Spring Creek Rehabilitation & Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, New York.
- Location
- 660 Louisiana Ave, Brooklyn, New York 11239
- CMS Provider Number
- 335125
- Inspections on file
- 13
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Spring Creek Rehabilitation & Nursing Care Center during CMS and state inspections, most recent first.
A resident was not readmitted to the facility after hospitalization for severe dysphagia, despite the hospital's assessment that a feeding tube was unnecessary. The facility cited care needs exceeding capacity and failed to provide a written discharge notice with appeal rights or notify the Ombudsman. The facility's policies did not address this situation, leading to a deficiency.
The facility experienced significant staffing shortages on weekends, as revealed by a recertification survey. The staffing plan was not met, leading to excessive workloads for CNAs and delays in resident care. Interviews with residents and staff confirmed the issue, with CNAs often responsible for 14-15 residents each. The Director of Nursing cited high turnover and staff having other jobs as contributing factors. The administrator was unaware of the summer staffing shortfalls, which were worsened by vacations and holidays.
The facility did not maintain corridor doors to resist smoke passage, as transfer grilles were found on doors across multiple floors, violating safety standards.
The facility did not ensure adequate sprinkler system coverage, as observed during a life safety survey. On the 2nd floor, a sprinkler head was missing under ductwork in the air handling room, and light fixtures were obstructing sprinkler heads in several utility closets, potentially affecting their spray patterns.
The facility did not ensure fire hoses were inspected, tested, and maintained as per 2011 NFPA 25 standards. During a survey, it was found that hoses on stairwell E landings were last marked in March 2018, indicating a lapse in the required five-year inspection or replacement schedule. The Director of Maintenance acknowledged the issue.
A resident with severe cognitive impairment alleged being slapped by staff, but the facility delayed reporting the incident to the state agency beyond the required two-hour timeframe. The DON did not report the allegation promptly due to disbelief in the resident's account, violating the facility's abuse prevention policy.
A resident's representative was not properly invited to care plan meetings due to outdated contact information, resulting in their inability to participate in the resident's care planning. The facility failed to verify the representative's address and phone number, leading to a lack of communication and involvement in the care process.
A resident with medical conditions including Atrial Fibrillation and Diabetes Mellitus expressed a preference for daily showers but received only six showers over nearly three months, contrary to the facility's policy of twice-weekly showers. Staff interviews revealed inconsistent documentation and communication regarding the resident's shower schedule and preferences, leading to a deficiency in honoring the resident's right to make significant life choices.
A facility failed to provide a resident with quarterly financial statements as required by policy. Despite the resident having intact cognition, they did not receive written statements of their account balance. Interviews revealed a lack of communication and adherence to the policy, with staff unaware of the resident's unmet needs.
A resident with multiple diagnoses was left with unattended medications at their bedside, contrary to facility policy. An LPN failed to ensure the resident took their medications before documenting administration. The RN Supervisor and DON confirmed that medications should not be left at the bedside and residents must be assessed for self-administration.
A CNA failed to perform hand hygiene between assisting multiple residents with hand hygiene before meal service, as observed during a survey. The facility's policy requires hand hygiene between residents to prevent cross-contamination, but the CNA did not adhere to this, acknowledging the oversight. Interviews with staff confirmed the requirement for hand hygiene to prevent infection spread.
During a survey, a facility was found to have an unducted air return used as a ceiling plenum, violating NFPA standards. This setup, located on the second floor of the extension building, had multiple penetrations that could allow smoke to enter the lobby, impeding egress during a fire. The Director of Maintenance acknowledged the issue.
A facility failed to ensure an accurate MDS assessment for a resident's psychiatric status. The assessment inaccurately documented the resident's psychiatric condition without confirmation from the facility's medical provider, despite the facility's policy requiring comprehensive assessment through communication with the resident and review of medical records. This led to a deficiency citation.
