Sapphire Nursing At Meadow Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Newburgh, New York.
- Location
- 172 Meadow Hill Road, Newburgh, New York 12550
- CMS Provider Number
- 335464
- Inspections on file
- 23
- Latest survey
- April 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sapphire Nursing At Meadow Hill during CMS and state inspections, most recent first.
The facility did not provide the required policy for inspecting Patient Care Related Electrical Equipment (PCREE) during a Life Safety survey. The Director of Plant Operations acknowledged the absence of the policy, which is a violation of NFPA 99 standards.
The facility did not maintain and test the emergency generator as required by NFPA standards. A review during a survey revealed that only a 2-hour load bank test was conducted instead of the mandatory 4-hour test, and documentation for the 4-hour test was missing. The Director of Plant Operations acknowledged the issue and planned to contact the vendor.
The facility failed to maintain its HVAC system according to NFPA standards, as discovered during a Life Safety recertification survey. Several fire/smoke dampers failed inspection, and a follow-up report on repairs was missing. The Director of Plant Operations acknowledged the issue, but documentation provided was incomplete and contained errors.
The facility was cited for failing to maintain its sprinkler system according to NFPA 101 standards. Observations included outdated water pressure gauges on the fire pump controller, corroded sprinklers in shower rooms, and missing documentation for fire pump repairs. The Director of Plant Operations acknowledged these issues and indicated that the vendor would be contacted.
A resident with severely impaired cognition did not receive necessary personal hygiene care, as observed with long, greasy hair and ungroomed nails. Despite a care plan requiring supervision and a physician's order for daily showers, staff interviews revealed time constraints and inadequate supervision as barriers to providing proper care.
The facility failed to document COVID-19 vaccination, education, or declination for two newly hired CNAs. Despite the facility's policy requiring written affirmation for those declining vaccination, there was no evidence of such documentation. Interviews revealed that verbal consent or education was given, but not documented, and the DON was unaware of this oversight.
A resident with limited mobility and severely impaired cognition was observed without a prescribed left palm guard on multiple occasions, despite facility policy requiring its daily application. A CNA admitted to not applying the device, and the RN Manager was unaware of the oversight. The palm guard was intended to prevent further contractures and protect the resident's hand.
The facility failed to maintain proper infection control practices for two residents. One resident with a pressure ulcer was not provided care with appropriate barrier precautions by staff, while another resident's urinary catheter drainage bag was found on the floor, violating infection control protocols. Staff acknowledged these oversights.
The facility failed to document that three CNAs received mandatory dementia care management training. One CNA, hired in 2023, had a last training record from 2024 without dementia care education. Another CNA, hired in 2019, also lacked documentation of dementia care training in their 2024 records. A third CNA, hired in 2023, had no documentation of completing the required training. The Assistant DON confirmed the missing documentation.
Two residents with severe cognitive impairment were not provided a dignified dining experience as CNAs stood over them while assisting with meals, contrary to facility policy. The CNAs acknowledged the requirement to sit at eye level but cited personal comfort and lack of available chairs as reasons for standing.
A resident with severe cognitive impairment and aphasia had a physician's order for oxygen at 2 L/min via nasal cannula as needed. Observations revealed the oxygen concentrator running at incorrect levels of 3 L/min and 1.5 L/min on separate occasions. An LPN confirmed that oxygen levels were set by licensed staff per physician orders but was unaware of the incorrect settings, suggesting a possible accidental adjustment by a CNA.
A facility failed to maintain a homelike environment due to a persistent urine odor in a resident's room and hallways. The resident, with impaired cognition and incontinence, had soiled clothing that was not properly bagged, contributing to the odor. Despite daily housekeeping, the odor persisted, and staff acknowledged that procedures for handling soiled clothing were not consistently followed.
The facility did not include a method for sharing information about occupancy, needs, and assistance capabilities in its emergency preparedness communication plan. This was identified during a life safety recertification survey, where the emergency preparedness binder lacked the necessary policy and procedure. The Administrator confirmed the absence of this information.
