiling tiles around sprinklers in various areas, including a resident room. Additionally, sprinklers on the 5th Floor were spaced too far apart, exceeding the maximum coverage area. The Director of Maintenance acknowledged these issues and stated that corrective measures would be taken.
During a life safety code recertification survey, it was found that the facility did not maintain fire hoses in accordance with NFPA standards. The hoses in Stairwell B on the basement and 1st Floor were stamped with a date of 4/2015, indicating they had not been tested or replaced within the required five-year period. The Director of Maintenance acknowledged the issue.
A survey identified deficiencies in the smoke barrier walls of an LTC facility, which did not meet the required ½-hour fire resistance rating. Observations included openings around cables and a missing junction box cover, compromising the integrity of the smoke barriers.
The facility was cited for improper garbage disposal as garbage bins in the kitchen and pickup area lacked lids, leaving waste exposed. This was against the facility's policy requiring covered, leak-proof containers. Staff confirmed the absence of lids, and the Administrator contacted the vendor to address the issue.
A resident with limited range of motion did not receive prescribed exercises due to staff oversight and documentation errors. Despite physician orders for daily exercises, staff interviews revealed a lack of awareness and execution of the care plan, with inaccurate documentation indicating exercises were completed. The facility's Director of Nursing acknowledged the need for improved staff training and oversight.
A resident was not provided with ordered Range of Motion exercises, despite documentation indicating otherwise. The resident, who required assistance with daily activities, reported not receiving exercises for months. Staff interviews revealed inconsistencies in care provision and documentation, with some staff unaware of the resident's care plan. The facility's policy required accurate documentation, but staff failed to adhere to this, leading to inaccurate records.
A facility failed to adhere to its policy prohibiting LPNs from administering IV medications through a central line, resulting in an LPN administering antibiotics via a PICC to a resident with impaired cognition. The LPN was unaware of the line type and had not received adequate training. Interviews revealed a lack of communication and oversight in medication administration processes.
A resident with severe cognitive impairment and existing ulcers did not receive necessary pressure-relieving devices or preventative measures, as required by facility policy. Observations showed the absence of heel booties, offloading, and a pressure-reducing mattress. Documentation and staff interviews revealed lapses in care, including missing orders and care plans for turning and repositioning, contributing to the deficiency.
A Life Safety Code survey revealed that a corridor wall in the facility did not meet NFPA 101 standards, as a door assembly failed to form a smoke barrier. An opening above the door frame in the Electrical Closet on the Lobby Floor was covered with wallpaper and a screw. The Director of Maintenance and Administrator acknowledged the issue, noting the door assembly was installed a year ago.
During a Life Safety Recertification survey, a facility was found non-compliant with NFPA 70 standards due to improper use of extension cords and power strips. Unmounted power strips were observed in the Dietary office, and extension cords were plugged into a power strip in the Dietician's office, violating electrical safety codes.
During a survey, it was found that electrical panels throughout the facility were not properly identified, including those in the Electrical Closets on the 1st and 2nd Floors. The Director of Maintenance acknowledged the issue and planned to conduct an audit.
The facility did not conduct a required fire drill for the night shift in the fourth quarter of 2024, as revealed during a Life Safety Code Survey. Drills were held at similar times in the early morning, failing to meet NFPA 101 standards for varied timing. The Director of Maintenance initially claimed all drills were conducted, but the Administrator acknowledged the deficiency.
The facility failed to conduct and document an NFPA 99 risk assessment, which is necessary for categorizing facility systems based on their potential impact on safety. This deficiency was identified during a Life Safety Code recertification survey when the required documentation was not found in the maintenance records.
The facility did not post the required daily nurse staffing information, including total staff and hours, as observed during a survey. Despite a policy mandating this information be accessible, it was not displayed in the lobby or nursing unit. Interviews revealed that staff were unaware of the oversight, and routine checks for compliance were not conducted.
The facility failed to maintain a safe and comfortable environment due to inadequate heating on the East unit. Residents were observed using multiple blankets and space heaters, and some wore thick clothing to stay warm. Interviews revealed that the cold affected their daily activities, such as physical therapy and dining. The facility's policy required temperature checks and adequate blankets, but there was no documentation of temperature monitoring. The Director of Maintenance acknowledged issues with drafts and an outdated heating system, while the Administrator was unaware of the sub-70-degree temperatures.
The facility failed to maintain its heating system, resulting in temperatures in resident rooms, shower rooms, and common areas falling below required ranges. The Director of Maintenance was unaware of the issues, and there was no regular maintenance schedule or temperature policy in place. Residents' room windows were not properly maintained to prevent air drafts, and portable heating units were in use. The facility's Cold Weather Emergency policy lacked specifics on temperature documentation.
During a survey, portable space heaters were found in use in residents' rooms, violating the 2012 NFPA101 Life Safety Code. The facility's Administrator stated heaters were provided for comfort, not due to heating issues. The Emergency Preparedness Plan lacked a policy on portable heaters, contributing to the deficiency.
The facility failed to serve meals at safe temperatures, with residents consistently receiving cold food. Despite awareness and recommendations from staff, no actions were taken to address the issue, and concerns were not documented in Resident Council minutes.
A survey revealed that a facility failed to maintain proper sanitation and food service safety standards. The dishwashing machine did not reach the required temperatures for effective sanitation, and residents reported being served cold meals. Despite staff awareness and recommendations for solutions, the issues persisted, leading to a deficiency.
The facility failed to maintain food at acceptable temperatures, with test trays showing readings below the required 135 degrees Fahrenheit across all resident units. Despite residents' complaints about cold food, these concerns were not documented in Resident Council minutes. Staff interviews revealed a lack of monitoring and implementation of solutions, with the Food Service Director aware of the issue but unable to recall the last Quality Assurance check on food temperatures.
The facility's QAPI committee failed to address complaints about hot meals being served cold, despite multiple reports from residents. The Food Service Director and Director of Recreation acknowledged the issue, but it was not documented in Resident Council minutes or discussed in QAPI meetings. The Director of Nursing Services confirmed the complaints were addressed in morning reports, not in QAPI meetings.
A facility failed to ensure a resident's advance directives were accurately reflected, leading to confusion about their code status. The resident had changed their directive from Do Not Resuscitate to Full Code, but this was not updated on their identification bands. Staff interviews revealed inconsistencies in the identification process, and the DON acknowledged the error, noting that the facility does not use red dots as identifiers.
The facility failed to maintain adequate hot water temperatures in resident areas on the East Unit, with temperatures recorded below the required range. Residents reported cold water issues, and staff confirmed the problem had persisted for weeks. The Administrator was aware of a mixing valve issue but faced delays in obtaining a replacement part.
A facility failed to accurately document a resident's advanced directive of Do Not Hospitalize in the MDS assessment, despite it being recorded in the MOLST form and Physician's Orders. The MDS Coordinator and social workers were responsible for ensuring accuracy, but an oversight led to the omission. Interviews confirmed the responsibility and acknowledged the error.
The facility failed to update the care plans for two residents to reflect changes in their advanced directives. One resident's directive changed from Do Not Resuscitate to CPR, and another had a Do Not Hospitalize order, but their care plans were not updated accordingly. Staff interviews revealed a lack of communication and responsibility for updating these care plans, contrary to facility policy.