Failure to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return following hospitalization, which was evident for one of six residents. The resident was initially transferred to the hospital for severe dysphagia evaluation and possible feeding tube placement. Despite the hospital's assessment that a feeding tube was not necessary, the facility refused to readmit the resident, citing care needs exceeding their current capacity. The facility did not provide the resident or their representative with a written notice of discharge, including notification of appeal rights, nor did they notify the Long-term Care Ombudsman. The facility's policies on admissions and discharge planning did not address the protocol for residents transferred to the hospital but not accepted back. The resident, who was cognitively intact, had been admitted with a diagnosis that included dysphagia. The facility's interdisciplinary team, including a medical doctor, determined that the resident was at high risk for aspiration and recommended hospital transfer for further evaluation. However, the facility did not follow the required procedure for discharge notification, failing to issue a 30-day notice with appeal rights. Interviews with the resident's representative and facility staff revealed that the decision not to readmit the resident was based on the facility's assessment of the resident's care needs and risk for aspiration. The medical team, including the medical director, reviewed the hospital's patient review instrument and decided against the resident's return. Despite discussions with the resident's family about the risks and necessary precautions, the facility did not document or communicate the discharge decision appropriately, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action 1. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. 2. The Director of Social Service was given an educational counseling and a 1:1 inservice on discharge protocol emphasizing that the resident / resident representative and the Long-term Care Ombudsman is notified of the discharge in writing, including notification of appeal rights. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service compiled a list of residents in the last 30 days who have been discharged from the facility. The list was reviewed to ensure that each resident / resident representative in addition to the Long Term Care Ombudsman was notified of the discharge in writing, including notification of appeal rights. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS and Director of Social Service reviewed and revised the policy on “Discharge Planning: Discharge Notification to Resident / Family” to include a protocol for a resident who was transferred to the hospital from the facility but is not being accepted back into the facility. The protocol includes that the resident / resident representative in addition to the Long Term Care Ombudsman will be notified of the discharge in writing, including notification of appeal rights. 2. The Director of Social Service and the social workers will be in-serviced on the revised policy “Discharge Planning: Discharge Notification to Resident / Family” by the administrator / designee with emphasis on ensuring that each resident / resident representative in addition to the Long Term Care Ombudsman are notified of the discharge in writing, including notification of appeal rights. 3. The Administrator, Medical Director, DNS and Director of Social Service reviewed the policy on “Admission Process” including not being able to accept a resident if the facility cannot provide adequate or appropriate care for that resident and found it to be compliant. 4. The Director of Admissions, Director of Social Service and the social workers will be in-serviced on the policy by the administrator regarding “Admission Process” by the administrator / designee with emphasis on appropriate admissions to the facility depending on the resident’s level of care. 5. A copy of the Lesson Plan and Attendance is filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that the resident / resident representative as well as the Long Term Care Ombudsman is notified in writing regarding the discharge including the notification of appeal process. 2. Audits will be done by the Director of Social Service/Designee on 10 random discharges weekly x 4 weeks, 10 random discharges monthly x 3 months and 10 random discharges quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible to ensure correction of this deficiency by 4/7/2025.
Staffing Shortages on Weekends in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, particularly on weekends, as identified during a recertification survey. The facility's policy required adequate staffing to provide necessary care and services, but the Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 indicated excessively low staffing levels on weekends. The facility's staffing plan outlined specific numbers of licensed nurses and certified nursing assistants (CNAs) required per shift, but actual staffing schedules revealed frequent shortages of both nurses and CNAs across various units on weekends. Interviews with residents and staff corroborated the staffing deficiencies. Several residents reported that the facility was short-staffed on weekends, leading to situations where CNAs were responsible for 14-15 residents each, which is above the facility's standard. This resulted in delays in care, such as residents not being changed on time. Staff members, including CNAs and a Registered Nurse Supervisor, confirmed the high workload and frequent call-outs on weekends, which necessitated reassigning staff to cover shortages. The Director of Nursing acknowledged the staffing issues, attributing them to high turnover rates and staff having other jobs or being in school. The facility's administrator was unaware of the staffing shortfalls over the summer, which were exacerbated by increased absences due to vacations and holidays. The report highlights the facility's failure to maintain adequate staffing levels, impacting the quality of care provided to residents. Interviews with residents and their families indicated dissatisfaction with the care received, particularly on weekends when staffing was insufficient.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. The monthly staffing patterns as of (MONTH) 2025 will be reviewed by the DNS, ADNS and the Staffing Coordinator to ensure that there is sufficient nursing staff provided to meet the needs of the residents on all shifts. 2. Facility will actively continue to enhance staffing by contacting more agencies, advertise for hiring more staff, pay overtime when needed, offer incentives to work extra shifts, increase orientation classes with sign-on bonuses and offer opportunities to join the union when appropriate. 3. Resident # 34 met with the DNS, ADNS and Social Worker who reinforced the facility’s commitment to staffing and the importance of their safety as well as maintaining their highest physical, mental and psychosocial well-being as determined by their assessments and person-centered plan of care. II. Identification of others 1. The facility is aware that they must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 2. The DNS/ADNS/RNS will review all staffing patterns prior to the schedule being posted to ensure that sufficient nursing staff is consistently provided to meet the needs of residents on all shifts. 3. An audit tool was developed by the DNS to review staffing to ensure that there is sufficient nursing staff provided to meet the needs of the residents on all shifts. This audit will be done for one week from 3/16/2025 to 3/22/2025 by the DNS / designee. All issues identified will be immediately corrected. III. System changes 1. The Administrator and DNS reviewed and revised the policy on “Staffing.” 2. ADNS, Staffing Coordinator, Licensed Nurses and Certified Nursing Assistants will be re-educated by the staff educator / designee on the above policy with emphasis on ensuring resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and person-centered care plans. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance 1. The DNS developed an audit tool to ensure that there is sufficient staffing every day on all three shifts. 2. Audits will be done by the ADNS / designee daily x 4 weeks, 3 days a week monthly for 3 months, 3 days a week quarterly thereafter. 3. Any issues identified will have immediate corrective action taken by the DNS & reported to the Administrator. 4. The outcome of this audit will be quantified & reported to the QA committee by the DNS. V. The Director of Nursing will be responsible to ensure correction of this deficiency by 4/7/2025.
