Sans Souci Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Yonkers, New York.
- Location
- 115 Park Avenue, Yonkers, New York 10703
- CMS Provider Number
- 335398
- Inspections on file
- 23
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Sans Souci Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with impaired cognition and mobility requested pain medication from an LPN, who became upset and physically attempted to force the resident back into their room by holding their hands and shoulders, despite the resident's resistance. Multiple staff and family interviews confirmed the LPN refused to provide the requested medication and used physical force, resulting in a failure to protect the resident from abuse and neglect.
A facility failed to thoroughly investigate an alleged abuse incident involving an LPN and a resident with impaired cognition and mobility. The internal investigation did not document a review of available video surveillance footage or an interview with a roommate who witnessed the event, despite facility policy requiring comprehensive evidence review and witness interviews.
A resident with recent knee surgery and cognitive impairment did not receive prescribed pain medication in a timely manner after requesting it from an LPN. The LPN, who was behind on medication administration, did not assess the resident for pain or provide the medication as ordered, resulting in a significant delay. Interviews with staff and family confirmed the delay and lack of assessment, in violation of facility policy and physician orders.
Two residents did not consistently receive or have documented ADL care, including incontinence care, showers, personal hygiene, and meal assistance, as required by their care plans. Additionally, a notable number of residents were observed dressed in hospital gowns rather than regular clothing, without clear documentation of preference or care planning. Staff interviews revealed inconsistent practices and understanding regarding documentation of care provided.
The facility did not consistently provide enough nursing staff to meet resident needs as outlined in its Facility Assessment, with multiple shifts on the 2nd floor falling below required nurse and CNA levels. Staffing records showed several occasions where only one nurse or fewer CNAs than required were present, and some shifts had no nurse or only one CNA scheduled. Leadership interviews confirmed awareness of staffing shortages and described efforts to fill gaps, but deficiencies persisted.
A nursing shift on one unit was left uncovered, resulting in 36 residents not receiving scheduled medications, including critical drugs such as antihypertensives, insulin, anticoagulants, and antipsychotics. The absence of a nurse was not reported to facility leadership, and the missed medications were only discovered after the fact. Residents affected had complex conditions including diabetes, hypertension, and heart failure.
A resident with severe cognitive impairment and a history of pressure ulcers did not consistently receive turning and repositioning as ordered by the wound care physician and outlined in the care plan. Documentation showed multiple missed instances of this essential care, and staff interviews revealed that the electronic system only allowed shift-based, not interval-based, documentation. This resulted in the resident not receiving care in accordance with professional standards and physician instructions.
A resident with severe cognitive impairment and malnutrition experienced a significant unplanned weight loss due to inconsistent documentation of meal intake and lack of timely communication to nursing and administration about poor intake, despite facility policies requiring monitoring and reporting of nutritional status.
The facility did not submit required 5-day investigative conclusion reports to the Department of Health within the mandated timeframe following incidents involving suspected abuse and a resident elopement. In each case, either the report was delayed or there was no documentation of submission, despite staff and leadership being aware of the reporting requirements.
The facility did not thoroughly investigate multiple allegations of abuse and financial exploitation, as required by policy. In several cases, written statements were not obtained from all staff assigned to the relevant units, investigative summaries were incomplete or unsigned, and not all involved staff were interviewed. These deficiencies affected the investigation of incidents involving inappropriate touching, physical altercations, and missing property among residents.
A resident with a history of behavioral issues struck another cognitively impaired resident on the head with a therapy device after the latter entered their room by mistake. The incident was witnessed by a CNA, and although staff intervened quickly and no injury was found, the event revealed a lapse in supervision and failure to protect a resident from physical abuse.
A resident with dementia and a documented history of wandering was not identified as an elopement risk during admission assessment, despite hospital records indicating such behaviors. The resident was assigned a low elopement risk score, placed in a first-floor room without a wander guard, and later exited the facility unescorted after being buzzed out by the receptionist. Staff interviews revealed that the resident's history of wandering was not recognized during the admission process, resulting in the omission of necessary safety precautions.
A deficiency occurred when a resident with dementia and a documented history of wandering was admitted without a care plan addressing wandering or elopement risk. Although the resident's hospital and family records noted prior wandering, the facility's care plans only addressed cognitive impairment and forgetfulness, omitting interventions for wandering or elopement. The DON stated that no wandering was observed during assessment and that hospital documentation did not indicate wandering, resulting in the lack of a targeted care plan.
A resident with severe cognitive impairment and a history of wandering exited the facility unescorted after being mistaken for a visitor by the Receptionist. The individual was not identified as an elopement risk on admission, did not have a wander guard or identification band, and was not listed on the elopement risk list at the front desk. The resident was later found by emergency services after entering a neighboring home, highlighting failures in supervision, risk assessment, and communication.
Two residents in an LTC facility did not receive adequate pain management. One resident with an amputation and neuropathy was not given pain medication as ordered, and non-medication interventions were not provided. Recommendations from a Physiatrist were not reviewed. Another resident with a shoulder replacement did not receive prescribed Oxycodone due to a failure to reorder the medication, and the emergency supply was not accessed. Staff interviews revealed lapses in communication and protocol adherence.