During a survey, it was found that a medication cart contained non-medication items like hearing aids and tape, stored alongside medications, violating the facility's policy. Staff interviews revealed a misunderstanding of storage requirements, with some believing these items were necessary in the cart. The DON clarified that only medications and related items should be stored there.
A resident with a history of falls and a hip fracture was unable to call for assistance due to a malfunctioning call bell in their bathroom. The resident attempted to transfer themselves from the toilet, resulting in a fall and injury. The facility lacked a routine process for checking call bell functionality, and staff were unaware of the malfunction prior to the incident.
Failure to Timely Report Alleged Verbal Abuse to Administration and State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of verbal abuse was reported to facility administration and the New York State Department of Health (NYSDOH) within the required two-hour timeframe. A cognitively intact resident with multiple fractures, including fractures of the left ulna, left humerus, and ribs, reported during the night shift that a staff member from the prior shift had threatened to further injure the resident’s already injured arm. The resident had a care plan for risk of abuse and neglect, and a separate care plan for behavioral symptoms related to fabrication/accusatory behavior, but the behavioral care plan did not document specific dates and events of prior accusatory behaviors. At approximately 2:00 AM, the resident told an LPN that someone wanted to hurt their arm; the LPN immediately reported this allegation to the RN supervisor. The RN supervisor interviewed the resident, who stated that a staff member from the previous shift had verbally threatened to hurt the resident’s arm after an argument, but denied being physically hurt. The RN supervisor initiated an Accident and Incident report but did not immediately notify the Director of Nursing Services (DON) or Assistant Director of Nursing Services (ADON). Instead, the RN supervisor focused on the resident’s wellbeing and on ensuring that the alleged perpetrator was no longer assigned to the resident. The ADON was not informed of the allegation until the morning of the following day, more than 24 hours after the allegation was first reported to the RN supervisor. The facility’s Nursing Home Facility Incident Report shows that the abuse allegation was submitted to NYSDOH the day after the allegation was made, at 4:55 PM, well beyond the two-hour reporting requirement. The facility’s written abuse policy defined verbal and mental abuse but did not include specific timeframes for reporting all reportable incidents, including allegations of abuse. Interviews with the ADON, DON, Administrator, and Medical Director revealed that the leadership involved in developing and reviewing the abuse policy were unaware that all alleged abuse must be reported to NYSDOH within two hours after the allegation is made, regardless of the presence or absence of physical injury. The ADON believed that only incidents resulting in serious harm required reporting within two hours and that other abuse/neglect incidents could be reported within four to 24 hours. The DON similarly believed that abuse or neglect with visible injury must be reported within an hour and those without injury within four to 24 hours, and acknowledged that the policy lacked required reporting timeframes. The Administrator and Medical Director also confirmed that the policy did not contain specific reporting timeframes, and the Medical Director did not know the exact required timeframe for reporting abuse allegations. Additionally, there was no documentation in the resident’s medical record regarding the abuse allegation, despite the incident and subsequent investigation. Overall, the deficiency centers on the facility’s failure to ensure that covered individuals immediately, but not later than two hours, reported an allegation of verbal abuse to facility administration and NYSDOH, as required by 10 NYCRR 415.4(b)(2). The RN supervisor delayed reporting the allegation to administration for more than 24 hours, and the facility’s leadership and written policy did not reflect or communicate the correct mandatory reporting timeframes for all alleged abuse incidents.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices and procedures, as evidenced by observations during a recertification survey. Specifically, three Licensed Practical Nurses (LPNs) did not adhere to Enhanced Barrier Precautions while administering medications and performing wound care. LPN #2 administered intravenous medications to a resident with a Peripherally Inserted Central Catheter without wearing a gown, despite the resident being under Enhanced Barrier Precautions. LPN #2 was unaware of the need for a gown due to a lack of education on Enhanced Barrier Precautions. Similarly, LPN #3 administered medications through a Gastrostomy tube to another resident without donning a gown. This resident was also under Enhanced Barrier Precautions, as indicated by signage on the resident's door and personal protective equipment cart. LPN #3 failed to notice the signage and did not follow the required precautions. Additionally, LPN #1 did not establish a clean field for wound care supplies and failed to perform hand hygiene after removing soiled dressings during a dressing change for a resident with multiple ulcers. LPN #1 admitted to omitting critical infection control steps due to nervousness during the procedure. These lapses in infection control practices were observed despite the facility's policies and procedures outlining the necessary precautions and steps for medication administration and wound care.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #389 has no negative outcome as evidenced by no signs and symptoms of infection of IV site and wound. Resident #63 has no negative outcome as evidenced by no signs and symptoms of infection of [DEVICE] site. LPN #2 & LPN #3 were in serviced on enhanced barrier precaution policy and procedure on 2/6/2025. LPN #1 was in serviced on dressing dry clean policy and procedure on 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents have the potential to be affected by this practice. - All residents with wounds and EBP are being reassessed to ensure no deficient practice occurs. Any outstanding issues will be addressed immediately. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The facility Policy on enhanced barrier precautions was reviewed and no revision needed. - All staff is being re-educated on enhanced barrier precaution. - EBP competency test is being administered to clinical staff and implemented as part of orientation and annual training. - All nurses are being re-educated on dressing change policy and procedure with emphasis on establishing a clean field for placement of wound supplies and hand hygiene. - Wound Dressing Change observation is being implemented to the orientation and thereafter annually. - Audit tools are being developed for enhanced barrier precaution and wound dressing dry clean. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for the first quarter, the director of nursing or designee will conduct an audit of 2 to 4 employees caring for residents on enhanced barrier precaution for compliance. Any outstanding issues will be corrected immediately and reported to the administrator. - On a weekly basis for the first quarter, the director of nursing or designee will conduct treatment observation on 1 nurse for proper dressing change including surface preparation and hand hygiene. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a quarterly basis, the Director of Nursing will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Asst. Dir of Nursing.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee included the Medical Director or their designee in quarterly meetings, as required by their policy. The facility's QAPI policy, last revised in 2022, mandates that the committee must consist of the director of nursing services, the medical director or designee, and at least one other member of the facility staff, with meetings held quarterly. However, a review of the Quarterly Meeting Attendance Sheets revealed that the Medical Director did not sign the attendance sheets for any of the four quarterly meetings in 2024, indicating a lack of participation. Interviews conducted during the survey revealed discrepancies in the Medical Director's involvement. The Director of Nursing stated that the Medical Director only attends quarterly meetings, while the Medical Director claimed to attend some meetings and be informed by the Administrator about the discussions. The Administrator confirmed that the Medical Director does not physically attend the quality assurance meetings but is briefed afterward. This lack of documented attendance and participation by the Medical Director in the QAPI and QAA meetings constitutes a deficiency in meeting the facility's policy requirements.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò The Medical Director was in-serviced on 2/13/25 on the requirement to attend the QAPI meetings quarterly or designate a qualified representative in their absence. ò The Medical Director was instructed to sign the attendance sheet for all QAPI meetings to ensure proper documentation of participation on 2/13/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? ò The facility Policy and Procedure was titled QAPI, was reviewed and dated, no revision needed. ò An Audit tool is being developed to monitor the attendance of all QAPI committee members. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a quarterly basis for the one quarter, the Administrator, or designee, will monitor the attendance of all QAPI committee members to ensure compliance. ò Quarterly, the Administrator or designee will formally invite the Medical Director to the QAPI meetings. ò Quarterly for on the Administrator or designee will ensure the Medical Director attends each quarterly QAPI meeting, either in person or via Zoom. ò The Administrator or designee will verify and document the Medical Director’s attendance at each QAPI meeting. 5. The title of the person responsible for correction of each deficiency: Administrator