Corridor Doors Not Smoke-Resistant
Penalty
Summary
The facility failed to ensure that all corridor doors were maintained to resist the passage of smoke, as required by safety regulations. During a life safety survey conducted on February 10, 2025, it was observed that transfer grilles were present on corridor doors across multiple floors, specifically on floors 1 through 4. These grilles were found on the doors to janitor's closets near rooms 4C25 and 4D08 on the 4th floor, near rooms 3A08, 3D08, and 3B25 on the 3rd floor, near rooms C25 and D08 on the 2nd floor, and on the utility room door near the activities room on the 1st floor. The presence of these grilles violates the requirement that corridor doors must be constructed to resist the passage of smoke, as outlined in the 2012 NFPA 101 and 2011 NFPA 25 standards, as well as 10 NYCRR 711.2 (a).
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action The transfer grilles which were found on corridor doors in the following locations were closed off with metal plates: 1) On the doors to the janitor's closets near rooms 4C25 and 4 DO8 on the 4th floor. 2) On the 3rd floor janitor's closets near rooms 3A08, 3D08 and 3B25. 3) On the 2nd floor near rooms 2C25 and 2D08. 4) On the 1st floor on the utility room near the activities room. II. Identification of Other Residents a. An audit has been conducted of all corridor doors throughout the facility to make sure all doors close and latch as required with proper sealing to prevent the transfer of smoke. b. No additional doors were found noncompliant. c. No residents' additional residents were found to be affected upon completion of this review. III. Systemic Changes 1. The facility has reviewed the Preventive Maintenance Plan and door inspection policy and revised the same to include directives for ventilation grilles, as well as inspection observations. 2. All Maintenance staff will be educated by the maintenance director on the Preventive Maintenance Plan and requirement for appropriate Door operation. 3. The Lesson Plan will concentrate on the following: > Overview of requirements for K363 > Preventive Maintenance plan for performing observational inspections of the doors > Responsibility for providing appropriate door closures. 4. A copy of the Lesson Plan and attendance will be filed for reference and validation. a. The facility reviewed and revised its policy regarding corridor doors. b. All maintenance staff were in service on the updated corridor door policies. IV. QA monitoring a. An audit tool was created to monitor the facility’s corridor doors. b. Monitoring of the facility’s doors shall be performed monthly for the first 3 months and then quarterly thereafter for 9 months. c. Any negative findings from inspections shall be reported to the administrator for further evaluation and will be addressed. d. All reports shall be brought to the Quality Assurance meeting to review with the team to ensure that repairs are being performed in a timely manner for 12 months. V. Title Responsible Director of maintenance
Inadequate Sprinkler System Coverage
Penalty
Summary
The facility failed to ensure that all areas of the building were adequately protected by the automatic sprinkler system, as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, it was observed that in the 2nd floor air handling room on the A unit, there was only one sprinkler head located on the door side of the room, with no sprinkler head under the wide ductwork suspended from the ceiling. Additionally, in the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station, and the 1st floor utility closet by the activities room, light fixtures were positioned directly under the upright sprinkler heads, potentially affecting the spray pattern of the sprinkler heads. These deficiencies were noted during the survey conducted on the 1st and 2nd floors of the facility.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action 1. The facility Director of Maintenance contacted the Fire Sprinkle Company upon Discovery to install the required missing fire sprinklers in the 2nd floor air handling room on the A unit, there was under the wide ductwork that is suspended from the ceiling. 2. In the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station and the 1st floor utility closet by the activities room, the light fixture which was located directly under the upright sprinkler heads has been relocated to provide proper clearance to not affect the spray pattern of the sprinkler heads and was provided with Appropriate coverage. II. Identification of Other Residents The Facility respectfully states that no residents were involved in this deficiency, however all residents were directly affected. The Director of Maintenance reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1. The Administrator, in conjunction with the Director of Maintenance, reviewed and revised the facility construction/renovation policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies for any Renovation Plan. 2. Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. IV. QA Monitoring 1. The Administrator, in conjunction with the Director of Maintenance, will conduct monthly reviews and inspections of sprinkler reports for the next 3 months, then upon completion of work thereafter. Documentation will be maintained in logbook for reference and validation. 2. The Director of Maintenance will review the findings and report to QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Title Responsible Director of Maintenance
Failure to Maintain Fire Hose Inspection Compliance
Penalty
Summary