The facility failed to provide sufficient nursing staff on the 2nd and 3rd floors, leading to delays in resident care. The Facility Assessment did not account for the higher resident capacity on these floors, resulting in staffing levels below the required 2.2 CNA hours per resident per day. Residents reported delays in receiving care, and staff confirmed frequent call-outs and high resident assignments. Despite efforts to address staffing shortages, the facility did not meet the necessary staffing levels, impacting resident well-being.
A resident with paraplegia and frequent incontinence experienced significant delays in receiving incontinence care, despite a care plan for changes every two hours. The resident waited up to 12 hours on one occasion, leading to concerns about their frequent urinary tract infections. The DON acknowledged the issue, but there was no documentation to support consistent care.
A facility failed to ensure a physician reviewed a resident's care program at each visit. A resident with a recent amputation reported persistent pain, but the Physician Assistant did not review the Nursing Pain Evaluation or Physiatrist's recommendations. Despite recommendations for increased Gabapentin and imaging, the Physician Assistant's notes lacked reference to these and did not assess pain using a numeric scale.
A medication error rate of 8% was observed in an LTC facility, exceeding the acceptable 5% threshold. An LPN administered a crushed form of enteric-coated aspirin and Depakote delayed-release tablet to a resident, contrary to the prescribed chewable form and manufacturer's instructions. The LPN acknowledged the error, and the DON highlighted the need for compliance with medication instructions.
The facility failed to maintain proper infection control practices, specifically in hand hygiene, for two residents. A CNA touched a resident's food directly, and an LPN did not wash hands between glove changes during wound care. Both staff members acknowledged their lapses, and the DON noted the need for further education on hand hygiene.
A facility failed to offer and document pneumococcal immunization for a resident with a history of Type II Diabetes Mellitus, bilateral leg absence, and end-stage renal failure. Despite facility policy requiring vaccine status confirmation and education upon admission, the resident's records were incomplete, and the vaccine was not offered. The Infection Preventionist admitted the oversight, noting the resident had been in the facility for several months.
A resident's grievance regarding missing clothing and glasses was not promptly resolved, and the facility's grievance policy lacked necessary elements. The resident, who was severely cognitively impaired, had their designated representative report the issue multiple times without resolution. The facility's grievance policy did not specify how residents were informed of the process or their right to a written decision.
A facility failed to ensure effective discharge planning for a resident with serious mental illness, issuing a Transfer/Discharge Notice without involving the resident's representative and listing a destination lacking necessary psychiatric services. The resident, with diagnoses including schizoaffective disorder, was moderately cognitively impaired and aggressive. The facility's actions were not aligned with the resident's rights, and there was inadequate documentation and involvement in the discharge process.
A resident with severe cognitive impairment and high risk for pressure ulcers developed a Stage 2 ulcer on the sacrum. The facility failed to promptly assess and notify the physician, delaying treatment. The registered nurse was not informed of the skin opening, leading to a lapse in care consistent with professional standards.
A resident with multiple mental health diagnoses did not receive individualized behavioral health care at an LTC facility. The care plan was not updated to address evolving symptoms, and Level II Preadmission Screening recommendations were not incorporated. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, contributing to the facility's inability to manage the resident's behavioral health effectively.
A resident with severe cognitive impairment and significant weight loss did not receive a required Speech Therapy evaluation for slow eating and chewing, despite a physician's order. The evaluation was not documented, and the resident continued to experience challenges during mealtimes. Staff interviews confirmed the oversight, highlighting a deficiency in providing necessary rehabilitative services.
A resident with dementia and other medical conditions was verbally threatened and had their necklace pulled by a dietary aide, as witnessed by a CNA. The facility's investigation confirmed verbal abuse occurred. The incident was reported immediately, and the dietary aide was asked to leave the building.
A resident with severe cognitive impairment and multiple diagnoses did not receive care as per their comprehensive care plan, which included the use of a foam positioning wedge and heel booties to prevent pressure injuries. Observations showed the resident's heels were not offloaded, and staff interviews revealed a lack of awareness and communication regarding the resident's care needs.