Corridor Doors Not Smoke-Resistant
Penalty
Summary
The facility failed to ensure that all corridor doors were designed to resist the passage of smoke, as required by the 2012 NFPA standards. During a life safety survey conducted on two consecutive days, it was observed that one panel of the double doors to the Electrical Closet had a manual bolt, which prevented the doors from latching properly and resisting the passage of smoke. This deficiency was found on all five resident floors of the facility. The Director of Maintenance acknowledged the issue and indicated that the manual bolts would be replaced with automatic flush bolts.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The facility contacted the construction vendor on 2/27/25 to remove the manual flush bolt from the inactive leaf on the identified room doors and will permanently install automatic flush mount bolts on the inactive corridor doors to provide positive latching. Automatic flush mounts bolts has been ordered on [DATE]. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of maintenance inspected all areas throughout the facility for the same deficiency. No deficiencies found. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility reviewed the Fire and Smoke Door policy and procedure. The policy was updated to include Corridor doors shall comply with 2012 NFPA 101: 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction. Double doors shall be equipped with auto flush mount bolts. Manual flush mount bolts are prohibited. The Maintenance staff will receive education on the Fire and Smoke Door policy and procedures. An audit tool was developed to check corridor doors equipped with auto flush mount bolts. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all Double doors to for auto flush mount bolts to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Annual Inspection of Receptacles Not Conducted
Penalty
Summary
During a life safety recertification survey conducted in early 2025, it was observed that there was no documentation to confirm that electrical receptacles in resident areas on the 6th Floor had been inspected annually as required. Specifically, inspection stickers on receptacles in resident rooms 601, 603, 605, and throughout the 6th Floor were dated January 2023, indicating that the required annual inspections had not been performed. Additionally, an outlet in the outdoor area outside of the Physical Therapy Room, which is part of the path of egress, showed signs of damage. The Director of Maintenance acknowledged the lack of inspections and noted that the outdoor outlet had been damaged prior to his tenure at the facility.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff completed the annual electrical receptacle inspection and testing on the 6th floor on 3/5/2025. The director of maintenance replaced the identified damaged outside electrical receptacle on the patio on 3/3/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents, visitors, and staff have the potential to be affected by this practice. The Director of maintenance inspected all areas throughout the facility for the same deficiency. No other deficiencies were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with the inspection and testing of electrical receptacles in compliance with NFPA 99: 6.3.4.1.3. An audit tool has been developed to inspect the electrical receptacle for damage and inspection. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all electrical receptacles for damage and inspection stickers if needed to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Deficient Sprinkler System Installation
Penalty
Summary
The facility failed to ensure comprehensive protection by an approved, supervised automatic sprinkler system as required by the 2012 NFPA 101 standards. During the Life Safety portion of the recertification survey, observations were made of missing escutcheons, concealed caps, and ill-fitting or missing ceiling tiles around sprinklers in various areas, including the Telecommunications Room, Recreation Storage room, Men's Locker Room, Staff bathroom on the 4th Floor, Oxygen Storage room on the 4th Floor, and Janitor's Closets on the 2nd and 4th Floors. Additionally, in a resident room, the sprinkler system was not adequately installed, compromising the safety standards set forth by the NFPA. Further inspection on another day revealed that the sprinklers in the corridor in front of resident rooms 518 through 521 on the 5th Floor were spaced 30 feet apart, exceeding the maximum coverage area per sprinkler. The Director of Maintenance acknowledged the deficiencies, noting that additional sprinklers would be installed and that the ceiling tiles had been recently upgraded, which might have affected the sprinkler pipes' visibility. The Director also confirmed that the missing ceiling tiles, escutcheons, and concealed caps would be addressed.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, the facility engaged our Sprinkler company to install the identified missing escutcheons and concealed caps in the Telecommunications Room, Recreation Storage room, Men's Locker Room, Staff bathroom on the 4th Floor, Oxygen Storage room on the 4th Floor, Janitor's Closets on 2nd and 4th Floors, and in resident room [ROOM NUMBER]. Visit scheduled for 3/17/2025. On 3/3/25, the facility engaged our Sprinkler company to adjust the sprinkler pendants in the corridor in front of resident rooms 518 through 521 to provide complete coverage in the corridor. The visit is scheduled for 3/17/2025. The maintenance staff replaced the identified missing ceiling tiles and the ceiling tiles that were not smoked tight on 2/27/25. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be corrected. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with installations of sprinklers in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. An audit tool has been developed to monitor the installation of the sprinkler system, escutcheons, and missing tiles. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all ceiling tiles and sprinklers to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, the Director of Maintenance or Designee will review monthly audits and report findings to the Administrator. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency: Administrator, Dir. Of Maintenance
Failure to Maintain Fire Hoses as per NFPA Standards
Penalty
Summary
During a life safety code recertification survey conducted on two consecutive days in 2025, it was observed that the facility failed to maintain the fire hoses in accordance with NFPA 101 and NFPA 25 standards. Specifically, the fire hoses located in Stairwell B on the basement level and the 1st Floor were found to be stamped with a date of 4/2015, indicating they had not been tested or replaced within the required five-year period prior to the survey. This deficiency was identified through observation, document review, and staff interviews, where it was confirmed that there was no documentation of the hoses being tested or replaced as required. At the time of the finding, the Director of Maintenance acknowledged the issue and stated that the hoses would be replaced or capped.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/5/25, the facility contacted the sprinkler vendor to install all new standpipe hoses throughout the building. The vendor will conduct a visit on 3/15/2025 to prepare a proposal. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The maintenance will survey the entire building for standpipe hoses. All standpipe hoses will be replaced. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All Maintenance staff will receive additional education, and all participants will understand the life safety issues identified during the facility’s survey and the importance of ensuring compliance with the requirements of inspection and testing requirements of Standpipe hoses 2011 NFPA 25 5.2* Inspection and 2011 NFPA 25: A Preventive Maintenance & Scheduling system will be developed to reflect the inspection and testing of the standpipe system as required by all codes, rules, and regulations. All inspection results will be recorded in the building Records & Logs and available for inspection by the Authority having jurisdiction at all times. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit the standpipe system to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency: Administrator, Dir. Of Maintenance.