The facility failed to ensure that all fire hoses were inspected, tested, and maintained in accordance with the 2011 NFPA 25 standards. During a life safety survey, it was observed that the fire hoses located on landings 1-4 of stairwell E were marked with a date of March 2018, indicating that they had not been inspected or replaced within the required five-year period. This deficiency was identified through both observation and staff interviews, where the Director of Maintenance acknowledged the oversight and indicated that a vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action 1. The Director of Maintenance engaged our Service Company to replace the identified standpipe hoses with new hoses in all locations more than five years old. 2. The Director of Maintenance engaged our Service Company to inspect the buildings standpipe system to determine hose testing years and complete NFPA required testing if necessary. II. Identification of Other Residents All Residents have the potential to be affected by this practice. The Director of Maintenance had the company check all hose stations and for similar issues. No other deficiencies were found. No other standpipe, hose or water-based fire prevention issues were found. III. Systemic Changes 1. The Administrator policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2. The existing rounds inspection form has added the monthly standpipe audit tool. 3. All environment of care staff were educated on the revision of this policy by the Director of Maintenance. Non-compliant hose systems shall be replaced with appropriate type and reported to the Administrator and Director of Maintenance for scheduled correction. 4. This has been added to the facility preventive Engineering program. 5. Staff involved in the sprinkler system were educated by the Director of Maintenance that any issues with standpipe system identified during rounds will be corrected asap and interim safety measures put in place as needed until repairs are complete. IV. QA Monitoring An audit tool was created by the Director of Maintenance to monitor compliance with required inspections of sprinkler systems. This audit includes inspection of hose racks. Any identified issues will be scheduled for correction asap. All of the facilities plenum will be audited monthly by the Director of Maintenance for the first 3 months and then quarterly for 9 months. Audit results shall be reported to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. Frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. V. Title Responsible Director of Maintenance
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required timeframe. On January 12, 2024, a resident with severe cognitive impairment and diagnosed with unspecified dementia, vascular dementia, and cerebrovascular disease, alleged that a staff member slapped them in the face. The incident was reported to a Certified Nursing Assistant (CNA) during the morning shift, who then informed a Licensed Practical Nurse (LPN). The LPN subsequently reported the allegation to a Registered Nurse (RN), who then informed the Director of Nursing (DON). Despite the facility's policy requiring immediate reporting of abuse allegations to the State Survey Agency within two hours, the DON delayed reporting the incident to the New York State Department of Health until 7:03 PM, citing disbelief in the allegation due to lack of injury and inconsistencies in the resident's account. The delay in reporting the alleged abuse was a violation of the facility's abuse prevention policy, which mandates that all alleged abuse violations be reported immediately, but not later than two hours after the allegation is made. The DON's decision to delay the report was based on their personal assessment of the situation rather than adhering to the policy requirements. This failure to comply with the reporting protocol was identified during the Recertification and Complaint Survey, highlighting a deficiency in the facility's handling of abuse allegations.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 97 was assessed by the DNP on 1/12/2025 and there were no visible signs of injury. There were no complaints of pain. 2. Resident # 97 was assessed by the RN Supervisor on 1/12/2025 and there were no visible signs of injury. There were no complaints of pain. 3. The Administrator received an Educational Counseling by the Medical Director with emphasis on ensuring that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency and Law Enforcement. 4. The Director of Nursing received an Educational Counseling by the Medical Director with emphasis on ensuring that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency and Law Enforcement. II. Identification of Others 1. The facility respectfully acknowledges that all residents who have accidents/incidents have the potential to be affected by this deficiency. 2. The DNS / designee reviewed Accident/Incident reports for the past 30 days to ensure that any residents with alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property, were reported no later than 2 hours if the event results in bodily injury or no later than 24 hours if the events that cause the allegation do not involve serious bodily injury. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the policy related to residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This policy was found to be compliant. This policy includes: Abuse Prevention with emphasis on ensuring residents remain free from abuse and neglect, and the immediate removal from the facility of any individual alleged to have been involved in the abuse / neglect until completion of the investigation. All alleged abuse or serious bodily injury must be reported to the Department of Health and law enforcement within 2 hours. It also emphasizes reporting guidelines to submit the outcome of investigations within 5 days. 2. All staff will be in-serviced by the DNS/Designee on the above policy with emphasis on the importance of ensuring all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency and law enforcement. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. An audit tool was developed by the Administrator and DNS to ensure that any residents with alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property, were reported no later than 2 hours if the event results in bodily injury or no later than 24 hours if the events that cause the allegation do not involve serious bodily injury. 2. Audits will be done by the DNS / Designee on 10 accident / incident reports weekly x 4 weeks, 10 accident / incident reports monthly x 3 months and 10 accident / incident quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA committee quarterly by the DNS / designee for monitoring of performance and recommendations and follow-up. V. The Director of Nursing will be responsible to ensure correction of this deficiency by 4/7/2025.
Failure to Ensure Resident Representative Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's representative was able to participate in the development and implementation of the resident's person-centered care plan. The resident, who had diagnoses including Dementia, Alzheimer's Disease, and Major Depressive Disorder, was severely impaired in cognition and unable to meaningfully participate in care plan meetings. Despite this, the facility did not ensure that the resident's representative was properly invited to these meetings. The representative, who lived out of state, did not receive any invitation letters or calls from the facility, as the facility had been using an outdated address and phone number for the representative. The facility's Social Services Director assumed that invitations were delivered if they were not returned and did not follow up to confirm receipt or participation. The facility's records lacked evidence that care plan meeting invitations were mailed to the correct address or that the representative's contact information was verified. This oversight resulted in the representative being unaware of and unable to participate in the care plan meetings, contrary to the facility's policy and federal and state requirements.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediately Corrective Action 1. Resident #36 representative was contacted and new information was obtained in order to ensure that the care plan meeting invitations were mailed and received by Resident #36’s representative by the Director of Social Service. 2. The Director of Social Service received a 1:1 inservice on the importance of ensuring that the resident and/or the resident’s representative participated in the development, review, and revision of the person-centered comprehensive care plan. This includes ensuring that the address the letter is mailed to is the most current contact information. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service and the MDS Coordinator compiled a list of residents in the last 30 days who have had a comprehensive care plan meeting to ensure a care plan meeting invitation was mailed and received by the resident’s representative. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS, and Director of Social Service reviewed and revised the policy & procedure for the Comprehensive Care Plan. 2. All Social Workers will be in-serviced by the Administrator/Designee on the revised policy and procedure. The lesson plan will focus on the Care Plan Meeting Invitation to the resident and the resident’s representative, the response to the letter, and accurate documentation. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that Care Plan Meeting Invitations are mailed to the resident’s representative, a response is received or follow-up is initiated and documented accordingly. 2. Audits will be done by the Director of Social Service/Designee on 10 random Care Plan Meeting Invitations for follow-up weekly x 4 weeks, 10 Care Plan Meeting Invitations monthly x 3 months, and 10 Care Plan Meeting Invitations quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow-up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible for overseeing this corrective action plan by 4/7/2025.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident's right to make choices about significant aspects of their life was honored, specifically regarding their preference for showering. Resident #7, who was admitted with diagnoses including Atrial Fibrillation, Heart Failure, and Diabetes Mellitus, expressed a desire to shower daily but was willing to accept the facility's offer of twice-weekly showers. However, the resident reported not receiving showers consistently since admission, instead receiving regular bed baths. The facility's policy required residents to be showered at least twice a week, with refusals documented and reported to a nurse. The documentation revealed that Resident #7 received only six showers over a period of nearly three months, despite the facility's policy and the resident's preferences. Interviews with staff, including CNAs and nurses, indicated a lack of consistent communication and documentation regarding the resident's shower schedule and preferences. CNA #11, who occasionally assisted Resident #7, stated they had never provided a shower to the resident and noted that sometimes the resident was already in bed when they realized a shower was due. CNA #5 mentioned that the resident could be difficult and sometimes refused showers, but this was not consistently documented. The Director of Nursing acknowledged that showers are mandatory at least twice a week and that residents can request more frequent showers. However, there was no documentation of Resident #7's preferences being discussed or recorded upon admission. The Director of Nursing also stated that supervisors should check accountability sheets to ensure tasks are completed, but this was not consistently done. The lack of proper documentation and communication led to the resident not receiving showers according to their preference, highlighting a deficiency in honoring resident choice and self-determination.