The facility failed to include a policy and procedure for sharing the emergency preparedness plan with residents and their families, as required by Section 483.73. During a survey, it was noted that the plan lacked a method for communication in emergencies, which was confirmed by the Administrator.
The facility did not ensure that hand washing fixtures in the kitchen's food prep areas could be operated without hands, as required by local codes. During a survey, it was found that all three food prep sinks lacked 4-inch wrist blades. The Director of Plant Operations acknowledged the issue.
Two residents in an LTC facility experienced abuse due to inadequate protection measures. One resident with cognitive impairment was inappropriately touched by another resident with a history of such behavior. Another resident reported being roughly handled by a CNA, resulting in a bruise. The facility's policies were not effectively implemented, leading to these deficiencies.
Missing Inspection Policy for Electrical Equipment
Penalty
Summary
The facility failed to ensure that Patient Care Related Electrical Equipment (PCREE) was inspected and tested in accordance with NFPA 99 standards. During a Life Safety recertification survey, it was observed that the facility's policy and procedure for inspecting both PCREE and non-PCREE were missing and not provided to the surveyors. This deficiency was noted during the survey conducted over two days. In an interview, the Director of Plant Operations acknowledged the absence of the policy and stated that it would be located. The lack of documentation and adherence to the required inspection protocols led to the citation under the relevant NFPA and state regulations.
Generator Maintenance and Testing Deficiency
Penalty
Summary
The facility failed to ensure that the emergency generator was maintained and tested in accordance with NFPA 101 and NFPA 110 standards. During a life safety recertification survey, it was observed that the facility's generator logs documented a 2-hour load bank test instead of the required 4-hour load bank test. Additionally, documentation for the 4-hour load bank test was missing and not provided at the time of the survey. In an interview, the Director of Plant Operations acknowledged the issue and mentioned that the vendor would be contacted to address the discrepancy.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Residents Identified ò All residents, visitors and staff have the potential to be affected by the deficient practice. ò Facility contacted the Generator company to conduct the 4-hour load test. ò Visit is scheduled to be completed on (MONTH) 7th, 2025. Residents at Risk ò All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes ò Re-education to the Director of Plant Operation on the importance of running the 4-hour load test once every 36 months. ò Ensure facility is maintaining a schedule for when test comes due with an audit. ò If not in compliance, vendor will be contacted immediately. Monitoring of Corrective Action ò The Director of Plant Operations or Designee will complete audit to ensure each testing is within compliance with the NFPA 101 Electrical system monthly x3 months or until 100% compliance. ò If non-compliance is found, this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues presented. ò All findings and results will be submitted to the monthly QAPI meeting. ò QAPI committee will determine if further information is required. Responsible: Director of Plant Operations or Designee
Failure to Maintain HVAC System in Compliance with NFPA Standards
Penalty
Summary
The facility failed to maintain its heating, ventilation, and air conditioning (HVAC) system in accordance with the National Fire Protection Association (NFPA) standards, specifically NFPA 101, 90 A, and NFPA 80. During a Life Safety recertification survey, it was discovered that the facility's fire/smoke dampers were inspected, tested, and cleaned by a vendor between April 4 and 6, 2025. However, several dampers failed, including damper 2 FD-008 on December 4, 2024, and damper 2 FD 124 in a specific room on December 6, 2024. A follow-up report indicating the repairs for these failures was missing and not provided at the time of the survey. In an interview with the Director of Plant Operations, it was stated that the vendor would be contacted to address the issue. On the following day, a statement was provided indicating that damper 2 FD-008 was corrected on June 16, 2023, but it did not specify how the deficiency was corrected. The Director of Plant Operations later mentioned that the date was a typo. The lack of proper documentation and follow-up on the damper repairs led to the deficiency being cited during the survey.