Deficiencies in Smoke Barrier Wall Construction
Penalty
Summary
During a Life Safety Code recertification survey conducted on two consecutive days in 2025, deficiencies were identified in the construction of smoke barrier walls within the facility. Specifically, the survey revealed that the smoke barrier walls on two of the six resident floors did not meet the required ½-hour fire resistance rating as stipulated by NFPA 101. Observations included an opening of approximately 2 inches around two armored cables on the 5th floor adjacent to a resident room, a missing cover on a junction box adjacent to another resident room, and a penetration of approximately 1 inch around multiple cables on a different floor. These deficiencies were noted during the survey, and the Director of Maintenance acknowledged the issues, indicating that the penetrations would be sealed with fire-stop material. The report highlights that the facility did not ensure the smoke barrier walls were constructed to provide the necessary fire resistance, as required by the relevant fire safety codes.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Director of Maintenance permanently sealed the identified penetrations above the ceiling tiles in the smoke barrier walls on the 5th Floor adjacent to resident room 506, adjacent to resident room 417, adjacent to resident room 217 with approved rated fire stop material on 2/10/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance checked all smoke barriers for penetrations. No deficiencies were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with smoke barrier requirements in accordance with the requirements of NFPA 101 2012 edition 19.3.7.3 and 8.5.6.2. A audit tool was developed to inspect smoke barriers for penetration. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all smoke barriers for penetrations to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter, the Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Improper Garbage Disposal Due to Lack of Bin Lids
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a recertification survey. Specifically, the garbage bins in the kitchen and garbage pickup area were found without lids or covers, leaving waste exposed. This was contrary to the facility's policy, which mandates that all waste be kept in lined containers with lids, leak-proof, and non-absorbent prior to disposal. Observations on multiple occasions confirmed the absence of lids on garbage bins, and staff interviews revealed that the bins have never been equipped with lids, as the waste company did not provide them. The Director of Food Service and the Housekeeping Director acknowledged the issue, and the Administrator stated that they had contacted the vendor to address the problem.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò The vendor was contacted on 02/12/2025 to supply the facility with 10 new metal garbage bins with covers. ò New metal garbage bins have been delivered to the facility on [DATE] & 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? ò The facility Policy and Procedure was titled Disposal of Garbage and refuse, was reviewed and dated; no revision needed. ò All Housekeeping and kitchen staff are in-serviced on the above policy. ò New metal garbage bins with covers are being implemented. ò An audit tool is being created to ensure compliance with garbage disposal. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? ò On a weekly for one quarter, the Director of Housekeeping or designee will conduct environmental audits of the compactor room and loading dock to ensure garbage bins are covered and in good condition. Any outstanding issues will be corrected and reported to the Administrator immediately and in good condition. ò On a monthly for one quarter, the Director of Housekeeping or designee will report audit findings to the Administrator. ò On a quarterly basis, the Director of Housekeeping or designee will present audit findings to the QAPI Committee. ò The QAPI Committee will review the findings and determine if further action is necessary. 5. The title of the person responsible for correction of each deficiency: Director of Housekeeping
Failure to Provide Ordered Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received the necessary treatment and services to maintain or prevent further decrease in their range of motion. This deficiency was identified during a complaint and recertification survey. Specifically, a resident who was cognitively intact and required assistance with activities of daily living was not provided with range of motion exercises as ordered by their physician. The resident had been ordered to receive active range of motion exercises for both upper extremities and active/passive range of motion for both lower extremities, but these exercises were not being performed as required. Interviews with staff revealed a lack of awareness and execution of the resident's care plan. Certified Nursing Assistants (CNAs) assigned to the resident were not performing the exercises, and there was confusion regarding the resident's inclusion in a restorative nursing program. Documentation inaccurately reflected that exercises were being completed, despite staff acknowledging that they were not providing the exercises. The Director of Nursing Service noted that unit nurse supervisors are responsible for reviewing care plans with staff and ensuring care is provided, indicating a breakdown in communication and oversight within the facility.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident # 66 was assessed by OT on (2/27/2025) and had no negative outcomes from the deficient practice. - Task in CNA Accountability (Point Of Care) was revised to provide clear instructions pertinent to Range of Motion exercises on 2/27/2025. - Certified Nursing Assistant # 9 was re-educated on the following plan of care listed in electronic Kardex on 2/27/2025. - Certified Nursing Assistant # 11 was re-educated on the accuracy of documentation on 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents on restorative nursing care have the potential to be affected by this practice. - An audit is being conducted on all residents on the Restorative Nursing Care to ensure the tasks are documented accurately based on actual provision of care. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: - The facility Policy and Procedure titled “Rehabilitative Nursing Care” was reviewed and revised to ensure restorative nursing care provided and accurately documented. - All nursing staff are being in-serviced on the above policy and procedure with an emphasis on the importance of the completion of the restorative care and accurate documentation of such. - All RNs and therapists are being re-educated on proper entry of restorative nursing tasks into EHR. - Weekly restorative nursing care meetings are being initiated to ensure the ordered restorative care is provided and documented. - The audit tool was created to ensure compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for the first quarter, the Director of Nursing, or designee, will randomly observe and audit 3-5 residents on the restorative nursing care for the completion of task and accurate documentation. Any outstanding issues will be addressed immediately and reported to the Administrator. - On a monthly basis, Director of Nursing will report the findings to the Administrator. - On a quarterly basis, Director of Nursing will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Assistant Dir. of Nursing.
Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure accurate documentation of resident care, specifically for a resident who was supposed to receive Range of Motion (ROM) exercises. The resident, who was cognitively intact and required assistance with activities of daily living, was ordered to receive daily ROM exercises after physical therapy was discontinued. However, the resident reported that these exercises had not been provided for several months, despite documentation indicating otherwise. Interviews with staff revealed inconsistencies in the provision and documentation of these exercises, with some staff unaware of the resident's care plan or mistakenly documenting that exercises were completed. The facility's policy required all services and changes in a resident's condition to be documented in the medical record. However, the Certified Nursing Assistants (CNAs) responsible for the resident's care did not perform the exercises and were unaware of the resident's current program. The Director of Nursing Service acknowledged the need for staff training on performing and documenting ROM exercises accurately. This deficiency highlights a failure in communication and adherence to care plans, resulting in inaccurate documentation of resident care.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident # 66 was assessed by OT on (2/27/2025) and had no negative outcomes from the deficient practice. - Task in CNA Accountability (Point of Care) was revised to provide clear instructions pertinent to Range of Motion exercises on 2/27/2025. - Certified Nursing Assistant # 9 was re-educated on the following plan of care listed in electronic Kardex on 2/27/2025. - Certified Nursing Assistant # 11 was re-educated on the accuracy of documentation on 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents on restorative nursing care have the potential to be affected by this practice. - An audit is being conducted on all residents on the Restorative Nursing Care to ensure the tasks are documented accurately based on actual provision of care. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The facility Policy and Procedure titled “Charting and Documentation” was reviewed, dated and no revision was required. - All interdisciplinary teams are being in-serviced on the above policy and procedure with an emphasis on the importance of documentation accuracy. - Thorough training on proper documentation practices was added to the orientation and thereafter annual education. - New process is being implemented to ensure compliance with documentation by interviewing 2-3 employees on a monthly basis regarding proper documentation policy and procedure. - The audit tool was created to ensure compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for the first quarter, the Director of Nursing, or designee, will randomly check and audit 3-5 residents’ medical records for accurate documentation of care provided. Any outstanding issues will be addressed immediately and reported to the Administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a quarterly basis, the Director of Nursing will report the findings to the QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Asst. Dir of Nursing.