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 7 was spoken to by the RN Supervisor regarding her shower schedule which is twice a week and as requested. Resident # 7 was also asked for her preference, but is agreeable to the shower schedule that is already in place. 2. The CNAAR for Resident # 7 was reviewed to ensure that the shower schedule was correctly documented and activated in the resident’s EMR. 3. CNA # 11 was given a 1:1 inservice on ADL care. This inservice included the importance of the resident receiving a shower twice a week and more often if requested. If the resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. 4. CNA # 5 was given a 1:1 inservice on residents refusing showers. If the resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The DNS / ADNS developed an audit tool to ensure that the resident’s CNAAR reflects residents preference for shower schedules with proper documentation. The DNS / designee developed a list of 10 random residents on each unit in order to audit the showering schedule and documentation on each resident. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the policy & procedure for the Activities of Daily Living and found the policy to be compliant. 2. RN, LPN and CNA will be in-serviced by the DNS/Designee on this policy with emphasis on the importance of the resident receiving showers twice a week as to their preference. If a resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that the resident’s CNAAR is accurate for the showering schedule with proper documentation. 2. Audits will be done by the DNS/Designee on 10 random residents weekly x 4 weeks, 10 random residents monthly x 3 months and 10 random residents quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/2025.
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide quarterly financial statements to a resident, as required by their policy and procedure. The policy mandates that residents or their legal representatives receive a statement showing the account balance, including funds deposited, withdrawn, and interest accrued, at least quarterly. However, during the recertification survey, it was found that a resident with intact cognition did not receive their account statements in writing within 30 days after the end of the quarter. The resident confirmed they had not been receiving copies of their account statements, despite having an account with the facility. Interviews with facility staff revealed a lack of communication and adherence to the policy. The Social Service Director claimed that statements were distributed to alert and oriented residents and mailed to families of those who were not. However, the Financial Controller and the Administrator were unaware that the resident had not been receiving their statements. The Social Worker reportedly informed the Administrator that the resident did not want a copy of the statement, which was contrary to the resident's statement. This discrepancy indicates a failure in the facility's process for managing and distributing resident financial information.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. On 1/28/2025, Resident #142 was provided with an account statement for October, (MONTH) and (MONTH) by the Director of Social Service. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Work reviewed all other residents' accounts. The residents who have funds were provided with a quarterly account statement and/or a copy is sent to the resident representative. 3. No other issues were identified. III. Systemic Changes 1. The Administrator, Medical Director, Director of Social Service, and the Controller reviewed the policy on “Resident Funds Accounts” and found it to be compliant. 2. Social Workers and the Controller will be inserviced on the above policy with emphasis on the resident’s and residents' representative receiving quarterly account statements. 3. A copy of the Lesson Plan and Attendance will be filed for reference and validation. IV. Quarterly Assurance 1. The Director of Social Service developed an Audit tool to ensure compliance with residents and residents' representatives receiving quarterly statements. 2. Audits will be done by the Director of Social Service / Designee on 10 random residents weekly x 4 weeks, 10 random residents monthly x 3 months, and 10 random residents quarterly thereafter. 3. Audits with negative findings will have immediate corrective action taken by the Director of Social Service & reported to the Administrator for review and follow-up. 4. Audit results will be presented to the QA committee by the Director of Social Service quarterly for evaluation and follow-up. V. The Director of Social Service will be responsible for overseeing this corrective action plan by 4/7/2025.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. During the recertification survey, it was observed that medications were left unattended at a resident's bedside. The Licensed Practical Nurse (LPN) responsible for administering the medications did not verify that the resident had taken them before leaving the room and documenting the administration in the Medication Administration Record. The facility's policy requires that the nurse observe the resident taking the medication and document any held or refused medications, which was not adhered to in this instance. The resident involved was cognitively intact and had multiple diagnoses, including anemia, coronary artery disease, renal insufficiency, diabetes mellitus, and malnutrition. The medications left unattended included Ferrous Sulfate, Eliquis, Aspirin, Famotidine, and Vitamin B2. The LPN admitted to placing the medications in the resident's hand and leaving the room without ensuring they were taken. The Registered Nurse Supervisor and Director of Nursing confirmed that medications should not be left at the bedside and that residents must be assessed for self-administration before being allowed to take their own medications.