Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Samaritan Keep Nursing Home Inc during CMS and state inspections, most recent first.
Two residents lost bed rails without documented education, therapy evaluation, or discussion of alternatives before the rails were removed. One resident with morbid obesity and L-sided paralysis said the rail helped with repositioning and rolling, while another resident with R-sided paralysis and muscle weakness said the rails helped with rolling and stability at the bedside. Staff confirmed the rails had supported bed mobility and that a trapeze trial was not helpful for one resident.
A resident with neurocognitive disorder, Parkinson’s disease, and epilepsy, who was otherwise cognitively intact and largely independent, was found with a medication cup at the bedside containing one whole and one half white pill. Facility policy required nurses to remain with residents until medications were swallowed and prohibited leaving medications at the bedside without a physician’s order, and a separate self-administration policy required an IDT evaluation and care plan documentation before self-medication. An LPN reported the pills were levodopa, had already signed the dose as given before the resident took it, and admitted leaving the room while the medication remained in the cup, even though the resident had no order to self-administer. The RN unit manager confirmed that no residents on the unit had self-medication orders and that medications should not be left at the bedside.
A resident admitted with a Stage 2 coccyx pressure ulcer, moderate cognitive impairment, incontinence, and dependence for toileting and hygiene did not receive continuous, ordered wound care consistent with facility policy. Although the wound was identified on admission and later documented again after a hospital readmission, there were no wound care orders in place for the first several days after initial admission and again for an extended period after a weekly skin check documented a coccyx pressure ulcer. During this time, staff notes referenced skin issues and an open area on the buttocks, but there was missing documentation of required skin evaluations, inconsistent wound assessments, and delays in obtaining provider orders for treatment, resulting in multiple gaps in ordered care and monitoring for the Stage 2 pressure ulcer.
A resident with dementia and a high elopement risk was care planned for a wander guard and increased supervision, including 30- or 60-minute safety checks and per-shift device checks, but staff failed to complete and document these interventions as required. On one occasion, the resident, who was supposed to be on frequent checks, was last seen in bed and later found in a basement area after the wander guard alarm sounded, with the safety check sheet showing no entries for many hours. In a later period, multiple days showed missing signatures on hourly safety check forms, and an LPN admitted signing for wander guard checks that were not actually performed, while relying on aides to report problems. Staff interviews confirmed that safety checks and wander guard monitoring were required, that documentation should not contain blanks, and that there was no effective process to monitor completion of these forms.
Two residents with indwelling urinary catheters did not receive appropriate catheter management. One resident had failed voiding trials, no documented urology follow-up, and a later voiding trial that failed without documented provider notification or a clear plan. Another resident with a history of bladder infections reportedly wore a leg bag to bed, with staff and the resident giving conflicting accounts about bag changes and no documented education or declination.
A resident with Alzheimer’s disease and abnormal weight loss had significant ongoing weight loss and was care planned for one-staff meal assistance with extensive verbal cues, supplements, and weekly weights. Despite this, staff did not provide the planned encouragement or assistance during observed meals, and the resident was seen spilling drinks, touching food, and falling asleep at the table while eating little. The RD documented significant weight loss, but there was no documented evidence the medical provider was notified or addressed the weight loss.
BiPAP Care, Cleaning, and Documentation Not Maintained: A resident with respiratory failure and OSA was ordered constant oxygen with BiPAP, but staff did not consistently document BiPAP use, settings, water checks, or respiratory assessments. The BiPAP reservoir was found empty at times, the mask had dried debris and was not being cleaned, and staff were unsure of the resident’s BiPAP orders, oxygen bleed-in directions, and who was responsible for cleaning and monitoring the equipment.
A resident with kidney failure who received hemodialysis had no documented ongoing pre- and post-dialysis assessment, access-site monitoring, or consistent communication between the facility and the dialysis center. The care plan and orders called for monitoring and notification parameters, but staff did not document routine vital signs, and an LPN said the facility usually assumed dialysis went smoothly if no report was received.