Improper IV Medication Administration by LPN
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of clinical quality and practice, specifically in the administration of intravenous medication. This deficiency was identified during a recertification survey, where it was observed that an LPN administered intravenous antibiotics through a Peripherally Inserted Central Catheter (PICC) to a resident, despite facility policy prohibiting LPNs from performing such tasks. The resident in question had severely impaired cognition and required intravenous medication administration. The LPN, who had been employed for only one month, was not aware that the intravenous line was a central catheter and had not been adequately in-serviced on intravenous administration. Interviews with facility staff revealed a lack of proper communication and oversight regarding the administration of medications through central lines. The unit supervisor and the Assistant Director of Nursing acknowledged that LPNs are not permitted to administer medications through a central line and that there was a failure in ensuring that the LPN was properly trained and supervised. The Director of Nursing also indicated that there should have been more effective monitoring and communication to prevent such an incident. The deficiency highlights a breakdown in the facility's processes for ensuring compliance with medication administration protocols.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? ò Resident # 389 had no negative outcomes from the deficient practice. IV medication via Central line was administered by RN after 2/6/2025. Licensed Practical Nurse # 2 was in-serviced on the “Administering Medications by Central Line Access” policy and procedure on 2/6/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? ò All residents receiving intravenous medications have the potential to be affected by this practice. All residents’ medication administration records who are currently receiving intravenous medications/ Fluids/Flush were reviewed, no outstanding issues were found. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: ò The facility Policy and Procedure titled “Administering medications by Central Line Access” was reviewed, no revision required. All nurses are being in-serviced on the above policy and procedure with an emphasis on the professional scope of practice of LPN. Education on administration of medications by central line access was added to the orientation and to the annual in-services. A new process of marking administration by RN only for medications administered via central lines is being implemented to ensure the scope of practice is being maintained. The audit tool was created to ensure compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? ò On a weekly basis for the first quarter, the Director of Nursing, or designee, will audit the intravenous medication(s) order and Medication Administration Record [REDACTED]. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, Director of Nursing will report the findings to the Administrator. On a quarterly basis, Director of Nursing will report findings to QAPI Committee. QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Assistant Director of Nursing.
Failure to Provide Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as observed during a recertification survey. Resident #389, who had severely impaired cognition and was dependent on staff for mobility, was admitted with venous and arterial ulcers. Despite the facility's policy on pressure ulcer prevention, the resident did not receive pressure-relieving devices or preventative measures to promote wound healing. Observations revealed that the resident lacked heel booties, offloading of heels, and a pressure-reducing mattress, both in bed and while seated in a wheelchair. The facility's documentation and staff interviews highlighted several lapses in care. The Braden Scale assessments indicated a moderate risk for pressure ulcers, yet there were no documented interventions for turning and repositioning the resident. The Electronic Medical Record lacked orders for pressure-relieving measures, and the Certified Nursing Assistant Accountability Record did not include tasks for turning and repositioning. Staff interviews revealed that the protocol for at-risk residents was not followed, and the necessary equipment and care plans were not implemented or documented. The Director of Nursing acknowledged the oversight and noted that new forms were being implemented, but the lack of documentation and preventative measures contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - For Resident # 389: - Pressure reduction mattress was provided on 2/12/2025 - Heel bootie for left foot was provided on 2/12/2025 - Turning and Positioning task was added to the CNA accountability on 2/26/2025 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents at risk for developing pressure ulcers have the potential to be affected by this practice. - A facility wide audit is being conducted to ensure all residents at risk for pressure ulcers or with pressure ulcers receive necessary services (preventative measures) to prevent skin breakdown and to promote wound healing. - Any outstanding issues will be addressed immediately. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: - The Policy and Procedure “Prevention of Pressure Ulcers” was reviewed, and no revision needed. - All nursing staff is being re-educated on the “Prevention of Pressure Ulcers” policy, with emphasis on implementation and documentation of preventative interventions being done. - All unit managers are being in-serviced on review of new admissions/re-admissions for initiation of preventative skin care/interventions on person-centered care plan and for activation of tasks in EHR (PCC) for documentation of care. - The audit tool was developed for monitoring compliance with implementation of preventative skin care/interventions and tasks activation in EHR. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for one quarter, ADNS or designee will audit newly admitted and readmitted residents’ charts to ensure compliance with preventative skin care is initiated and documentation of such; and residents’ with newly developed skin breakdown charts for appropriate interventions. Any outstanding issues will be addressed immediately and reported to DNS. - On a weekly basis for one quarter, MDS Director or designee, will audit 2-4 newly admitted/readmitted residents and residents with new skin breakdown to ensure skin care tasks activation in PCC and report the findings to DNS. - On a monthly basis DNS or designee will report findings to Administrator. - On a quarterly basis DNS or designee will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Assistant Director of Nursing.
Deficiency in Corridor Wall Construction
Penalty
Summary
During a Life Safety Code recertification survey, it was observed that the facility did not ensure that corridor walls were constructed in accordance with NFPA 101 standards. Specifically, a door assembly in the corridor wall failed to form a barrier to limit the transfer of smoke. This deficiency was noted on one of the six floors, specifically in the Electrical Closet on the Lobby Floor. An opening measuring approximately 3 inches by 4 inches was found in the corridor wall just above the corner of the door frame. This opening was covered by wallpaper on the corridor side and held down with a screw. The Director of Maintenance acknowledged that the opening occurred when the new door assembly was installed, and the Administrator confirmed that the door and door frame had been installed about a year prior.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff permanently sealed the opening in the identified corridor wall above the Electrical Closet door on the Lobby Floor on 2/7/2025. The corridor wall resists the passage of smoke. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No negative outcome. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues identified, with the proper construction of corridor walls in compliance with 2012 NFPA 101 19.3.6.2. An audit tool was developed to inspect the corridor walls for penetration. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all corridor walls for penetration to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Improper Use of Extension Cords and Power Strips
Penalty
Summary
During the Life Safety Recertification survey conducted in 2025, the facility was found to be non-compliant with NFPA 70 standards regarding the use of extension cords and power strips. Specifically, surveyors observed two unmounted power strips in use within the Dietary office located in the Kitchen. Additionally, in the Dietician's office situated in the basement, two extension cords were plugged into a power strip to power computer equipment. These observations indicate a failure to adhere to the electrical safety standards outlined in NFPA 70, which prohibits the use of extension cords and power strips in such a manner. The Director of Maintenance acknowledged the findings during the survey and indicated that corrective actions would be taken. However, the report focuses on the deficiency itself, which is the improper use of electrical systems that do not comply with the National Electrical Code. The deficiency highlights the facility's failure to ensure that electrical equipment is used safely and in accordance with established safety codes, potentially posing a risk to the safety of the facility's environment.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The maintenance staff removed the two unmounted power strips in the Dietary office in the Kitchen on 3/7/2025. The maintenance staff removed the two extension cords plugged into a power strip powering computer equipment in the Dietician's office in the basement on 3/7/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents, visitors and staff have the potential to be affected by this practice. The facility checked all areas for the same deficiency. Any power strips or extension cord deficiencies were immediately corrected. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The facility reviewed and updated the Electrical Safety Policy and Procedures. All staff will receive additional education, and all participants will understand the life safety issues identified during the facility’s survey and the importance of ensuring compliance with the Electrical Safety Policy and Procedures with particular emphasis on power strips and extension cord prohibitions. An audit tool was developed to check for the improper use of power strips and extension cords monthly. The Director of Maintenance will utilize an audit tool to document any findings. Any issue identified. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a weekly basis, for one quarter, the Dir. Maintenance or designee will audit all areas for improper use of power strips and extension cords to ensure compliance. Any outstanding issues will be addressed immediately and reported to the Administrator. On a monthly basis, for one quarter, The Director of Maintenance or Designee will review monthly audits and report findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Electrical Panel Identification Deficiency
Penalty
Summary