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Actions for Residents Identified: - All residents, visitors, and staff have the potential to be affected by the deficient practice. - Fire damper vendor was contacted 5/1/2025 and will be on site to inspect fire dampers. Resident at Risk: - All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - Education to Director of Plant Operations to ensure that if there are issues with inspection that needs to be repaired, it is to be completed in a timely manner to remain in compliance. - Audit will be created to ensure that all reports received are dated correctly and no damper failure reported. - If damper failure is noted, the Vendor will be contacted to repair the dampers. Monitoring of Corrective Actions: - The Director of Plant Operations or Designee will ensure all reports are dated appropriately when receiving report from fire damper vendor and that any damper failure is addressed. Weekly x4, monthly x3 or until 100% compliance. - If non-compliance is found, this will be reported to the Administrator and Director of Plant Operations. Vendors will be contacted to fix any issues present. - All findings will be submitted to monthly QAPI. - QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 101 standards, as observed during a Life Safety recertification survey. On two resident floors and in the basement, several deficiencies were noted. The water pressure gauge on the fire pump controller was found to be outdated, with no evidence of replacement or recalibration. Additionally, documentation confirming the replacement or recalibration of the water pressure gauge was missing. During an interview, the Director of Plant Operations acknowledged the issue and mentioned that the vendor would be contacted. Further inspection revealed that sprinklers in the shower rooms on both the first and second floors exhibited signs of corrosion. Additionally, a review of the facility's sprinkler logs indicated that the fire pump had failed during its annual service, and a follow-up report detailing the repairs was not available at the time of the survey. The Director of Plant Operations again stated that the vendor would be contacted to address these issues.
Deficiency in Personal Hygiene Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene. Resident #90, who had severely impaired cognition and required supervision with activities such as toileting, dressing, and personal hygiene, was observed multiple times with long, greasy hair, an unshaven face, and long, ungroomed fingernails. The resident's care plan indicated a need for supervision in personal hygiene, and a physician's order specified daily showers. However, observations on several occasions revealed that these hygiene needs were not met. Interviews with staff members, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), and a Registered Nurse Unit Manager, highlighted a lack of adequate time and supervision to ensure the completion of personal hygiene tasks. The CNA acknowledged responsibility for daily personal hygiene care, including nail grooming, but cited time constraints as a barrier. The LPN and Unit Manager confirmed that CNAs were expected to provide nail care and that nurses were responsible for supervising these tasks. Despite these expectations, the resident continued to exhibit signs of neglect in personal hygiene, indicating a failure in the facility's care processes.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified ADL care Provided for Dependent Residents. Resident #90 did not suffer ill effect from deficient practice. Residents who are dependent will be provided with ADL care every shift as evidenced by appearance will be well groomed. Nails will be trimmed and clean. Hair will be washed and without odor. Facial hair will be shaved to residents liking. Upon notification of this deficiency, Resident #90 was immediately provided nail care, shaved, and had his hair washed and groomed. Resident #90 was assessed and appeared to suffer no ill effects as a result of this deficient practice. Nurse Aide #17 was immediately reeducated regarding providing all ADL and grooming care to residents daily as ordered. Nurse Aide #17 was also provided guidance on time management to assist with completion of all tasks. LPN #18 and Nurse Manager #11 were both provided education regarding supervising Nurse Aides care to ensure all ordered cares were provided. Resident at Risk: Dependent residents can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficiency. All other residents appeared to be appropriately groomed. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Change: All nursing staff (CNA’s and Nurses) will be provided in-service education in regard to expected care of residents by Nurse Staff Educator/Designee. Specifically, residents who require total assistance with care. ADL level of care is listed on Resident Care profile card in EMR. The Administrator reviewed the facility’s policy on Activities of Daily Living and found it to be incompliance with all State and Federal Regulations. Education regarding the provision of daily ADL care, and grooming was provided to all nursing staff. Education regarding supervising CNAs to ensure daily grooming is provided to all residents was provided to all nurses. Monitoring of Corrective Actions: The DON has created an audit to ensure that daily grooming and ADL care is provided to all residents on a daily basis. Audits will be conducted on resident hygiene and grooming on all units daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS. The DNS/Designee will be responsible for completion of this plan of correction.
