Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Vincent Depaul Residence during CMS and state inspections, most recent first.
The facility failed to adhere to professional standards for food storage and staff hygiene. Expired food items were found in the kitchen, and a dietary staff member was observed preparing food without a beard net. Despite existing policies and training, these oversights pose a risk of food contamination.
The facility failed to maintain a clean and functional environment, with issues such as a lack of hot water in a resident's room for three weeks, disrepair in multiple rooms, and unsanitary conditions in common areas. Staff interviews revealed a lack of communication and follow-up on these issues, with maintenance only addressing problems when work orders were submitted.
The facility did not ensure that the Arbitration Agreement was explained to residents or their representatives in an understandable manner. Three residents or their representatives were not informed that signing the agreement was not mandatory, nor were they made aware of their right to refuse. The Admissions Director read the agreement aloud without paraphrasing, and the facility's administrator acknowledged the need for clearer explanations.
The facility failed to offer the Pneumococcal immunization to several residents, as required by policy. This deficiency was identified during a survey, revealing that there was no documented evidence of the vaccine being offered or declined. The lapse was attributed to a recent change in the Infection Preventionist role, with the new staff unable to provide documentation of compliance with the facility's immunization policy.
A facility was cited for inaccurate MDS documentation for two residents. One resident, with a history of wandering, was incorrectly documented as not using a Wanderguard, despite observations and care plans indicating otherwise. Another resident, with impaired communication, was inaccurately recorded as having clear speech, although they used gestures to communicate. The MDS Coordinator could not explain the errors as the responsible nurse was on medical leave.
A CNA failed to perform hand hygiene between assisting multiple residents during dining, violating infection control practices. Additionally, expired hand sanitizers and disinfecting wipes were found in various facility locations, indicating lapses in inventory control. Staff interviews revealed a lack of adherence to infection control policies and oversight in monitoring supply expiration.
The facility failed to mail the Notice of Medicare Non-Coverage to residents' representatives on the same day as telephone notifications, as required by policy. Two residents' representatives were informed by phone but did not receive mailed notices, and there was no documented evidence of refusal to receive them.
The facility failed to ensure the Medical Director's participation in at least four quarterly QAPI meetings, as required. The Medical Director missed two of the quarterly meetings, with a Clinical Assistant occasionally attending in their place. Despite being invited via email and having the option to attend in person or via Microsoft Teams, the Medical Director's inconsistent attendance led to a deficiency citation.
The facility did not ensure continuous illumination in the kitchen area, as manual switches were found that could disable all lighting. This issue was observed during a Life Safety Code Survey on one of the resident units, and confirmed through an interview with the facilities director.
A resident with a history of falls and impaired cognition was found with injuries of unknown source and was not reported to the Department of Health within the required two-hour timeframe. The resident was later confirmed to have a fracture. Facility staff showed confusion about reporting requirements, leading to a delay in reporting the incident.
The facility failed to post the last three years of survey results in a location readily accessible to residents, family members, and legal representatives. Survey results were not in plain view, and five residents attending a Resident Council meeting were unaware of where to find them without asking. The facility's policy requires transparency and compliance, but observations revealed missing postings from 2022, and interviews confirmed the oversight.
A resident with severe cognitive impairment was not promptly informed of a UTI diagnosis and subsequent antibiotic treatment. The facility failed to notify the resident's physician and family about positive urine test results, leading to a delay in treatment. Staff interviews revealed confusion over notification responsibilities, and the Director of Nursing confirmed the protocol was not followed.
A resident with severe cognitive impairment experienced a 26-day delay in treatment for a UTI due to a failure in communication and procedure adherence at the facility. Despite a positive urine test for Escherichia coli, the results were not reviewed by medical staff until weeks later, leading to delayed antibiotic treatment. Nursing staff interviews revealed a lack of awareness and follow-up on the test results, highlighting a breakdown in the facility's process for handling lab results.
Deficiencies in Food Storage and Staff Hygiene Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in accordance with professional standards for food service safety. During a recertification survey, it was observed that several food items in the kitchen were stored past their use-by or best-by dates. Specifically, there were open boxes of mirepoix vegetable soup mix, Capi vegetable blend, coleslaw, and expired raw frozen shrimp found in the refrigerator and freezer. Interviews with the food service staff revealed a lack of awareness and training regarding the importance of checking expiration dates and the potential risks of using expired food items. Additionally, the facility did not enforce proper hygiene standards for food preparation staff. A dietary staff member with a beard and mustache was observed preparing food without wearing a beard net, which is against the facility's uniform dress code policy. This oversight was noted during kitchen observations, and interviews with the staff confirmed that the individual had removed the beard net, acknowledging the requirement to wear one to prevent hair from contaminating the food. The facility's policies on food storage and handling, as well as uniform dress code, were not adequately followed or enforced. Despite having policies in place and conducting in-service training sessions on food safety and the use of hair and beard nets, the staff failed to adhere to these guidelines. The lack of compliance with these standards poses a risk of food contamination and potential foodborne illness among residents.