Failure to Protect Resident from Abuse and Neglect During Medication Request
Penalty
Summary
On the evening of 08/19/2025, a resident with a history of aphasia, cerebral infarction, hemiplegia, and recent right total knee arthroplasty revision was involved in an incident with an LPN. The resident, who had moderately impaired cognition but was independent with eating, bed mobility, and wheelchair use, was observed on video surveillance seated in their wheelchair in the doorway of their room. The LPN, while at the medication cart, engaged in a verbal exchange with the resident, who was requesting pain medication. The LPN turned around, moved behind the resident's wheelchair, and attempted to hold the resident's hand down and force them back into their room, despite the resident resisting and holding onto the doorway frame. The LPN continued to attempt to pull the resident into the room by holding onto their hands and shoulders, even as the resident resisted these actions. Multiple interviews corroborated the events seen on video. The resident reported that the LPN appeared upset, refused to provide pain medication, and physically pulled their wheelchair backward while holding their arms. A family member stated the resident informed them that the LPN refused to provide pain medication and put hands on the resident without permission. Certified Nurse Aide #1 heard yelling and observed the LPN wheeling the resident backward into their room, reporting the incident to the night nurse. The LPN involved stated they were running late with medication pass and were unable to provide the pain medication, and that they became scared when the resident began yelling, leading them to attempt to bring the resident back into their room. Further, another LPN and the Director of Nursing confirmed that the LPN was still passing medications late into the shift and that the resident was upset about not receiving pain medication. The second LPN observed the first LPN attempting to push the resident back into their room while yelling and intervened to stop the situation. The Director of Nursing acknowledged that the incident could have been prevented and that staff should not place their hands on a resident to force compliance, especially when the resident is upset. The facility failed to ensure the resident was free from abuse, neglect, and mistreatment during this incident.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
Surveyors found that the facility failed to thoroughly investigate an alleged incident involving possible abuse, neglect, or mistreatment of a resident. The incident involved a Licensed Practical Nurse (LPN) who was observed on video surveillance engaging in a verbal exchange with a resident, followed by the LPN forcefully pulling the resident, who was seated in a wheelchair, back into their room despite the resident's resistance. The facility's internal investigation concluded that no abuse, neglect, or mistreatment had occurred, but the investigation summary did not include a review of the video surveillance footage or documentation of an interview with the resident's roommate, who was present during the incident. The resident involved had diagnoses including aphasia, cerebral infarction, hemiplegia, and was status post revision of a right total knee arthroplasty. According to the most recent assessment, the resident was independent with eating and bed mobility, required supervision and setup assistance with transfers and toileting, and was independent with wheelchair mobility, but had moderately impaired cognition. The incident was initially reported after a Certified Nurse Aide observed the LPN speaking loudly to the resident and allegedly pulling the resident by the shoulders while maneuvering the wheelchair. The LPN reported attempting to assist the resident back into a seated position and move the wheelchair to clear the path for the medication cart. Despite the availability of video surveillance footage, the facility's investigation summary did not document a review of this footage, nor did it include an interview with the roommate who witnessed the event. Both the Director of Nursing and the Administrator acknowledged that the omission of the video review from the investigation summary was an oversight. The facility's policy requires that all investigations be thorough and complete, including reviewing all relevant evidence and interviewing witnesses, but these steps were not fully documented in this case.
Failure to Provide Timely Pain Management as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of aphasia, cerebral infarction, hemiplegia, and recent right total knee arthroplasty revision did not receive pain management as ordered. The resident had a physician's order for Oxycodone HCL 5 mg orally every 6 hours as needed for pain. On the evening in question, the resident requested pain medication from an LPN at approximately 11:54 PM due to significant knee pain. The LPN did not administer the medication, and the resident did not receive the next dose until 1:28 AM, resulting in an interval of approximately eight hours and thirty-four minutes between doses. The facility's policy required consistent pain assessment and timely administration of pain medication, which was not followed in this instance. Interviews revealed that the LPN was behind on medication administration and told the resident that the night nurse would provide the pain medication, as the LPN needed to finish their shift. The resident, their family member, and a CNA all reported that the resident's request for pain medication was refused or delayed, and the LPN did not assess the resident for pain at the time of the request. The DON confirmed that the LPN failed to follow the physician's order and facility policy by not assessing and administering the pain medication as needed.
Failure to Provide and Document Required ADL Care and Personal Grooming
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary care and assistance to maintain good nutrition, grooming, and personal care. For two residents reviewed, documentation by certified nurse assistants (CNAs) showed multiple instances where bladder and bowel incontinence care, showers, personal hygiene, and meal assistance were either not provided or not documented as provided. Specifically, one resident with severe cognitive impairment and significant physical limitations had numerous days in January and February 2024 where required ADL care was not signed off by staff, including incontinence care, showers, personal hygiene, and meal assistance. Another resident, who was cognitively intact but required maximal assistance for mobility and was dependent for toileting and transfers, also had many occasions where incontinence care and showers were not documented as provided. Observations during facility rounds revealed that a significant number of residents were dressed in hospital gowns rather than regular clothing. On two separate days, a total of 22 and 33 residents, respectively, were observed in gowns across different floors of the facility. Interviews with staff indicated that while some residents may prefer gowns or are care planned for them, not all residents dressed in gowns had such preferences or care plans. Staff confirmed that residents had access to regular clothing and that the occurrence of residents in gowns was not typical. Interviews with facility leadership revealed inconsistencies in the interpretation of blank documentation fields. The DON stated that a blank spot in CNA documentation does not necessarily mean care was not provided, but rather that the CNA may have forgotten to sign. In contrast, the Assistant DON indicated that a blank spot would mean the task was not done. Oversight of CNA documentation was described as involving reminders and checks by nursing leadership, but the documentation reviewed for the period in question showed persistent gaps in recording required care.