Lack of COVID-19 Vaccination Documentation for New Staff
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the COVID-19 vaccine, and provided with education regarding the benefits, risks, and potential side effects of the vaccine. Specifically, there was no documented evidence of immunization records for two certified nurse aides who were newly hired. The facility's policy, revised in November 2024, mandates that all staff and residents who decline vaccination must sign a written affirmation indicating they were offered the opportunity for COVID-19 vaccination but declined. However, the immunization records for the two certified nurse aides lacked documentation of COVID-19 immunization, education, or declination. During interviews, the Infection Control Preventionist/Assistant Director of Nursing acknowledged that the facility offered immunizations for COVID-19, influenza, and pneumococcal vaccinations to staff and residents. They admitted that the two newly hired certified nurse aides had only received verbal consent or education, with no documentation to support that education was provided or that declinations were recorded. The Director of Nursing was unaware of the lack of documentation for these two staff members, highlighting a gap in the facility's adherence to its own policy and regulatory guidelines.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified CNA #1 and CNA #2 was offered COVID-19 vaccine. Residents at Risk: - No resident at risk by deficient practice. - No resident at risk by deficient practice. An audit of new hires was conducted to ensure all new hires have either received the COVID-19 vaccine or have a declination signed on file. Systemic Changes: - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - Audit tool created to ensure declination is received if staff does not have COVID vaccine. Monitoring of Corrective Actions: - The Director of Nursing or Designee will review all new hires to ensure the facility has a declination on file should the staff choose not to be vaccinated. Bi-weekly x 8 weeks, then monthly x 3 months. Any issues noted will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Failure to Apply Prescribed Palm Guard for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion and mobility received the necessary care and equipment to maintain or improve function. Specifically, a resident with severely impaired cognition and an upper extremity impairment was observed on three separate occasions without the prescribed left palm guard, which was ordered by the physician to prevent further contractures. The facility's policy required the nursing department to apply and remove such devices daily, and the nurse manager was responsible for ensuring this information was recorded in the Certified Nurse Aide Accountability Record. During interviews, a Certified Nurse Aide admitted to not applying the resident's palm guard despite knowing it was their responsibility. The Registered Nurse Manager was unaware that the resident was not wearing the palm guard, and the Director of Rehabilitation confirmed the importance of the device in preventing contracture worsening and protecting the resident's hand. The deficiency was identified during a recertification survey, highlighting a lapse in adherence to the facility's policy and physician's orders.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified ò Upon notification of this deficiency, resident #40 was reassessed and noted to have no new injuries nor ill effects as a result of this deficient practice. ò Resident 40 left palm guard was immediately placed. ò Palm guard placed in treatment orders to be signed off by nurse. ò Nurse manager #10 and CAN #8 were both provided education on ensuring that resident devices were placed daily as per order. Residents at Risk ò The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficiency, and no other resident was identified. ò While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes ò The facility reviewed Policy and Procedure titled Issues of Splints, Orthoses, and Prostheses and no revision is needed. ò All nursing staff will be educated on policy listed above and the importance of placing adaptive equipment per physician order. ò An audit tool was created by the DON to ensure compliance with adaptive equipment for individuals with limited position and mobility. Monitoring of Corrective Actions ò The Director of Nursing or Designee will randomly observe 3-5 residents who have limited position and mobility to ensure their equipment are being used and physician orders [REDACTED]. Any issues noted will be addressed immediately and reported to the administrator. ò On a monthly basis, the Director of Nursing will report the findings to the Administrator. ò On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. ò QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a resident with severe cognitive impairment and a Stage 3 pressure ulcer was on enhanced barrier precautions. However, during an observation, a Certified Nurse Aide and an LPN were seen providing incontinence care to this resident without wearing gowns, which was against the facility's policy for handling residents with wounds and indwelling medical devices. Both staff members acknowledged the oversight, with the CNA admitting they should have checked the precaution information before providing care. In the second incident, another resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter drainage bag and a portion of the drainage tube lying on the floor. This was noted during two separate observations. An LPN confirmed that the drainage bag and tube should not be on the floor due to infection control concerns and stated that the privacy bag straps should be adjusted to prevent this. The CNA responsible for the resident's care admitted to missing the issue due to being busy.