An unlabeled cup with two tablets was left on a 4th floor med cart after a resident was unavailable, and an open vial of tuberculin PPD in the med room refrigerator lacked an open date. The 8th floor med cart and 3rd floor treatment cart were also observed unlocked and unattended, with staff stating carts should be locked when not in use.
A resident with dementia and dysphagia was ordered a level 1 pureed diet with thin liquids, but during lunch was served a regular consistency brownie instead of a pureed brownie. The resident’s care plan did not include the ordered food texture, and staff interviews confirmed the tray was supposed to be checked by dietary and CNA staff, yet the incorrect food consistency still reached the resident.
Failure to Follow Enhanced Barrier Precautions During Catheter Care: A resident with an indwelling urinary catheter and EBP signage outside the room was observed receiving catheter-related care without required hand hygiene and without the required gown. A CNA entered and exited the room without cleaning hands, emptied the catheter drainage without a gown, and changed gloves without hand hygiene in between. Interviews showed staff were unclear on EBP requirements, while the IP stated hand hygiene was required before and after resident contact and PPE was required for high-contact catheter care.
An LPN, reportedly frustrated with a cognitively impaired, wandering resident who was frequently out of bed and triggering alarms, used plastic zip ties and a sock to restrain the resident’s hand to the bed rail/able riser for an extended period during a night shift. Staff later observed the resident with a zip tie on the wrist, heard commotion from the room, and reported that the LPN had previously spoken of giving the resident “personal protective bracelets” despite being warned that restraints were illegal. Oncoming staff found cut zip ties under the bed and in the trash and assessed the resident, who had Alzheimer’s dementia, Parkinson’s disease, and was care planned as an elopement risk. The facility’s investigation and a police report confirmed that plastic zip ties had been used as an unlawful restraint, constituting abuse and resulting in Immediate Jeopardy past non-compliance.
The facility failed to report incidents involving a resident's fracture during a mechanical lift transfer and another resident's elopement to a non-resident area. Despite the injuries and risks involved, the incidents were not reported to the New York State Department of Health as required.
Removal of Bed Rails Without Resident Education or Alternatives
Penalty
Summary
The facility failed to honor residents’ rights to a dignified existence and self-determination when it removed side rails from two residents without documented evidence that they were educated, offered alternatives, evaluated by therapy, or given an opportunity to discuss concerns before the rails were taken away. The report states that the facility had a policy requiring non-bed rail alternatives to be attempted first and that residents or their representatives were to receive education on the risks and benefits so they could make an informed decision. A facility letter also stated that all bed rail use would be discontinued and staff were trained in alternative safety measures, but the report notes that the rails were removed quickly and that there was no time allotted for discussion. Resident #257 had diagnoses including morbid obesity and left-sided paralysis following a stroke. The resident’s assessments documented intact cognition and dependence for rolling and returning to lying in bed, and the care plan reflected substantial assistance of two for bed mobility after the rail removal. Earlier bed rail evaluation documented poor bed mobility and recommended bilateral side rails as an enabler to promote independence, but a later evaluation stated side rails were not indicated. The resident stated that no one explained the removal beforehand, that the left rail had helped them reposition, shift weight, and turn to the left, and that without it they could not move at all. Staff interviews confirmed the resident had used the rail to help roll and that a trapeze was tried after the rails were removed but was not helpful and was removed. Resident #184 had diagnoses including right-sided paralysis and muscle weakness. The resident’s assessments documented intact cognition, functional impairment on one side of both upper and lower extremities, and maximum assistance with bed mobility. Earlier bed rail evaluation documented poor bed mobility and recommended bilateral side rails as an enabler to promote independence, but a later evaluation stated side rails were not indicated. The resident reported that two maintenance workers removed both rails without explanation and that no alternatives were offered. The resident stated the rails had been used to roll in bed and to steady themselves when sitting at the edge of the bed, and that since removal they did not move around in bed as well. Staff interviews confirmed the resident had used the rails to roll and stabilize themselves, and that after removal the resident required more assistance with bed mobility.