Failure to Maintain Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as determined by its own Facility Assessment. Record review of daily staffing sheets for January and February 2024 revealed that both nursing and certified nurse assistant (CNA) staffing levels were frequently below the minimums established by the facility for various shifts on the 2nd floor. Specific deficiencies included shifts with only one nurse or fewer CNAs than required, and several instances where no nurse or only one CNA was scheduled for a shift, contrary to the documented staffing requirements. The facility's policy stated that sufficient numbers of nursing staff would be provided in accordance with care plans and the facility assessment, but actual staffing did not consistently meet these standards. Interviews with facility leadership confirmed awareness of staffing shortages, particularly on weekends, and acknowledged that agency staff were sometimes used to fill gaps. The Director of Human Resources and nursing leadership described processes for attempting to cover shifts, such as using a staff roster and supervisors or assistant directors of nursing stepping in when needed. However, there were documented occasions when no nurse was scheduled for a unit, and leadership could not recall or confirm all such instances. These findings demonstrate that the facility did not consistently ensure adequate nursing coverage as required by regulation and its own assessment.
Significant Medication Errors Due to Unstaffed Nursing Shift
Penalty
Summary
On 2/25/2024, the facility failed to ensure that residents were free from significant medication errors when there was no nurse present on the second floor during the 7 AM to 3 PM shift. As a result, 36 out of 42 residents on the unit did not receive their scheduled medications, with 30 of these residents missing significant medications. The medications omitted included antihypertensives, retrovirals, anti-seizure drugs, antidepressants, antidiabetics, insulin, narcotics, anticoagulants, antibiotics, immunosuppressants, anti-Parkinsonism, and antipsychotics. Specific residents affected included individuals with complex medical histories such as Type 2 Diabetes Mellitus, Essential Hypertension, Cerebral Infarction, Peripheral Vascular Disease, Atrial Fibrillation, Vascular Dementia, and Chronic Kidney Disease. For example, one resident missed doses of Losartan, Clopidogrel, Paroxetine, Metoprolol, and two types of insulin; another missed Clopidogrel, Lisinopril, Glucophage, Levemir, and Novolog. Other residents missed critical medications for heart failure, diabetes, hypertension, deep vein thrombosis, and more. The absence of a nurse was not communicated to facility leadership in a timely manner. The DON was unaware of the staffing gap until after the incident, as the nursing supervisor did not report the sick call or the lack of coverage. The administrator was informed by the supervisor that everything was fine, and the scheduler was not contacted for additional staffing. The medication errors were only discovered after the fact, when the DON returned to work and was notified by the Assistant DON.
Failure to Provide and Document Required Turning and Repositioning for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, major depressive disorder, and mood disorder, who was dependent on staff for bed mobility and transfers, did not consistently receive turning and repositioning as required for pressure ulcer prevention and treatment. The resident had a stage 2 sacral pressure ulcer that resolved but later reopened, and the care plan specified repositioning at least every two hours. Certified nurse aide documentation revealed multiple instances across several months where the resident was not turned and repositioned as required, both before and after the wound reopened. The wound care physician provided specific instructions for turning and repositioning every 1-2 hours in bed and every 30 minutes while in a chair, but documentation and staff interviews confirmed that these interventions were not consistently implemented. Certified nurse aides reported that the electronic documentation system only allowed them to record turning and repositioning per shift, not every two hours, and that they did not reposition the resident while in a wheelchair. There were also several days where no documentation was present, indicating the care may not have been provided. Interviews with nursing staff and management confirmed awareness of the care requirements but also highlighted limitations in the documentation system and inconsistent adherence to the prescribed interventions. The lack of detailed, timely documentation and the failure to follow the care plan and physician orders led to the resident not receiving the necessary treatment and care for pressure ulcer prevention and management.
Failure to Monitor and Report Significant Weight Loss
Penalty
Summary
A deficiency was identified when a resident with dementia, protein-calorie malnutrition, and severe cognitive impairment experienced a significant unplanned weight loss of over fifteen percent in thirty days. The resident required maximal assistance with eating and was dependent on staff for nutrition. Documentation revealed that direct care staff did not consistently record the resident's meal intake, with numerous occasions where the amount eaten or the assistance provided was not signed off. There were multiple instances where the resident consumed only twenty-five percent or none of their meals, and there was no documented evidence that nursing or administration was informed of the resident's poor intake during this period. The facility's policy required systematic monitoring and timely management of significant weight loss, including regular documentation and communication with the physician and interdisciplinary team. Despite these requirements, the resident's declining intake and weight loss were not promptly identified or addressed due to lapses in documentation and communication. The registered dietician later confirmed the significant weight loss and noted the resident's ongoing challenges with eating, but this was only after the weight loss had already occurred and was brought to the attention of the interdisciplinary team.