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Infection Prevention & Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Resident #129 and #118 did not suffer ill effect from this deficient practice. Staff will follow Infection prevention and control guidelines in regards to EBP as well as other transmission-based precautions. Resident’s medical devices, such as indwelling catheter/tubing will be placed in proper position and avoid touching the floor to prevent contamination. Resident #118 foley drainage tube, foley bag and privacy bag were immediately changed upon notification of this deficiency. This resident was assessed and found to have not [MEDICATION NAME] negative effects as a result of this deficiency. License Practical Nurse #15 and Certified Nurse Aide #14 were both re-educated on the facility’s infection control Policy and the need to ensure that residents foley drainage bags or tubes do not touch the floor. Resident #129 was assessed and found to have no signs of infection, no other signs of negative effects as a result of this deficiency. License Practical Nurse 21 and Certified Nurse Aide 20 were both re-educated on the facility’s Enhanced Barrier Precaution Policy and Procedure and the need to wear the recommended PPE. Monitoring for any signs of infection will be ongoing for this resident. Residents at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficient practice and no other resident was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes All staff will be provided in-service education in regards to EBP/Transmission based precautions by Infection Preventionist/Nurse Staff Educator/Designee. All nursing staff (Nurses and CNA’s) will receive in-service education in regards to proper placement of indwelling catheter tubing when residents are in and out of bed to prevent tubing touching the floor. The Administrator reviewed the facility’s infection control and Enhanced Barrier Precaution Policies and found them to be in compliance with all local, state and federal regulations. The Director of Nursing will initiate Infection Control and Enhanced Barrier Precaution re-education for all staff. Monitoring of Corrective Actions The DON has created an audit to monitor foley drainage bags and tubes not touching the floor. The DON has also created an audit to monitor compliance with PPE usage for all residents on EBP. Audits will be conducted on indwelling catheter placement in/out of bed for those residents that are applicable. Audits will be performed every shift x 1 week, daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee. Audits will be conducted on all units in regards to staff use of EBP, to include signage outside of applicable rooms/Donning & Doffing of PPE. Audits will be performed every shift x 1 week, then daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Deficiency in CNA Dementia Care Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required hours of training and annual in-services on dementia care management, as mandated by regulations. Specifically, the facility could not provide documentation that three CNAs had completed the necessary training. CNA #23, hired in July 2023, had a last recorded training in November 2024, which did not include dementia care management. CNA #24, hired in March 2019, had their most recent training documented in November 2024, also lacking evidence of dementia care management education. CNA #25, hired in May 2023, had no documentation confirming completion of the required dementia care management education. During an interview, the Assistant Director of Nursing acknowledged the absence of documentation for these CNAs.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified Required in-service training for Nurse Aides must include dementia management training and resident abuse prevention training. Certified Nurse Aides #23, #24, and #25 did not have the required hours of the mandatory training in regards to Dementia training. No residents suffered ill effects. Upon notification of this deficiency, Certified Nurses Aides #23, #24, and #25 were all contacted and provided with Dementia in-service and all now meet the standard for the 12 hours of annual in-service. Audits of the employees assigned residents and units revealed no ill effects to those or any other resident as a result of this deficiency. Residents at Risk: Any resident can be affected by this deficient practice. In-service coordinator/educator conducted an audit of all CNAs to determine if any other CNA was out of compliance with Dementia education or the annual 12 hour education, and none were noted out of compliance. The facility respectfully states that while all staff and therefore residents could have been affected, no other staff or resident was affected. Systemic Changes: All CNAs will receive mandatory training on an annual basis by Nurse Staff Educator/Designee. The Administrator has reviewed the facility’s policy on Employees Annual Mandatory Education and found it to be in compliance with all local, state and federal regulations. Monitoring of Corrective Actions: Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Audits will be completed in regards to Dementia training/Annual Mandatory for certified aides biweekly x 4 then monthly x 3 months. Audits to be completed by Human Resource Director/Nurse Staff Educator/Designee. Audits will be presented at QAPI meetings monthly by the Human Resource Director/DNS to determine continued need. The DNS/Designee will be responsible for completion of this plan of correction. The Administrator has created an audit tool to monitor compliance with CNA annual mandatory education including Dementia education. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Dignity in Dining Experience Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents during the recertification survey. Resident #2, who was admitted with severe cognitive impairment and required extensive assistance for eating, was observed being fed by a Certified Nurse Aide (CNA) who stood over the resident while assisting with their meal. The CNA acknowledged awareness of the requirement to sit at eye level with residents during feeding but chose to stand for personal comfort. Similarly, Resident #113, who also had severe cognitive decline and was totally dependent on staff for eating, was observed being fed by another CNA who stood over the resident due to the unavailability of chairs. This CNA also acknowledged the requirement to sit at eye level with residents during feeding. A Licensed Professional Nurse confirmed that CNAs should always be at eye level with residents to maintain dignity during meals.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Residents #2 and #13 Resident Rights The resident has a right to a dignified existence and respect. Residents #2 and #13 suffered no ill effects related to deficient practice. Residents will be provided with dignity and respect as evidenced by staff will be seated next to residents at eye level that require assist with meals. Resident Rights Following notification of this deficiency, resident #2 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects related to this deficient practice. Resident #13 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects as a result of this deficient practice. Aide #13 and Aide #5 were re-educated on 4/1/2025 on resident’s rights and the procedure for providing feeding assistance, the need to sit beside residents while providing assistance with feeding. Resident at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident who was affected by this deficient practice and none was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. The Administrator/Designee has conducted an audit of chairs within the facility, available for use by staff providing feeding assistance, and found that there are sufficient numbers of available chairs. Dependent residents can be affected by this deficient practice. Systemic Changes All nursing staff (CNA’s and Nurses) will be educated by Nurse Staff Educator/ADON/Designee on procedure with assisting residents with eating during meals. Specifically, staff should be seated next to resident at eye level while assisting with meal. The Administrator has reviewed the facility’s Policy on Quality of life-Dignity, and found it to be in compliance with all state and federal regulations. Education will be provided to all Nurses and CNAs on the procedure for providing feeding assistance, specifically, staff should be seated next to the resident and at eye level while assisting with meals. Monitoring for Corrective Action The DON has created a meal time audit to monitor for staff sitting while providing feeding assistance. Meal time audits will be conducted for lunch & dinner daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Failure to Maintain Prescribed Oxygen Levels for Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident reviewed for respiratory care. The resident, who was severely cognitively impaired and aphasic, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula as needed for wheezing or shortness of breath. However, during observations, the oxygen concentrator was found running at incorrect levels of 3 liters per minute and 1.5 liters per minute on separate occasions, contrary to the physician's order. Licensed Practical Nurse (LPN) #6 confirmed that oxygen levels were set by licensed staff according to physician orders and were checked at the start of each shift. The LPN was unaware of why the concentrator was observed at incorrect settings and suggested that a Certified Nurse Aide might have accidentally adjusted the dial during care. Despite the LPN's assertion that the oxygen was set at 2 liters per minute daily, the observations indicated a failure to maintain the prescribed oxygen level, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified - Upon notification of this deficiency, resident #29's oxygen was immediately adjusted to the prescribed 2L/min. - An assessment revealed that resident #29 suffered no ill effects as a result of the deficient practice. - Resident #29 will be seen by the MD/NP for possible discontinuation of his oxygen therapy. - LPN #6 was provided re-education on the importance of ensuring that residents' oxygen devices were set to the recommendations ordered by the MD/NP. - Nurses to review and sign the flow of oxygen each shift. Residents at Risk - An audit of all residents with oxygen therapy was conducted to identify any other resident that may have been affected by this deficiency, and none were identified. - While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes - The facility reviewed Policy and Procedure Oxygen Therapy- Face Mask and Canula; no revision was needed. - Nursing staff to be in-service on the policy and procedure Oxygen Therapy- Face Mask and Canula. - The DON developed an audit tool to ensure the oxygen flow matched the doctor's order. The audit will include the residents who are on oxygen, whether nurses sign off that the correct flow is being given, and if there is a physician order [REDACTED]. Monitoring of Corrective Actions - The Director of Nursing or Designee will conduct audits daily x2 weeks, then weekly x 4 weeks, then monthly x 3 months. Any issues will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - The QAPI Committee will determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Failure to Maintain a Homelike Environment Due to Urine Odor