Medication Left at Bedside Without Self-Administration Assessment or Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure the interdisciplinary team determined a resident’s ability to safely self-administer medications and to follow facility policy prohibiting medications from being left at the bedside without a physician’s order. Facility policy stated that nurses were personally responsible for every drug they administered, were to remain with the resident until medications were swallowed, and were not to leave medications with residents except with a doctor’s order. A separate self-administration policy required evaluation of residents’ desire and competence to self-medicate, review by the interdisciplinary team, and documentation in the care plan. For the resident involved, there was no documented evidence of a self-medication assessment or a medical order authorizing self-administration. The resident had diagnoses including neurocognitive disorder, Parkinson’s disease, and epilepsy, and was documented as cognitively intact and largely independent in activities of daily living. The care plan documented use of carbidopa-levodopa and directed staff to administer medications as ordered and monitor for side effects. During observation, surveyors found a medication cup at the resident’s bedside containing one whole and one half white pill; the resident stated a nurse had left the medication, was unsure what it was, and was unsure how long it had been there. The LPN later identified the medication as levodopa, admitted they had signed it as administered before the resident took it, and acknowledged they became distracted and left the room before ensuring ingestion, despite the resident having no order to self-medicate. The RN unit manager confirmed that nurses were expected to ensure residents swallowed medications at the time of administration, that no residents on the unit had self-medication orders, and that medications should not be left at the bedside.
Failure to Maintain Continuous Treatment and Monitoring for Stage 2 Coccyx Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards, to prevent new ulcers and promote healing for a resident admitted with a Stage 2 coccyx pressure ulcer. The facility’s wound care policy required an interdisciplinary process for prevention, identification, assessment, treatment, and monitoring of wounds, with nurse managers responsible for comprehensive skin assessments, obtaining provider orders, and overseeing wound care. On admission, the resident’s assessment by the RN Unit Manager documented redness and a dime-sized Stage 2 pressure ulcer on the coccyx, and the admission MDS identified the resident as at risk for pressure ulcers, with moderate cognitive impairment, frequent incontinence, and dependence for toileting and hygiene. Despite this, there was no documented evidence of wound care orders for the coccyx at admission, and no wound care orders were in place for the first five days. The comprehensive care plan initiated shortly after admission identified an actual/potential skin integrity impairment related to impaired mobility and referenced following facility protocols for treatment, monitoring and documenting the wound, and reporting signs of infection. A skin-only evaluation later documented skin issues on the back and coccyx, and a provider order was eventually entered to apply a foam dressing to the coccyx every three days for protection. A subsequent RN progress note stated that wound care orders were put in place and the wound healed. The resident was then hospitalized and readmitted with a reopened Stage 2 coccyx pressure ulcer, and admission assessment again documented this wound. A provider order to resume previous orders was entered, but the foam dressing order was discontinued two days later, and an RN progress note shortly thereafter documented that the resident’s skin was clear at that time. Later, a weekly skin check by an LPN documented a pressure ulcer on the coccyx, and a family call reported an open area on the resident’s buttocks, with the nurse manager notified and assessing the resident. There was no documented skin-only evaluation on the date following the family complaint, and an LPN note documented the resident’s refusal to be repositioned on their side for an open area on the right buttock. An RN progress note a few days later, after assessment with the wound care nurse, described the coccyx as red with no open areas. New provider orders for Stage 2 coccyx pressure ulcer treatment were not entered until nearly two weeks after the LPN’s skin check documented the pressure ulcer, resulting in a 12-day period without wound care orders for the Stage 2 coccyx ulcer. Interviews with the RN Unit Manager, LPNs, the wound nurse, and the DON confirmed gaps in obtaining and maintaining wound care orders, lack of consistent wound monitoring and documentation, and uncertainty about why the wound was not tracked and treated continuously as required by facility policy.