During a life safety code recertification survey conducted over two days, it was observed that the facility failed to ensure proper identification of electrical panels. Specifically, the Electrical Closet on the 1st Floor contained three electrical panels, all of which were missing identification. Similarly, the Electrical Closet on the 2nd Floor, located adjacent to Stairwell A, also contained three electrical panels that lacked identification. This issue was consistent throughout the facility, as electrical panels were not properly marked to indicate their purpose or use. The Director of Maintenance acknowledged the deficiency and indicated that an audit would be conducted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The facility contacted the electrician vendor on 3/3/2025 to come in and permanently mark all electrical panels with the proper identification. Visit is set for 3/13/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The Director of maintenance shall inspect all areas throughout the facility for the same deficiency. All electrical panels will be marked permanently with proper identification. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: All maintenance staff will receive additional education, and all participants will understand the life safety issues with the identification of electrical panels in compliance with 2011 NFPA 70:700.10. An audit tool was developed to check all electrical panels for proper identification. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter, the Director of Maintenance or Designee will audit all electrical panels to make sure proper identification. Any outstanding findings will be reported to the administrator. On a quarterly basis, the QAPI committee will review the facility risk assessment. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Failure to Conduct Quarterly Fire Drills on Night Shift
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101 standards, specifically not holding a fire drill for the night shift (11 PM - 7 AM) during the fourth quarter of 2024. The review of the facility's fire drill logs during the Life Safety Code Survey on June 6, 2025, revealed this deficiency. The drills that were conducted on March 20, June 20, and August 22, 2024, were all held at similar times in the early morning hours, specifically at 6:00 AM, 6:30 AM, and 6:50 AM, respectively. This lack of variation in timing and the omission of a drill for the night shift in the specified quarter led to the citation. The Director of Maintenance initially stated that all drills had been conducted, but the Administrator later acknowledged the finding during the exit interview.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Director of Maintenance will complete the fire drills at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency. All fire drills will be a minimum of 1 hour apart on each shift and not duplicated in the same 12 month period. Fire drills conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that all residents have the potential to be affected by this practice. All Fire Drills are conducted by the Director of Maintenance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: The Director of Maintenance was re-educated on how to properly conduct fire drills to ensure the facility meets standards established by the National Fire Protection Association (NFPA). The Director of Maintenance developed a Fire Drill spreadsheet to document varied times and conditions of each monthly drill to maintain compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter, The Director of Maintenance or Designee will review the fire drill spreadsheet to ensure compliance and report any outstanding findings to Administrator. On a quarterly basis, The Director of Maintenance or Designee will report the result of the audits to the QAPI. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Failure to Document NFPA 99 Risk Assessment
Penalty
Summary
The facility was found deficient during a Life Safety Code recertification survey for failing to conduct and document a required NFPA 99 risk assessment. This assessment is crucial for categorizing facility systems based on the potential impact of their failure on patient and caregiver safety. The surveyors noted that during a record review, a completed NFPA 99 Risk Assessment was not present in the maintenance documentation folders. This deficiency was communicated to the Director of Engineering and the Administrator during the exit conference.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The Administrator met with the multidisciplinary team which included the Director of Nursing, the Director of Physical Therapy, and the Director of Maintenance. The team reviewed the risk category definitions in NFPA 99 and completed the annual assessment on 3/5/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility acknowledges that residents have the potential to be affected by this practice. The worksheet is used to record the risk level for listed systems in a given area. Any changes in systems will generate a review of the worksheet. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The Administrator reviewed and updated the Facilities Risk Assessment Procedure Policy. Any changes in systems will generate a review of the worksheet. The multidisciplinary team will also conduct an annual review and update the NFPA 99 worksheet. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? On a monthly basis, for one quarter, the Director of Maintenance or Designee will review the risk assessment to identify any changes. Any outstanding findings will be reported to the administrator. On a quarterly basis, the QAPI committee will review the facility risk assessment. On a quarterly basis, the Director of Maintenance or Designee will report the result of the audits to the QAPI committee. 5. The title of the person responsible for correction of each deficiency: Administrator, Director of Maintenance.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information, including the total number of staff and total number of hours, was posted as required. Observations conducted from February 5 to February 11, 2025, revealed that this information was not displayed in the lobby or nursing unit, contrary to the facility's policy. The policy, last revised on January 2, 2025, mandates that nurse staffing information be readily available in a readable format in prominent places accessible to residents and visitors. Despite the daily schedule being posted in the lobby, the specific details of total staff and hours were not included. Interviews with facility staff highlighted a lack of awareness and oversight regarding the posting requirements. The Staffing Coordinator acknowledged that the detailed staffing information was attached to the schedule at the end of the day but not posted as required. The Director of Nursing admitted to not being aware that the information was not being posted and did not routinely check for compliance. Similarly, the Administrator stated that while they usually check the postings every morning, they had not done so since the survey began and were unaware of the missing information.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - The daily nurse staffing data was posted in a prominent place for residents and visitors to see in the facility’s lobby by front desk on 2/11/2025 and daily thereafter. - Facility Staffing Coordinator and Director of Nursing were educated on a policy “Posted Nurse Staffing Information” with an emphasis on posting in a prominent place readily accessible to residents and visitors on 2/11/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents have the potential to be affected by this practice. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The Policy and Procedure titles “Posted Nurse Staffing Information” was reviewed and no revision is required. - Nursing Administration, Staffing Coordinator, RN Supervisors and RNs are being in-serviced on the above policy. - Director of Nursing is going to oversee daily nurse staffing data posting. - The audit tool was developed for monitoring compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - Twice a week for one quarter, Director of Nursing or designee, will randomly check 2 prominent locations to ensure the nurse staffing data is posted and is accurate. - Any outstanding findings will be addressed immediately and reported to the Administrator. - On a weekly basis Director of Nursing or designee will report the findings to the Administrator. - On a monthly basis Director of Nursing or designee will report findings to Administrator. - On a quarterly basis Director of Nursing or designee will report findings to QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Administrator.
Inadequate Heating in Facility Affects Resident Comfort
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the inadequate heating on the East unit. Observations revealed that multiple residents were using multiple blankets and space heaters to keep warm, and some were wearing thick robes and sweatshirts. Interviews with residents indicated that the cold temperatures affected their daily activities, such as attending physical therapy and dining in the main area. Residents reported that the cold was more severe at night, and some resorted to using makeshift solutions like placing boxes in front of windows to block drafts. The facility's policy on cold weather emergencies required immediate temperature checks and adequate blanket supplies if temperatures fell below 70 degrees Fahrenheit. However, there was no documented evidence that room temperatures were monitored to ensure comfort. The Director of Maintenance acknowledged issues with drafts from windows and an older heating system needing repairs. Despite complaints, the Administrator was unaware of the sub-70-degree temperatures and relied on space heaters and room changes as solutions. Staff, including a registered nurse, confirmed that residents complained about the cold, and makeshift measures were taken to provide warmth.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 i. Residents rooms that were below 70 were immediately offered a room change. i.a The Administrator and Director of Maintenance in consultation with plumber/boiler vendor did a complete assessment of the heating system and identified multiple issues. 1. Hallway thermostat schedule wasn't set properly. 2. Visitor Bathroom heater was defective. 3. One boiler would go into standby mode. 4. Some windows needed to be resealed. 5. Some rooms were missing insulation above the windows. 6. Some of the vents on the room units were in the open position. 7. Some units fan blower motors need to be replaced. 8. East Shower room, one West shower room didn't have heating units. 9. One west shower room, North shower room heating unit weren't working. i.b 1. Hallway thermostat was reprogrammed, a lock box was replaced with access restricted to maintenance. 2. Visitor Bathroom heater was replaced, staff bathroom repaired. 3. Computer control board on the boiler was replaced. 4. Windows were resealed. 5. Insulation above the windows was replaced. 6. All vents were checked and closed. 7. All blower motors were checked and those that were broken were replaced. 8. A ductless unit was installed in the East Shower room, A ductless unit was installed in the West shower room. 9. West shower room heating unit was repaired, A ductless unit was installed in the North shower room. ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is functioning properly and a daily room temperature log will be added to the daily room check log. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for F584 tag.