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the strong odor of urine in Resident #10's room and the hallways of the 2 West Unit. Observations made during the recertification survey revealed that Resident #10's room consistently had a strong smell of urine, and the hallways of the 2 West Unit were similarly affected. Resident #10, who had moderately impaired cognition and was dependent on assistance for toileting, was noted to be incontinent of bladder and bowel. The resident's care plan indicated a self-care deficit related to toileting, requiring extensive assistance. Despite daily housekeeping and laundry services, the odor persisted, suggesting inadequate handling of soiled clothing and linens. Interviews with staff revealed that Resident #10's clothing, which often smelled strongly of urine, was not consistently bagged and tied before being placed in the laundry hamper, contributing to the odor. Housekeeping staff confirmed that laundry was picked up daily, and soiled clothing should be bagged to contain odors. However, observations showed that the laundry hamper in Resident #10's room contained soiled clothing that was not properly bagged, leading to the persistent odor. Additionally, the use of pull-up style disposable briefs, which were prone to leakage, further exacerbated the issue. Staff acknowledged that the odor should not be present and that proper procedures for handling soiled clothing were not consistently followed, resulting in the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified: - Upon notification of this deficiency, resident #10 was removed from his room to allow for terminal cleaning. - Assessment revealed that this resident suffered no ill effects as a result of the deficient practice. - Resident #10 room was terminally cleaned on - Soiled laundry bagged and removed from room down to laundry on - Hallways were mopped and cleaned to eliminate odor on 4/2/2025 and continues to be cleaned daily. - LPN #6, and CNA #12 were all reeducated on the facility’s homelike environment policy with an emphasis on how soiled clothing should be managed to ensure odor control. Residents at Risk: - A facility wide audit will be conducted to ensure a safe, clean, and homelike environment is maintained and no other issues were identified. - Although all residents had the potential to be affected by this deficient practice, no other resident was found to be affected. Systemic Changes: - The Administrator reviewed policy on Homelike Environment and no revision is needed. - All staff will be in-service on Policy and Procedure Homelike environment. - The facility utilizes a complete room schedule to do a thorough cleaning. - An audit tool was developed to ensure safe, clean, and homelike environment is maintained. Monitoring of Corrective Actions: - The Housekeeping Supervisor or designee will conduct environmental Room and hallway audits for urine odors. The audit will be conducted weekly x3 months, then monthly x3 months. Any outstanding issues will be addressed immediately and reported to the administrator. - On a monthly basis the Housekeeping Supervisor will report findings to the administrator. - On a monthly basis the Housekeeping Supervisor or designee will report audit finding to Qapi Committee. - Qapi committee to determine if further action is required based on report. Responsible: Director of Plant Operation/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to ensure that its communication plan included a method for providing necessary information to the incident command center or the authority having jurisdiction during an emergency. During a life safety recertification survey, it was discovered that the facility's emergency preparedness binder lacked a policy and procedure for sharing information about its occupancy, needs, and ability to provide assistance. This deficiency was identified through documentation review and confirmed during an interview with the Administrator, who acknowledged the absence of this critical information in the emergency preparedness binder.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Residents Identified: ò All residents, visitors and staff have the potential to be affected by the deficient practice. ò Policy for sharing information regarding occupancy, needs and the ability to provide assistance was located. Resident at Risk: ò All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes: ò Policy reviewed and no revision needed. ò Education to the Director of Plant Operation on the importance of having policy readily available. ò Policy added to the emergency preparedness binder. Monitoring of Corrective Actions: ò The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information regarding occupancy is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance. ò If non-compliance is found this will be reported to the administrator and the Director of Plant Operations. ò All findings will be submitted to monthly QAPI. ò QAPI Committee will determine if further action is needed. Responsible: The Director of Plant Operations or designee.