Failure to Complete Elopement Safety Checks and Wander Guard Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and complete required safety checks for a resident at high risk for elopement. The resident had dementia with moderately impaired cognition, could ambulate independently with a walker, and used an elopement alarm daily. An elopement risk assessment identified the resident as high risk, and the comprehensive care plan included interventions such as checking the placement and function of the wander guard every shift. Facility policies required that residents on increased supervision receive visual checks at specified 30- or 60-minute intervals, that these interventions be reflected in the care plan and resident care instructions, and that wander guard devices be checked each shift for proper function and documented accordingly. On one incident date, the resident had been placed on 30-minute safety checks following a prior elopement risk assessment and a nurse’s progress note documenting initiation of 30-minute checks. However, there was no evidence that these 30-minute checks were added to the comprehensive care plan. The resident was last seen in bed at 2:00 AM and was later found in the basement lobby around 5:00 AM after the wander guard system alarmed. The safety check form for that date showed that 30-minute checks were not documented from midnight through mid-afternoon, leaving large undocumented intervals despite staff statements that the resident was on 30-minute or 60-minute checks at the time. Interviews with the RN unit manager and DON confirmed that the checks should have been on the care plan and resident care instructions and that the safety check sheet should not have been blank, but there was no process in place to monitor completion of these forms. In a later review period, the resident remained identified as high risk for elopement, with the care plan and physician orders directing that the wander guard on the right ankle be checked every shift and that 60-minute safety checks continue. March safety check forms showed multiple dates where hourly checks were not signed, indicating missed or undocumented safety checks. The MAR showed that an LPN signed for wander guard checks for this resident on a specific day, but in interview the LPN admitted they had not actually performed all the checks and instead relied on aides to report issues, citing workload. Multiple staff, including CNAs, LPNs, the RN unit manager, and the DON, acknowledged that safety checks and wander guard checks were required, that there should be no blanks on the safety check sheets, and that nurses should not sign for checks they did not perform. They also confirmed there was no consistent follow-up or monitoring process to ensure completion and accuracy of the safety check documentation.
Failure to Manage Indwelling Catheter Care and Voiding Trial Follow-Up
Penalty
Summary
The facility failed to provide necessary services and treatment related to indwelling urinary catheter use for two residents. One resident had diagnoses including urinary retention and arrived with a catheter placed in the hospital after failed voiding trials. The hospital discharge summary stated that a voiding trial could be attempted at the rehabilitation facility and that the resident should be referred to urology, but there was no documented evidence that a urology appointment was made. The resident’s record also lacked a physician order for the catheter for the period after admission until later in the stay, and multiple provider progress notes documented the catheter without any plan to address it. A physician later ordered a one-time catheter removal for a voiding trial, and the catheter was removed in the morning. The resident was unable to void after eight hours and the catheter was replaced, but there was no documented evidence that the nurse practitioner was notified of the failed voiding trial. Subsequent provider notes continued to document the catheter, yet there was still no documented plan to address it, no documented additional voiding trial, and no documented urology appointment. During observation, the resident was seated with the catheter drainage bag hanging from the recliner chair wrapped in a pillowcase, and the resident stated the catheter had been in place since admission. The second resident had diagnoses including obstructive uropathy, bladder cancer, and bladder infection, and had an indwelling catheter with orders to change the catheter monthly and as needed. The resident stated they used a leg bag and did not change to a large collection bag at bedtime, and said no one had explained why they should. Staff interviews showed conflicting information about whether the resident switched bags at night, but multiple staff members stated leg bags should be changed to large bags when going to bed because the bag should remain below the level of the bladder. Staff also stated the resident depended on assistance to switch bags and that education and declination should be documented, but they were not aware of documented education or documented declination for this resident.