Heating System Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain its heating system in proper working condition, resulting in temperatures in resident rooms, shower rooms, and common areas falling below the required range. Observations revealed that the hot water coil heating system in several resident rooms and a shower room was not delivering heat, and portable heating units were in use in some resident rooms. Additionally, three out of four resident shower rooms lacked any type of heating system, and residents' room windows were not properly maintained to prevent air drafts. The Director of Maintenance (DOM) was unaware of the temperature issues and stated that they did not receive any complaints from residents or staff. The DOM admitted that air temperatures were not taken daily, and there was no regular maintenance schedule in place. Environmental rounds were conducted once per month without documentation, and the facility did not have a temperature policy. The heating system had not been changed since 2013, and residents could control the heating coil units and open windows themselves. The facility's policy named Cold Weather Emergency was updated, but it did not specify how temperatures should be taken and documented. The DOM stated that repairs would be done in-house, and a plumbing company was scheduled to check the heating system. However, no maintenance records were provided to indicate regular inspection and maintenance of the facility's heating system for all three nursing units. The lack of a systematic approach to maintaining the heating system and addressing air drafts contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved February 17, 2025 i. Residents rooms that were below 70 were immediately offered a room change. i.a The Administrator and Director of Maintenance in consultation with plumber/boiler vendor did a complete assessment of the heating system and identified multiple issues. 1. Hallway thermostat schedule wasn't set properly. 2. Visitor Bathroom heater was defective. 3. One boiler would go into standby mode. 4. Some windows needed to be resealed. 5. Some rooms were missing insulation above the windows. 6. Some of the vents on the room units were in the open position. 7. Some units fan blower motors need to be replaced. 8. East Shower room, one West shower room didn't have heating units. 9. One west shower room, North shower room heating unit weren't working. i.b 1. Hallway thermostat was reprogrammed, a lock box was replaced with access restricted to maintenance. 2. Visitor Bathroom heater was replaced, staff bathroom repaired. 3. Computer control board on the boiler was replaced. 4. Windows were resealed. 5. Insulation above the windows was replaced. 6. All vents were checked and closed. 7. All blower motors were checked and those that were broken were replaced. 8. A ductless unit was installed in the East Shower room, A ductless unit was installed in the West shower room. 9. West shower room heating unit was repaired, A ductless unit was installed in the North shower room. ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is functioning properly and a daily room temperature log will be added to the daily room check log. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for F908 tag.
Violation of NFPA101 Due to Portable Space Heaters in Resident Rooms
Penalty
Summary
The facility was found to be in violation of the 2012 NFPA101 Life Safety Code during an Abbreviated Survey (Complaint NY 340) due to the use of portable space heaters in residents' sleeping rooms. The survey, conducted on January 16, 2025, revealed that portable space heaters were in use in five residents' rooms across two nursing units, despite the code's stipulation that such devices are prohibited in all health care occupancies unless used only in nonsleeping staff and employee areas and the heating elements do not exceed 212°F (100°C). The temperatures in these rooms varied, with some rooms experiencing drafts and others having heating units covered or turned off. The facility's Administrator acknowledged that portable space heaters were provided to residents upon request for comfort, not due to any issues with the heating system. However, the facility's Emergency Preparedness Plan and Equipment Management policy did not address the use of portable space heaters, indicating a lack of compliance with the required safety standards. The absence of a specific policy for portable space heaters contributed to the deficiency, as the facility failed to ensure adherence to the NFPA 101 Life Safety Code requirements.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 i. Heaters were immediately removed from all the resident rooms, all resident rooms checked for heaters and none were found. ii. This deficiency has the potential to affect all residents in the facility. iii. Policy & Procedure for Heating system was created and included 2012 NFPA101 19.7.8 Portable Space-Heating Devices regulation, maintenance staff inserviced on new policy. iv. An audit tool will be developed to ensure that the heating system is functioning properly and there are no portable space heaters in resident areas. Any negative findings during monitoring will be addressed by the Maintenance Director or designee and referred to the QAPI committee for further review. Audits will be conducted weekly x 4 weeks, then monthly x 3 months. v. Director of Maintenance/designee will be responsible for K781 tag.
Deficiency in Serving Hot Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that residents were served food and drink that were palatable, attractive, and at a safe and appetizing temperature. This deficiency was identified during a Recertification Survey, where ten out of eleven residents in a Resident Council meeting complained about being served cold meals that should have been hot. Observations during the lunch meal service confirmed that hot food items were served below the required temperature of 135 degrees Fahrenheit, with test tray temperatures ranging from 95 to 128 degrees Fahrenheit. The facility's policy on food temperatures mandates that all hot food items must be cooked, held, and served at a minimum of 135 degrees Fahrenheit. However, the Food Service Director admitted that while temperatures were monitored in the kitchen, they were not checked on the units during meal service. Despite discussions in morning meetings and suggestions for solutions like insulated food trucks and a pellet system, no actions were taken to address the issue. The Director of Recreation, responsible for recording Resident Council minutes, failed to document the residents' concerns about cold food, which had been ongoing for several months. Interviews with various staff members, including the Food Service Director, Dietician, and Director of Nursing Services, revealed awareness of the issue but a lack of implementation of recommended solutions. The Ombudsman also noted that residents had been complaining about cold food for two to three months, but these concerns were not reflected in the Resident Council minutes. The deficiency highlights a breakdown in communication and action among the facility's staff, leading to the continued serving of cold meals to residents.
Deficiency in Food Service Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper sanitation practices and food service safety standards, as identified during a recertification survey. The dishwashing machine used in the facility's kitchen did not maintain the required temperatures for effective sanitation. Observations showed that the dishmachine's temperature gauge read below the necessary 120 degrees Fahrenheit for both the wash and rinse cycles, contrary to the facility's policy and the manufacturer's recommendations. Interviews with the Food Service Director and Dietary Aide revealed awareness of the temperature issues, yet the problem persisted, with the dishmachine often operating at temperatures as low as 95 degrees Fahrenheit. Additionally, residents expressed dissatisfaction with the temperature of their meals during a Resident Council meeting, where ten out of eleven residents reported being served cold food that should have been hot. Test trays from different units confirmed that hot food items were served at temperatures significantly below the required 135 degrees Fahrenheit. The Food Service Director acknowledged the issue but noted that food temperatures were only monitored in the kitchen and not on the units, leading to prolonged distribution times and cold meals. Interviews with staff, including the Dietician and Director of Nursing Services, highlighted awareness of the residents' complaints about cold meals. Despite recommendations for solutions such as insulated food trucks and a pellet system to maintain food temperatures, these were not implemented. The facility's failure to address these issues resulted in a deficiency related to food service safety and sanitation practices.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in food being served at unacceptable temperatures across all three resident units. During a re-certification survey, it was found that the facility did not adhere to its policy of maintaining hot food at a minimum of 135 degrees Fahrenheit. Test trays revealed that food temperatures were significantly below this standard, with readings as low as 95 degrees Fahrenheit for noodles and 113 degrees Fahrenheit for carrots. Residents had previously complained about being served cold food during meals, but these concerns were not documented in the Resident Council minutes. Interviews with staff revealed a lack of monitoring of food temperatures on the units, despite awareness of the issue. The Food Service Director acknowledged the problem and mentioned that potential solutions, such as using insulated food trucks and a pellet system, were discussed but not implemented. The Director of Recreation, responsible for recording Resident Council meeting minutes, admitted that the cold food concern had been discussed for the past three months but was not documented. The Administrator stated they were doing their best to serve food at acceptable temperatures, indicating a lack of effective action to resolve the issue.