Deficiency in Emergency Preparedness Communication
Penalty
Summary
The facility was found deficient in ensuring a method for sharing information from the emergency preparedness plan with residents and their families or representatives, as required by Section 483.73. During the Life Safety recertification survey, it was observed that the facility's Emergency Preparedness plan lacked a policy and procedure for communicating components of the emergency plan to residents, their families, or representatives in the event of an emergency. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of such a policy and procedure in the plan.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. Policy for sharing components of the emergency preparedness plan with residents, families, and representatives was located. Resident at Risk: All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - Policy reviewed and no revision needed. - Education to the Director of Plant Operations on the importance of having policy readily available. - Policy added to emergency preparedness binder. Monitoring of Corrective Actions: - The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance. - If non-compliance is found, this will be reported to the administrator and the Director of Plant Operations. - All findings will be submitted to monthly QAPI. - QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee.
Deficiency in Hand-Free Operation of Kitchen Sinks
Penalty
Summary
The facility failed to ensure that hand washing fixtures in the food preparation areas of the kitchen could be operated without the use of hands, as required by local building codes. During a life safety recertification survey, it was observed that all three food prep sinks in one of the kitchen's food prep locations lacked the necessary 4-inch wrist blades. This deficiency was noted during an inspection conducted at 3:20 PM, and the Director of Plant Operations acknowledged the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Resident Identified: All residents, visitors, and staff have the potential to be affected by the deficient practice. Kitchin wrist blades ordered for the sink. Wrist blades were installed on 4/16/2025. Residents at Risk: All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - All kitchen staff will be educated on the wrist blade and putting in work orders to ensure the kitchen is in compliance with the standards of construction. - If the wrist blade is missing, the kitchen staff will notify the maintenance department by putting in a work order. Monitoring of Corrective Action: - Food Service Director or Designee audit will be created to ensure there are no deficient sinks in the kitchen. - Audit will be done Monthly x3 to ensure kitchen sinks remain in compliance with standards of construction. - All audits will be reviewed at monthly QAPI. - QAPI committee will determine if further action is required. Responsible: Director of Food Service
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving inappropriate behavior and physical harm. In the first incident, a resident with severe cognitive impairment and a history of wandering was found in another resident's room, where they were being inappropriately touched by the other resident. The resident who committed the act had a history of sexually inappropriate behavior and was known to have behavioral symptoms directed towards others. Despite the facility's policy against abuse, the incident occurred, and the victim was unable to verbalize the event due to their cognitive condition. In the second incident, a resident with dementia and rheumatoid arthritis reported being roughly handled by a certified nurse assistant while their shirt was being changed. The resident sustained a bruise on their forearm, which was confirmed by a skin assessment. The resident expressed that the staff member did not heed their request to stop when they were being hurt. The facility's investigation initially found cause to believe abuse occurred, but later documentation was altered to state the incident was not substantiated, despite the resident's continued anxiety and fear of being hurt again. Both incidents highlight a failure in the facility's duty to ensure residents' safety and freedom from abuse. The facility's policies were not effectively implemented, leading to situations where residents were either physically harmed or subjected to inappropriate behavior. The lack of a care plan to address potential abuse victims and the inadequate response to the residents' complaints contributed to the deficiencies observed during the survey.
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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