Failure to Provide Planned Meal Assistance and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate food and fluid intake for one resident with Alzheimer’s disease and abnormal weight loss. The resident’s quarterly assessment documented severely impaired cognition, a need for supervision/touching assistance with eating, and recent significant weight loss. The care plan identified inadequate oral intake related to decreased appetite and sleeping during meals, with interventions including nutritional supplements, weekly weights, and one-staff assistance with extensive verbal cues at meals. The resident’s documented weights showed a progressive decline from 128 pounds to 122.4 pounds, then 119.4 pounds, and later 114.8 pounds, with continued weights around 115 pounds and 114.2 pounds. The registered dietitian documented significant weight loss and noted the resident benefited from staff redirection during meals, but there was no documented evidence that the medical provider was made aware of the resident’s weight loss. The nurse practitioner stated they expected to be notified of significant weight loss and did not see medical notes addressing the December weight loss. During meal observations, the resident was seen spilling drinks, touching food with their hands, appearing asleep at the table, and consuming only limited portions of meals. On both dinner and lunch observations, staff did not provide assistance or encouragement during much of the meal, and the tray was removed without the resident receiving the planned verbal cues or meal support. Staff interviews confirmed the resident required supervision and verbal cues at meals, but they were not aware the resident was not eating or receiving the planned assistance.
BiPAP Care, Cleaning, and Documentation Not Maintained
Penalty
Summary
Resident #257, who had diagnoses including respiratory failure and obstructive sleep apnea, was documented as needing constant oxygen with bilevel positive airway pressure (BiPAP). The resident’s care plan included monitoring for signs of respiratory distress and bleeding oxygen through the BiPAP at 5 liters per minute. Physician orders directed staff to check the water level in the BiPAP machine every shift, document whether the resident had shortness of breath or trouble breathing while lying flat or needed to sleep with the head of the bed elevated, and use BiPAP settings of 22/18. However, the orders did not document when to use the BiPAP equipment or include directions for oxygen bleed-in. The March 2026 treatment record showed the water level in the BiPAP machine was not checked as ordered on multiple shifts, and the resident’s respiratory status while lying flat was also not documented on multiple shifts. During observations, the BiPAP reservoir was found empty on one occasion, and the nasal mask had dried brown debris on the inside. The resident stated they used the BiPAP all the time and that the nasal mask was never cleaned. On another observation, the reservoir was again empty, and later it was filled with clear fluid. The oxygen concentrator was observed connected to the BiPAP tubing and set at 5 liters at one point and 4.5 liters at other times. The administration of the BiPAP and its settings was not documented on the treatment administration record. Staff interviews showed uncertainty about the resident’s BiPAP orders, who was responsible for cleaning the mask, how often it should be cleaned, and how the effectiveness of the BiPAP was monitored. One LPN stated they thought the mask was cleaned monthly and did not know who was responsible, while another LPN stated oxygen required an order and the setting should be checked once per shift. The unit manager stated they expected nurses to know the BiPAP and oxygen settings were correct, but were unsure how effectiveness was monitored beyond checking oxygen levels on the night shift.
Dialysis Monitoring and Communication Deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with kidney failure who received hemodialysis at a community dialysis center. Resident #13 had intact cognition and a care plan for hemodialysis, but the record did not show ongoing assessment of the resident’s condition before and after dialysis or monitoring for complications. The facility policy required communication with the dialysis team and monitoring for signs of fluid retention or dehydration, yet the care plan did not document pre- and post-dialysis monitoring, access-site checks, or ongoing communication with the dialysis center. Physician orders required hemodialysis every Monday, Wednesday, and Friday and instructed staff to notify the physician if systolic blood pressure was below 90 or heart rate was above 110 every shift, but there was no documented evidence that blood pressures were checked every shift or that vital signs were obtained before and after dialysis treatments. The dialysis binder sent with the resident contained a post-dialysis weight form and orders, but it did not include communication from the dialysis center about medications, treatment orders, lab values, vital signs, or the resident’s response to treatment. The resident stated that staff did not check vital signs or the dialysis access site after returning from dialysis, and an LPN stated staff usually did not receive communication from the dialysis center and did not consider pre- or post-dialysis vital signs a requirement.