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 101 was immediately given the morning medications with no adverse reactions. 2. The DNP assessed the resident since his medication was left at his bedside. There were no ill effects noted. 3. LPN # 4 was given educational counseling, a 1:1 in-service, and written warning on medication administration with proper medication administration techniques and not leaving medication unattended. 4. A medication administration observation was completed with LPN # 4 by the DNS II. II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. On 2/5/2025, the RN Supervisor checked all resident’s rooms on unit 2 AB and no other medications were left unattended at the bedside. 3. On 2/25/2025, the RN Supervisor checked all resident’s MAR indicated [REDACTED]. 4. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the Medication Administration policy and found it to be compliant. 2. All RNs and LPNs will be in-serviced by the DNS/Designee on the above policy with emphasis on administering a full dose of medication to the resident via correct route, offers the resident a drink and observes the resident to ensure medication consumption. Medication should never be left unattended. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that medication was being administered to the resident and not left at the bedside. 2. Audits will be done by the RN Supervisor / Designee on 10 random resident’s room / bedside for medication weekly x 4 weeks, 10 random resident’s room / bedside for medication monthly x 3 months and 10 random resident’s room / bedside for medication quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/2025.
Infection Control Deficiency During Dining Task
Penalty
Summary
The facility failed to maintain proper infection control practices during a dining task, as observed during a recertification survey. Certified Nursing Assistant #7 did not perform hand hygiene between assisting multiple residents with hand hygiene before meal service. This was observed with 11 out of 24 sampled residents. The facility's policy requires staff to perform hand hygiene in accordance with CDC guidelines and to clean their hands between providing direct care to different residents. However, the CNA was seen picking up used hand wipes with bare hands and then using clean wipes to assist residents without cleaning their hands in between. Interviews conducted during the survey revealed that the CNA acknowledged the failure to perform hand hygiene, stating they were not thinking at the time. A Registered Nurse and the Assistant Director of Nursing both confirmed that hand hygiene is required between residents to prevent cross-contamination. The deficiency was noted under the regulation 10 NYCRR 415.19 (b)(4), highlighting the facility's failure to adhere to its own infection control policies and procedures.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 1 had no ill effects from the CNA who did not conduct proper hand hygiene. 2. Resident # 8 had no ill effects from the CNA who did not conduct proper hand hygiene. 3. Resident # 26 had no ill effects from the CNA who did not conduct proper hand hygiene. 4. Resident # 31 had no ill effects from the CNA who did not conduct proper hand hygiene. 5. Resident # 39 had no ill effects from the CNA who did not conduct proper hand hygiene. 6. Resident # 44 had no ill effects from the CNA who did not conduct proper hand hygiene. 7. Resident # 54 had no ill effects from the CNA who did not conduct proper hand hygiene. 8. Resident # 82 had no ill effects from the CNA who did not conduct proper hand hygiene. 9. Resident # 102 had no ill effects from the CNA who did not conduct proper hand hygiene. 10. Resident # 145 had no ill effects from the CNA who did not conduct proper hand hygiene. 11. Resident # 157 had no ill effects from the CNA who did not conduct proper hand hygiene. 12. CNA # 7 was given Educational Counseling and 1:1 Inservice on Handwashing and Hygiene with emphasis on cleaning her hands in between residents while assisting multiple residents with hand hygiene before meal service. II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by these deficient practices. 2. The RN supervisors conducted a meal observation on each unit for lunch on 2/6/2025 to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. No further issues were identified. III. System Changes 1. The Administrator, Medical Director and DNS reviewed the policy on “Handwashing and Hygiene” and found it to be compliant. 2. The Administrator, Medical Director and DNS reviewed and revised the policy on “Dining Meal Service” to include the CNA performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. RN, LPN and CNA will be inserviced on the “Handwashing and Hygiene” policy and the policy on “Dining Rooms Meal Service” with emphasis on performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 4. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The DNS / ADNS developed an audit tool to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 2. Audits will be done by the RN Supervisor / Designee on 10 meals weekly x 4 weeks, 10 meals monthly x 3 months and 10 meals quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS is responsible for overseeing this plan of correction by 4/7/2025.