Failure to Timely Submit 5-Day Investigation Reports to State Authorities
Penalty
Summary
The facility failed to ensure that the results of investigations into suspected abuse, neglect, or theft were reported to the New York State Department of Health within five working days, as required by state law and facility policy. In three separate cases involving three different residents, the facility either delayed submission or did not provide documented evidence of submitting the required 5-day investigative conclusion report. The facility's policy clearly states that all findings of investigations must be documented and reported within five business days, but this was not followed in the cited incidents. In one incident, a resident with a history of psychosis and mood disorder struck another resident on the head with a therapy device. The incident was witnessed by two certified nurse aides, and the involved residents were separated, with one being sent for psychological evaluation. However, the 5-day investigative conclusion was not submitted to the Department of Health until six days after the incident, exceeding the required timeframe. In another case, a resident with severe cognitive impairment and no wander guard exited the facility unescorted and was found in a neighboring yard before being taken to the hospital. The investigation concluded there was no evidence of abuse or neglect, but there was no documented evidence that the 5-day investigative conclusion report was submitted to the Department of Health. Interviews with facility leadership confirmed awareness of the reporting requirements, but also revealed lapses in timely submission, particularly when incidents occurred over weekends.
Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, exploitation, or misappropriation were thoroughly investigated for six residents. In multiple instances, the facility did not obtain written statements from all staff assigned to the relevant units during the periods of the alleged incidents. For example, after a resident reported inappropriate touching by a former roommate, the facility did not collect statements from the certified nurse aides on duty or the registered nurse involved, and the investigative summary was neither dated nor signed by the Medical Director. Similarly, in an incident where a resident was struck on the head with a therapy device by another resident, the investigative summary was unsigned and undated, and not all required staff statements were obtained. In cases involving missing property and alleged financial exploitation, the facility did not secure statements from all staff assigned to the affected units during the relevant timeframes. For three residents who reported missing credit cards and unauthorized charges, the investigation lacked comprehensive staff interviews and written statements, including from the alleged perpetrator in one case. The facility's incident reports concluded that exploitation or misappropriation by staff was inconclusive due to insufficient evidence, but the lack of thorough documentation and staff statements was evident. Throughout these events, the facility's own policy required that all allegations be thoroughly investigated, with interviews conducted with all staff members on all shifts who had contact with the residents during the periods in question. However, the documentation reviewed showed that investigative summaries were often incomplete, unsigned, or undated, and that not all relevant staff were interviewed or provided written statements. These deficiencies in the investigative process were confirmed by interviews with facility leadership, who acknowledged that some steps were missed or overlooked.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of inappropriate behaviors, including psychosis and mood disorder, struck another resident on the head with a therapy device. The incident took place in a hallway and was witnessed by a certified nurse aide, who reported that the aggressor was upset because the other resident, who had severe cognitive impairment and a history of wandering, had entered their room by mistake. The aggressor verbally expressed frustration before using a flexi-bar to hit the other resident from behind. The resident who was struck had significant cognitive impairment, exhibited wandering behaviors, and required supervision as documented in their care plan. Despite interventions such as frequent checks and redirection, the resident was able to enter another resident's room, which led to the altercation. The staff present intervened immediately after the incident, but the event still resulted in one resident physically striking another. The facility's investigation concluded that no abuse had occurred, citing the aggressor's psychiatric issues and lack of intent to harm, as well as the absence of injury to the resident who was struck. However, the incident itself demonstrated a failure to protect a resident from physical abuse, as required by regulation, and highlighted lapses in supervision and monitoring of residents with known behavioral risks.
Failure to Accurately Assess Elopement Risk on Admission
Penalty
Summary
The facility failed to ensure the accuracy of a resident's assessment upon admission, resulting in the resident not being identified as at risk for elopement. The resident, who was admitted with diagnoses including dementia, muscle weakness, and generalized anxiety disorder, had a documented history of wandering as noted in the hospital discharge records. However, the facility's admission assessment did not reflect this history, instead documenting that the resident was disoriented but had not attempted to leave prior residences and did not wander. As a result, the resident was assigned a low elopement risk score and was not provided with a wander guard. The resident was placed in a first-floor room, and subsequently exited the facility unescorted after being buzzed out by the receptionist. Interviews with facility staff revealed that the admissions process involved reviewing the resident's medical history and physicals, but the Director of Nursing who completed the assessment did not recall seeing documentation of wandering in the hospital records. The failure to accurately assess and document the resident's elopement risk led to the omission of necessary safety measures, such as the use of a wander guard and appropriate room placement.
Failure to Develop Comprehensive Care Plan for Resident with Wandering History
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan addressing all of a resident's needs, specifically regarding wandering and elopement risk. One resident was admitted with a documented history of dementia, muscle weakness, generalized anxiety disorder, and prior incidents of wandering and aggression as reported by family and hospital records. Despite this history, the facility did not initiate a care plan for wandering or elopement risk. The resident's care plans focused on impaired cognition and forgetfulness/confusion, with interventions such as maintaining a consistent routine and providing reminders for activities, but did not address the risk of wandering or elopement. The Director of Nursing stated that the assessment on admission did not reveal wandering or exit-seeking behaviors, and that the hospital documentation reviewed did not indicate wandering, which led to the omission of a wandering or elopement care plan. However, the hospital records and family reports did document a history of wandering prior to admission. As a result, the facility did not meet the regulatory requirement to develop a comprehensive care plan that includes measurable objectives and timetables to address all identified needs, including the risk of wandering and elopement.