Unlabeled Medications and Unsecured Medication and Treatment Carts
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles on multiple units. On the 4th floor medication cart, a nurse left two white circular tablets in an unlabeled plastic cup after the resident was not available for the scheduled 4:00 PM dose, and the medication was left in the cart for later administration. The 4th floor medication room refrigerator also contained an open vial of tuberculin purified protein derivative with a dispensed date of 01/20/2025, and staff stated multi-dose vials should be dated when opened and discarded if there was no open date. The unit manager stated the vial was used for newly admitted residents and that medications should not be pre-poured or saved for later. In addition, the 8th floor medication cart was observed unlocked and unattended while multiple residents and unlicensed staff passed by, and the 3rd floor treatment cart was also observed unlocked and unattended. The treatment cart contained an electric razor, gait belt, medicated creams, sunscreen, alcohol prep pads, and wound gel. Staff stated medication and treatment carts should be locked when unattended, and the unit manager stated the carts should be locked to prevent residents from accessing them and to prevent medication diversion.
Pureed Diet Not Followed for Resident With Dysphagia
Penalty
Summary
The facility failed to ensure that Resident #241 received food prepared in the ordered form designed to meet the resident’s individual needs. The resident had diagnoses including dementia, pneumonia, and difficulty swallowing, and the Minimum Data Set documented moderate cognitive impairment, supervision or touching assistance with eating, and a mechanically altered diet. A physician order dated 12/20/2025 directed a level 1 pureed texture with thin liquids, and the Speech Language Pathologist’s evaluation documented the resident tolerated level 1 pureed solids and thin liquids, had absent mastication with mechanical soft food, and was not appropriate for a diet upgrade. The resident’s Comprehensive Care Plan documented impaired swallowing related to difficulty moving solids and liquids from the mouth to the stomach, with coughing with thin liquids and difficulty chewing solids, but it did not include the ordered food texture. During the lunch meal observation, the resident’s tray contained pureed items, but a smaller plate on the tray held an untouched regular consistency brownie with green frosting instead of a pureed brownie. The resident was coughing at the time of the observation, and the Speech Language Pathologist checked the meal ticket, identified the mismatch, and obtained a pureed brownie from Food Service. Interviews with staff showed the meal ticket was used by dietary staff to plate items and was also checked by the CNA and the staff member delivering the tray, with a stated two-point check process. Despite these checks, staff acknowledged the resident was on a pureed diet and should not have received a regular consistency brownie. The Food Service Director stated the server referenced the meal ticket and the CNA ensured the tray matched the ticket, but the regular brownie was still served to the resident.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident who had an indwelling urinary catheter and was on enhanced barrier precautions. The resident had diagnoses including urinary retention, moderate cognitive impairment, substantial to maximum assistance needs for most activities of daily living, and a urinary catheter that had been placed prior to admission. The care plan documented catheter-related interventions, including monthly catheter changes, monitoring for urinary tract infection signs and symptoms, and keeping the drainage bag below bladder level. During an observation, the enhanced barrier precaution sign was posted outside the resident’s room, indicating that staff and providers must clean their hands before entering and when leaving the room and must wear gloves and a gown for high-contact care activities, including device care of urinary catheters. Certified Nurse Aide #37 entered the room without performing hand hygiene, later removed gloves and left the room without hand hygiene, returned without hand hygiene, and emptied the urinary catheter without wearing a gown. The aide also changed gloves without performing hand hygiene in between glove changes and handled items from the room while gloved before discarding them in the soiled linen bin. Interviews showed the aide stated they did not put on a gown because they did not think the resident had any sickness and acknowledged they should have performed hand hygiene before putting on gloves and between glove changes. An LPN stated PPE was only worn with urinary catheter care if a resident had an active infection, while the unit manager stated enhanced barrier precautions were new and staff were expected to look for the sign and follow it. The Infection Preventionist stated hand hygiene should be performed before and after any resident contact, gloves did not negate the need for hand hygiene, and staff should wear the required PPE for high-contact activities involving urinary catheter care.