Failure to Address Cold Food Complaints in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address and correct issues related to cold food being served to residents. Despite multiple complaints from residents during Resident Council meetings about hot meals being served cold, the QAPI committee did not review, analyze, or act on the available data to make necessary improvements. The facility's QAPI plan, which aims to provide quality care and improve resident experiences, was not effectively utilized to address this issue. The Food Service Director acknowledged awareness of the cold food complaints but admitted that food temperatures were not monitored during meals and that the issue was not discussed in QAPI meetings. The Director of Recreation, responsible for recording Resident Council meeting minutes, confirmed that the cold food concern was discussed but not documented in the minutes. The Director of Nursing Services, a member of the QAPI committee, was aware of the complaints but stated that they were addressed in morning reports rather than in QAPI meetings. This lack of documentation and action by the QAPI committee contributed to the deficiency.
Failure to Accurately Reflect Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately identified and honored, as required by their policy. Specifically, the facility did not correctly update and reflect the resident's preferred code status in the event of cardiac or pulmonary arrest. The resident, who had moderately impaired cognition, had expressed a change in their advance directive from Do Not Resuscitate to Full Code, but this change was not accurately reflected in their identification bands. The facility's policy required that changes in advance directives be updated in the electronic medical record, physician's orders, and the resident's hard chart, but this was not properly executed. During the survey, it was observed that the resident was not wearing an identification band, and two different identification bands were attached to their wheelchair, one of which incorrectly indicated a Do Not Resuscitate status with a red dot. Interviews with staff revealed confusion and inconsistency in the identification process, with a Licensed Practical Nurse unaware of the two bands and a Social Worker responsible for updating the bands not ensuring the correct status was reflected. The Director of Nursing Services acknowledged the error and stated that the facility does not use red dots as identifiers for advance directive status, highlighting a discrepancy between practice and policy.
Inadequate Hot Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for residents on the East Unit, as evidenced by inadequate hot water temperatures in resident areas. During the recertification survey, it was observed that the hot water temperatures in the rooms of two residents and the East unit shower room were below the required range of 90-110 degrees Fahrenheit, with measurements as low as 79 and 81 degrees Fahrenheit. Residents complained about the cold water, and it was noted that they had to use showers on other units due to the lack of hot water in their own rooms. Interviews with staff revealed that the issue had been ongoing for several weeks, with Certified Nurse Assistants reporting that they had to run water for over an hour to achieve a warm temperature, which was still insufficient. The Director of Environmental Services and Maintenance Personnel were unaware of the specific cold water issues, despite daily checks being conducted. The Administrator acknowledged awareness of a problem with the mixing valve since mid-October, which had not been resolved due to a delay in obtaining the necessary part from the supply company.
Inaccurate Documentation of Advanced Directives in MDS Assessment
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the advanced directives for a resident, specifically regarding the directive of Do Not Hospitalize. This deficiency was identified during a recertification survey for a resident with multiple diagnoses, including Metabolic Encephalopathy, Moderate Protein-Calorie Malnutrition, and Type 2 Diabetes Mellitus. The resident's Quarterly MDS assessment did not document the advanced directive of Do Not Hospitalize, despite it being recorded in the resident's Medical Orders for Life-Sustaining Treatment (MOLST) form and Physician's Orders. Interviews revealed that the MDS Coordinator and social workers were responsible for ensuring the accuracy of the advanced directives on the MDS assessment. The MDS Coordinator acknowledged the oversight, stating that the assessment should have included the Do Not Hospitalize directive. Social Worker #1, who was responsible for completing the advanced directives section, admitted the omission was an oversight. The Director of Nursing Services confirmed that social workers were tasked with ensuring the accuracy of advanced directives on the MDS assessment, which should have aligned with the resident's MOLST form and Physician's Orders.
Failure to Update Advanced Directive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments for residents. This deficiency was identified for two residents who had changes in their advanced directives that were not accurately reflected in their care plans. Specifically, one resident's advanced directive changed from Do Not Resuscitate to Cardiopulmonary Resuscitation, but the care plan was not updated to reflect this change until a later date. Another resident had a physician's order for Do Not Hospitalize, but the care plan still included instructions to send the resident to the hospital. The facility's policy on comprehensive care plans requires that they be reviewed and revised on a quarterly basis, with significant changes in condition, annually, on re-admission from an inpatient hospital stay, and as requested by the resident or their representatives. Additionally, the policy on advanced directives states that these should be reviewed during admission and throughout the resident's stay, and any changes should be promptly reflected in the care plan. However, the facility did not adhere to these policies, resulting in discrepancies between the residents' wishes and their documented care plans. Interviews with facility staff revealed a lack of communication and responsibility regarding the updating of advanced directive care plans. The Registered Nurse Manager and Social Worker both acknowledged that the care plans were not updated as required, with the Social Worker admitting to forgetting to update one resident's care plan due to a clerical error. The Director of Nursing Services confirmed that the care plans should have been updated to accurately reflect the residents' wishes and physician's orders, indicating a failure in the facility's processes to ensure compliance with their own policies.
Improper Storage of Medications in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were properly stored in the medication carts, as observed during the Recertification Survey. Specifically, Unit North Medication Cart #1 was found to contain non-medication items such as hearing aids, a dirty measuring tape, rolls of surgical tape, hearing aid batteries, and loose rubber bands. These items were stored alongside medications, which is against the facility's Medication Storage policy that requires medications to be stored in a manner that maintains product integrity and ensures residents' safety. Interviews with staff revealed a misunderstanding of the policy. The Registered Nurse Manager and a Licensed Practical Nurse both stated that the non-medication items needed to stay in the medication cart because they were related to medical needs. However, the Director of Nursing Services clarified that only medications and items directly related to medication administration should be stored in the medication carts. This discrepancy in understanding and adherence to the policy led to the improper storage of medications, as identified by the surveyors.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that the resident call system was fully operational, leading to a deficiency in one of the three resident units. Specifically, a resident with a history of falls and a diagnosis of a periprosthetic fracture of the left hip was placed on the toilet by staff and instructed to use the call bell for assistance. However, the call bell in the resident's bathroom was not functioning, preventing the resident from calling for help. As a result, the resident attempted to transfer themselves from the toilet, resulting in a fall and injury. The facility's policy on call bells did not include a process for routinely checking their functionality, and interviews revealed that call bells were not checked regularly. Maintenance personnel confirmed that the call bell in the resident's bathroom was not lighting up or making an audible sound, and it required replacement. The Director of Nursing Services and other staff were unaware of the malfunction before the incident, highlighting a lack of routine checks and audits for the call bell system.
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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