Non-compliance with NFPA Standards in HVAC System
Penalty
Summary
The facility was found to have a deficiency related to the heating and ventilation system during a Life Safety Code portion of the recertification survey. Specifically, on the second floor of the extension building, an unducted air return was being used as a ceiling plenum in the office suite located on the lobby level. This setup was not in compliance with the 2012 NFPA 101 and 2012 NFPA 90A standards, which require that air-conditioning, heating, and ventilating systems be installed according to specific safety standards to prevent the spread of smoke and fire. During the survey, it was observed that there were multiple penetrations above the ceiling between the lobby, which serves as a means of egress, and the adjacent offices. This arrangement posed a risk as it could allow smoke to enter the lobby area, potentially impeding egress in the event of a fire in the adjacent spaces. The deficiency was identified through both observation and staff interviews, highlighting a lapse in maintaining the integrity of the fire and smoke stopping measures required by the relevant NFPA standards. At the time of the survey, the Director of Maintenance acknowledged the deficiency and indicated that it would be corrected. However, the report does not provide details on any corrective actions taken or planned to address the issue. The focus of the deficiency was on the non-compliance with the NFPA standards, which are critical for ensuring the safety and proper functioning of the facility's heating and ventilation systems.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrections: 1. The facility conducted a review of the lobby and office area plenum for compliance with NFPA 90A 4.3.11.2.1 through 4.3.11.2.7. The integrity of the fire and smoke stopping for penetrations shall be maintained. 2. The facility maintenance department has sealed with appropriate material all openings that were found throughout the above ceiling to adjoining rooms to prevent the transfer of smoke. II. Identification of Other Residents: 1. The Facility respectfully states that all residents were potentially affected but no residents were involved in this deficiency. 2. There were no additional issues identified from this environment review, as all egress doors functioned appropriately. III. Systemic Changes: 1. The Director of Maintenance has reviewed and implemented a Preventive Maintenance Program whereby the above ceilings are checked in accordance with 2012 NFPA 90A: 4.3.11.2.1 through 4.3.11.2.7 and documented on the inspection log with any corrective actions required or completed. 2. If repairs cannot be completed in house, then the items shall be logged on master work log and appropriate service company called with completion noted on master work log. 3. Staff performing the required inspections shall be in-serviced on the requirements set forth above. IV. QA-Monitoring 1. The Director of Maintenance will audit the completed inspection and testing log for completeness and completed repairs. 2. The audit will be completed weekly by the Maintenance staff/designee as assigned and reviewed by the Director of Maintenance. 3. Any quality issues identified will be communicated to the Administrator and repaired for compliance as identified. 4. Audit findings from the monthly tool will be presented to the Quarterly QA Committee by the Director of Maintenance for evaluation and follow-up as indicated. The review will continue for 6 months and then semiannual if there are no deficiencies found. Responsible Person: V. Title Responsible: Director of Maintenance
Inaccurate MDS Assessment of Psychiatric Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's psychiatric/mood disorder status. This deficiency was identified during a recertification survey, where it was found that the MDS assessment for a resident inaccurately documented their psychiatric condition. The facility's policy requires interdisciplinary team members to communicate with the resident and their family and review the resident's medical record to perform an accurate assessment. However, the MDS assessment inaccurately indicated that the resident was severely impaired in cognition, had no behavior symptoms, and had an active psychiatric diagnosis, despite the lack of confirmation from the facility's medical provider. The resident's medical history included a diagnosis of a psychiatric condition, as documented in a hospital Patient Review Instruction and a Trauma/Medical Condition Screening. However, the facility's medical provider had not diagnosed the resident with this condition, and the resident's representative was unaware of such a diagnosis. The MDS Coordinator, who conducted the assessment, acknowledged the error in coding the psychiatric diagnosis without confirmation from the facility's medical provider. This discrepancy highlights a failure in the facility's assessment process, as the MDS did not accurately reflect the resident's psychiatric status, leading to a deficiency citation under 10 NYCRR 415.11(b).
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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