Resident Unlawfully Restrained to Bed With Zip Ties by LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and neglect when an LPN used zip ties to restrain the resident to their bed for approximately 45 minutes to one hour during an overnight shift. Facility policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff education on appropriate interventions for aggressive behaviors and on reporting abuse and neglect. Despite this policy, the resident, who had Alzheimer’s dementia, Parkinson’s disease, moderately impaired cognition, and was care planned as an elopement/wandering risk, was subjected to an unlawful restraint using zip ties attached to the bed’s able riser/side rail. Resident #3’s care plan identified them as disoriented to place, with impaired safety awareness and wandering behavior, and interventions included distraction with activities, food, conversation, and allowing time to verbalize feelings and fears. On the night of the incident, the resident was reportedly up frequently, leaving their room, moving around the unit, and had a history of frequent falls from bed with pressure mats in place to alert staff. According to interviews, the LPN became increasingly upset and “tired” of responding to the resident’s bed alarms and movements, and stated an intention to give the resident “personal protective bracelets,” despite being told by a CNA that restraining residents was illegal. Subsequently, the LPN and a CNA took the resident back to bed, and later the resident was found with a sock over the hand and zip ties securing the wrist to the bed rail/able riser. Multiple staff statements described witnessing or discovering the restraint and related events. One CNA reported seeing the LPN place a white zip tie around the resident’s wrist and connect it to the bed rail in the down position, with a black zip tie intertwined around the rail, and hearing commotion near the resident’s room. Another CNA later observed the resident sleeping with a sock and zip tie on the wrist and cut the zip tie off, placing it at the nurse’s station. Staff also reported the LPN holding the resident’s door shut while the resident attempted to open it, telling the resident through the door to go back to bed. When the oncoming LPN was informed of the incident, they assessed the resident, found no physical injuries, and discovered used zip ties under the bed and in the trash. The facility president confirmed that zip ties had previously been used only to secure old bed rails and that those beds had been removed, indicating there was no legitimate need for zip ties on the unit at the time of the incident. The police report documented that plastic zip ties had been used to restrain the resident’s hand to the bed, and the facility’s investigation concluded that the LPN had zip tied the resident’s wrist to the bed rail, constituting abuse and resulting in Immediate Jeopardy Past Non-Compliance.
Removal Plan
- Resident #3 was immediately assessed by a registered nurse for physical and psychological harm; the physician and family were notified, and the resident's care plan was revised to include potential for abuse.
- Licensed Practical Nurse #7 and Certified Nurse Aides #4 and #6 were placed on administrative leave pending investigation.
- Certified Nurse Aide #4 received discipline for timely reporting and received additional education.
- Licensed Practical Nurse #7 and Certified Nurse Aide #6 were terminated.
- The accused Licensed Practical Nurse's actions were reported to the Office of Professions.
- The facility initiated training regarding restraints, dementia care, abuse prevention, identification, and reporting.
- All staff were educated.
- A full house abuse assessment was conducted on each resident.
- The facility initiated restraint audits for all residents, and findings were reported to the Quality Assurance Team.
Failure to Report Incidents Involving Resident Injury and Elopement
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported to the New York State Department of Health as required. Specifically, Resident #2 sustained a fracture from a transfer with a mechanical lift, and Resident #3 eloped to a non-resident area, and these incidents were not reported as required. Resident #2, who had diagnoses including anemia, anxiety disorder, and difficulty walking, sustained a left clavicle fracture during a transfer using a sit-to-stand mechanical lift. The incident occurred when the lift became jammed under the resident's wheelchair, causing the resident to become anxious and remove their hands from the machine, leading to a fall. Despite the resident's complaints of pain and the subsequent identification of a fracture, the facility concluded there was no evidence of abuse, neglect, or mistreatment and did not report the incident to the New York State Department of Health. Resident #3, who had diagnoses including dementia with behavioral disturbance and anxiety disorder, eloped from their unit and was found in a non-resident area, specifically the 8th-floor diet kitchen. The resident had a history of wandering and exit-seeking behavior, and the incident occurred after the resident's wander alert device was trialed off. There was no documented incident report or evidence that the facility reported the resident's elopement to the New York State Department of Health.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Samaritan Senior Village, Inc | 1.5 mi | ★★★★★ | 0 | 0 |
| Carthage Center For Rehabilitation And Nursing | 16.1 mi | ★★★★★ | 0 | 0 |
| Lewis County General Hospital-nursing Home Unit | 23.8 mi | ★★★★★ | 0 | 0 |
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