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
A deficiency occurred when a resident with a documented history of dementia, muscle weakness, and generalized anxiety disorder exited the facility unescorted. The resident, who had severe cognitive impairment and required supervision with daily activities, was admitted without a wander guard and was assigned a room on the first floor. The resident was able to leave the facility through the front doors after being buzzed out by the Receptionist, who did not recognize the individual as a resident and mistook them for a visitor. The facility's elopement risk assessment, completed at admission, did not identify the resident as a wander or elopement risk, despite family reports of wandering and aggressive behavior prior to admission. The resident was not included on the elopement risk list at the front desk, did not have an identification band, and was not known to the Receptionist as a new resident. The Receptionist allowed the resident to exit the building without verifying their identity, and the absence of a wander guard or other alert system contributed to the resident's ability to leave unnoticed. The resident was discovered missing during staff rounds, prompting a search of the facility. The resident was later located by emergency medical services after entering a neighboring home and was transported to the hospital for evaluation. The incident revealed gaps in the facility's supervision, risk assessment, and communication processes, which allowed the resident to exit the facility without appropriate safeguards in place.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, Resident #88 and Resident #213, as observed during the recertification and abbreviated surveys. Resident #88, who had a left above the knee amputation and neuropathy, was not administered pain medication in accordance with Physician's Orders and did not receive non-medication interventions for pain relief. Despite experiencing persistent pain, the recommendations from a Physiatrist to increase Gabapentin and conduct imaging studies were not reviewed or acted upon by the Physician Assistant. The resident's pain was not adequately assessed or documented, and the prescribed Tylenol was not administered when Oxycodone was ineffective. Resident #213, admitted with a left shoulder replacement and other conditions, did not receive Oxycodone as prescribed due to a failure to reorder the medication in a timely manner. The Narcotics Log indicated that the medication was unavailable for several doses, and there was no evidence that the emergency supply box was accessed to provide the necessary pain relief. The nursing staff did not follow the protocol for medication refills, and there was no documentation of alternative pain relief interventions being provided. Interviews with facility staff, including Licensed Practical Nurses and the Director of Nursing, revealed lapses in communication and adherence to pain management protocols. The Physician Assistant did not adequately assess or document the residents' pain levels, and there was a lack of coordination in reviewing and implementing the Physiatrist's recommendations. These deficiencies highlight significant gaps in the facility's pain management practices, impacting the residents' quality of care.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, particularly on the 2nd and 3rd floors, as identified during a recertification and abbreviated survey. The Facility Assessment did not account for the higher resident capacity and census on these floors compared to the 1st floor. The projected and actual staffing levels were below the facility's assessed needs of 2.2 Certified Nursing Assistant (CNA) hours per resident per day. This deficiency was evident in the staffing patterns and the inability to provide adequate care, as reported by residents and observed by surveyors. Specific incidents highlighted the impact of insufficient staffing. Resident #95 experienced significant delays in receiving incontinence care, waiting up to 12 hours on one occasion. The actual staffing on the 3rd floor during this period was below the required levels, contributing to the delay in care. Additionally, Resident #7 was observed with a strong odor of urine, indicating a lack of timely assistance with activities of daily living. Residents expressed concerns about staffing shortages during a Resident Council Meeting, with reports of difficulty finding staff during the night shift and delays in being assisted to bed. Interviews with staff further corroborated the staffing issues. CNAs and LPNs reported frequent call-outs and the need to cover additional shifts, often resulting in staff being responsible for a high number of residents, some of whom required two-person assistance. The facility's attempts to address staffing shortages, such as using a staffing application and offering incentives, were noted, but the staffing coordinator and nursing administration were unable to provide explanations for unfilled slots and unconfirmed staffing documentation. Despite these efforts, the facility did not meet the required staffing levels, impacting the quality of care provided to residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely incontinence care for Resident #95, who was dependent on staff for activities of daily living due to conditions such as paraplegia and respiratory failure. The resident, who was cognitively intact, frequently experienced bowel and bladder incontinence. Despite a grievance resolution stating the resident should be changed every two hours and as needed, there were instances where the resident waited excessively long periods to be changed. Specifically, the resident reportedly waited 12 hours on one occasion and 9 hours on another to have their soiled brief changed, which was a concern given their history of frequent urinary tract infections. Interviews and observations revealed that the resident continued to experience delays in receiving incontinence care, with one instance where the resident was not changed from 5:00 AM until 12:38 PM. The Director of Nursing acknowledged that there was no justification for such delays and confirmed the expectation for changes every two hours. However, there was no documented evidence to support that this care schedule was consistently followed. Additionally, there was a lack of documentation regarding the resident's refusals to get out of bed, which may have contributed to the care delays.
