Samaritan Keep Nursing Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Watertown, New York.
- Location
- 133 Pratt St, Watertown, New York 13601
- CMS Provider Number
- 335431
- Inspections on file
- 18
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Samaritan Keep Nursing Home Inc during CMS and state inspections, most recent first.
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.
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.
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.
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.
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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