Failure to Review Resident's Pain Management Plan
Penalty
Summary
The facility failed to ensure that the physician reviewed a resident's total program of care at each visit, as required. This deficiency was identified during a recertification survey for one resident who had undergone a surgical amputation and was experiencing persistent pain. The resident reported their pain to the Physician Assistant, but no changes were made to their treatment plan. The facility's policy on pain assessment and management required a multidisciplinary team, including the physician, to reconsider approaches if pain was not adequately controlled. However, the Physician Assistant did not review the Nursing Pain Evaluation or the Physiatrist's pain management recommendations for the resident. The resident's comprehensive care plan documented chronic pain issues, including neuropathy and potential phantom pain. Despite a Physiatry Consult recommending an increase in Gabapentin and further imaging to rule out neuroma, the Physician Assistant's notes did not reference these recommendations or assess the resident's pain using a numeric scale. Interviews with facility staff revealed that the Physician Assistant was responsible for reviewing and ordering the Physiatrist's recommendations, but there was no documented evidence that this was done. The Physician Assistant admitted to not reviewing the pain scale documented by nursing unless the resident reported pain during their visit.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a recertification survey, with an observed error rate of 8%. This deficiency involved the incorrect administration of medications to one resident. Specifically, the resident was given a crushed form of enteric-coated aspirin instead of the prescribed chewable form, and a crushed form of Depakote delayed-release tablet, both of which were against the manufacturer's instructions. The facility's policy required medications to be administered safely and in accordance with prescriber's orders, which was not adhered to in this instance. The resident involved had diagnoses including seizures, schizophrenia, and hypertension, and was on a regular diet with thin liquids. The LPN responsible for the medication administration acknowledged the error, stating they were aware that Depakote should not be crushed and failed to notice the warning on the blister pack. The LPN also admitted to not checking if an alternative form of the medication was available. The Director of Nursing emphasized the importance of following medication instructions and the need to consult physicians if a medication form is not suitable for a resident.
Infection Control Deficiencies in Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, specifically in hand hygiene, for two residents during a recertification survey. One incident involved a Certified Nurse Aide who, during a lunch meal observation, placed their uncovered palm on a resident's hamburger bun while cutting it in half. The resident, who had diagnoses including hypertension, diabetes mellitus, and coronary artery disease, required tray setup for eating due to mild cognitive impairment. The aide acknowledged awareness of the rule against touching food directly but admitted to not considering it at the moment. Another incident involved a Licensed Practical Nurse who did not perform hand hygiene between glove changes during a wound care treatment for a resident with multiple sclerosis, hemiplegia, dementia, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and had a Stage 3 and Stage 4 pressure ulcer. The nurse, who was distracted due to working on another floor, admitted to not washing hands between glove changes despite knowing the protocol. The Director of Nursing acknowledged the need for more education on hand hygiene despite previous in-services and rounds.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. Specifically, for one resident reviewed, there was no documented evidence that the resident was offered, declined, or educated on the pneumococcal immunization. The facility's policy, last revised in 2017, required that residents be asked about their pneumococcal vaccine status upon admission and that this information be confirmed through medical records. If the vaccine had not been received, the resident was to be provided with information and given the opportunity to ask questions before signing a consent or declination form. The resident in question had a medical history that included Type II Diabetes Mellitus, acquired absence of both legs below the knee, and end-stage renal failure requiring dialysis. An assessment tool dated June 2024 indicated that the resident had mild cognitive impairment and was independent in self-care. However, the pneumococcal vaccine was not up to date and had not been offered by the facility. During an interview, the Infection Preventionist acknowledged that the resident's records were incomplete and that the pneumococcal vaccine status should have been obtained since the resident had been at the facility since April.
Failure to Resolve Grievance and Incomplete Grievance Policy
Penalty
Summary
The facility failed to ensure the prompt resolution of a resident's grievance and did not establish a comprehensive grievance policy. The grievance policy lacked details on how residents were informed of the grievance process and their right to receive a written decision. This deficiency was identified during a survey, where it was found that a resident's designated representative reported missing clothing and glasses, but the facility did not provide a prompt resolution. The facility's grievance policy did not specify whether residents were informed of the grievance process individually or through postings, nor did it document the right to obtain a written copy of the grievance review. The resident involved had severe cognitive impairments and a history of mental health disorders. The designated representative reported the missing items to the Director of Social Work multiple times, including during a care plan meeting, but did not receive a resolution. The Director of Social Work claimed the issue was resolved without a formal grievance investigation, and the facility's records did not show any investigation into the complaint. The administrator and social work department were unclear on how residents and families were informed of grievance outcomes, and the facility did not provide written copies of grievance reports unless requested.
Deficient Discharge Planning for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an effective discharge planning process for a resident with serious mental illness, resulting in a deficiency. The resident, who had diagnoses including schizoaffective disorder and bipolar disorder, was moderately cognitively impaired and physically aggressive. After a psychiatric hospitalization, the facility issued a Transfer/Discharge Notice without involving the resident's Designated Representative, listing a destination that lacked the necessary specialized psychiatric services. The Ombudsman and the Designated Representative were involved in care plan meetings and discovered that the facility listed on the Transfer/Discharge Notice did not have the required psychiatric unit. Despite the facility's claim that the resident's behaviors were unmanageable, the Transfer/Discharge Notice lacked adequate documentation and did not include contact information for advocacy agencies. The facility's Social Work Department and Administrator failed to properly involve the resident and their representative in the discharge planning process. Interviews with the Director of Social Work and the Administrator revealed that the facility had issued several Transfer/Discharge Notices without proper documentation or involvement of the resident's representative. The facility's actions were not aligned with the resident's rights, and there was no evidence that the discharge care plan was reviewed or revised in light of the developments, including the issuance and rescission of the Transfer/Discharge Notice.
Failure to Timely Address Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for a resident with a pressure ulcer. Specifically, a resident was found with a skin opening on the sacrum, but a registered nurse did not assess the area or notify the physician until the following day. The facility's policy required that any change in a resident's condition, including skin alterations, be documented and that the physician be notified. However, this protocol was not followed, leading to a delay in the assessment and treatment of the pressure ulcer. The resident involved had severe cognitive impairment and was at high risk for developing pressure ulcers. Despite being incontinent and having a care plan in place to prevent skin breakdown, the resident developed a Stage 2 pressure ulcer on the sacrum. The issue was not addressed promptly, as the registered nurse on duty was not informed of the skin opening, and the physician was not notified until the following day. This oversight resulted in a delay in the implementation of appropriate interventions and modifications to the resident's care plan.
Failure to Provide Individualized Behavioral Health Care
Penalty
Summary
The facility failed to ensure that a resident with multiple mental health diagnoses received individualized behavioral health care and services. The resident, diagnosed with schizoaffective disorder, bipolar disorder, catatonia, and major depressive disorder, had a care plan that was not reviewed or revised to address their symptoms effectively. Despite documented mood symptoms and behavioral issues, such as physical aggression and noncompliance, the care plan remained unchanged since its initiation, lacking necessary updates to address the resident's evolving needs. The resident's behavioral health care plan did not incorporate the recommendations from a Level II Preadmission Screening, which included psychiatric care, ongoing consultations, and therapeutic interventions. The facility's documentation showed a lack of individualized non-pharmacological interventions to manage the resident's behavior. Additionally, there was no evidence of a psychology referral or intervention following the resident's psychiatric hospitalization, indicating a gap in the continuity of care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's behavioral health needs and the Level II recommendations. The Physician Assistant and Certified Nursing Assistant were not informed of the necessary interventions, and the Director of Social Work admitted to not referring the resident for further evaluation after behavioral changes. This lack of coordination and failure to update the care plan contributed to the facility's inability to manage the resident's behavioral health needs effectively.
Failure to Provide Required Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide necessary rehabilitative services for a resident who was experiencing significant weight loss. The resident, who had severe cognitive impairment and required assistance with eating, had a physician's order for a Speech Therapy evaluation due to slow eating and chewing. Despite this order being placed on 7/17/2024, the evaluation was not completed. The resident's medical record lacked documentation of the speech therapy evaluation, which was confirmed by the Occupational Therapist and the Speech Therapist. The Speech Therapist acknowledged being informed of the order on 8/2/2024 but did not document the screening they conducted. Observations during mealtimes revealed that the resident was served meals in soup bowls and required assistance with feeding. Interviews with the Clinical Nutrition Manager and the Director of Rehabilitation Department highlighted the resident's risk for weight loss due to slow eating and the expectation that evaluations should occur within 72 hours of an order. The failure to conduct and document the speech therapy evaluation as ordered contributed to the deficiency identified during the survey.
Resident Abuse Incident Involving Dietary Aide
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a dietary aide and a resident. On the specified date, a dietary aide was witnessed by a certified nurse aide verbally threatening a resident and pulling on the resident's beaded necklace. The resident's written statement corroborated the account, indicating that a staff member entered their room, held them by the shirt and chest area, and verbally threatened them. The facility's investigation concluded that verbal abuse had occurred. The resident involved had a medical history that included osteoarthritis of the right shoulder, depression, and dementia, with moderately impaired cognition and no behavioral symptoms. The resident required supervision for various activities of daily living. The incident was immediately reported by the certified nurse aide to the charge nurse, and the facility's investigation was initiated promptly. The dietary aide involved was asked to leave the building, and the police were notified. At the time of the onsite visit, the resident was no longer at the facility.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including Multiple Sclerosis and severe cognitive impairment, had a care plan that required the use of a foam positioning wedge to maintain a side-lying position and elevate heels off the bed surface to prevent pressure injuries. Additionally, a physician order mandated the application of bilateral heel booties at all times for prophylaxis. However, observations on a specific day revealed that the resident's heels were resting on the mattress without heel booties, and the foam positioning wedge was not used as directed. Interviews with staff indicated a lack of communication and awareness regarding the resident's care needs. A Certified Nursing Assistant, who was new to the unit, was unaware of the requirement to use a foam positioning wedge and heel booties. A Licensed Practical Nurse acknowledged the resident's risk for pressure ulcers and the necessity of heel booties or offloading pillows but admitted that the booties were not applied that day. The deficiency was identified under 10 NYCRR 415.11(c)(1), highlighting the facility's failure to adhere to the care plan and physician orders, potentially compromising the resident's care.
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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