Facility Fails to Maintain Sanitary and Functional Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, functional, and sanitary environment for its residents, as observed during a recertification survey. In one instance, a room had no hot water supply for approximately three weeks after a sink replacement. Residents in this room had to use a bathing room across the hallway to access hot water, which was inconvenient, especially during winter. Despite the maintenance department's records indicating the sink was reinstalled and in working condition, there was no documentation of the hot water issue in the maintenance book. Interviews with staff revealed a lack of communication and follow-up regarding the hot water problem, with several staff members assuming others had reported the issue. Additionally, several rooms and common areas were found in disrepair, with issues such as deep scratches on walls, broken tiles, and dust accumulation. The shared shower room on Unit 3 had broken tiles, a missing shower head clamp, and a brownish to black substance in the corners. The maintenance logs did not reflect these issues, and staff interviews indicated a lack of awareness and reporting of these environmental problems. The Director of Housekeeping and Maintenance stated that rounds are conducted weekly, but the issues observed during the survey were not documented or addressed. The 2nd Floor Unit also had multiple deficiencies, including cracked window screens, debris in air conditioning/heater units, and peeling baseboards. Flies were observed in the dining room and hallway, and there were white granules and black stains in the dining room pantry. Maintenance staff indicated that repairs are only made when work orders are submitted, and there was a lack of proactive identification and resolution of environmental issues. The Director of Plant Operations and Maintenance mentioned that rounds are conducted weekly, but the observed deficiencies were not addressed in a timely manner.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F584 483.10 Safe/Clean/Comfortable/Homelike Environment SS=E I. The following actions were accomplished for the resident(s) identified in the sample: 1. The facility engaged a certified plumber to permanently repair the hot water to the sink in room [ROOM NUMBER]. Completed 1/9/25. 2. The maintenance staff repaired and painted the wall scratches in the wall behind the bed and behind the door in room [ROOM NUMBER]. Completed 1/23/25. The maintenance staff replaced the headboard on the bed in room [ROOM NUMBER]. Completed 1/26/25. The maintenance staff will repair the identified panel molding in room [ROOM NUMBER]. Completed on 1/30/25. In Unit 3 Shared Shower Room, the maintenance staff permanently repaired the broken yellow tiles. Completed 1/8/25. The maintenance staff will replace the shower hose holder assembly and replace the changed stained ceiling tiles. Completed 1/27/25. The housekeeping staff completed a deep cleaning of the shower walls, floors, and the identified screen. Completed 1/8/25. 3. A. The maintenance staff will replace the identified window screen in the 2nd floor Dining Room. Completed on 1/30/25. B. The housekeeping staff cleaned the items from within the HVAC unit in room [ROOM NUMBER]. Completed 1/8/25. The maintenance staff will repair or replace the identified cove base in room [ROOM NUMBER]. Completed on 1/30/25. C. The housekeeping staff cleaned the items from within the HVAC unit in room [ROOM NUMBER]. Completed 1/8/25. The maintenance staff will repair or replace the identified cove base and repair and paint the damaged wall in room [ROOM NUMBER]. Completed on 1/30/25. D. The maintenance staff replaced the footboard on the bed in room [ROOM NUMBER]. Completed 1/26/25. Maintenance repaired the bathroom pipe faucet dripping and left faucet not closing to stop water from dripping. Completed 1/24/25. E. The maintenance staff will repair or replace the identified cove base, repair and paint the damaged wall (Completed on 1/30/25), and repaired the leaking sink faucet in room [ROOM NUMBER]. Completed 1/8/25. F. The maintenance staff will replace the window screen in room [ROOM NUMBER]. Completed on 1/30/25. The housekeeping staff removed the two round items from the top of the HVAC unit. Completed 1/8/25. G. The maintenance staff will replace damaged window screens on the 2nd floor. Completed on 1/30/25. The Director of Plant Operations contacted the facility's pest control vendor to provide a mitigation plan for flies. Mitigation plan and implementation was completed on 1/30/25. H. The housekeeping staff cleaned the 2nd floor Dining Room Pantry shelves and cabinets. Completed 1/24/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance will inspect all areas throughout the facility for the same deficiencies. Any deficiencies found will be scheduled for correction. III. The following system changes will be implemented to ensure continuing compliance with regulations: All maintenance staff, housekeeping, and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483.10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff, and the Director of Plant Operations will report the findings to the QAPI Committee for the period of six (6) months. The Policy & Procedures will be reviewed and updated to include that all staff must report issues promptly in the maintenance log. Resident safety issues must be immediately reported to a supervisor in addition to the maintenance log. The Director of Plant Operations/Housekeeping will conduct weekly rounds to identify maintenance and housekeeping issues. The Director of Plant Operations/Housekeeping will each complete documentation of the weekly rounds in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as the correction plan if warranted. Responsibility: The Director of Plant Operations/Designee will be responsible for compliance.
Failure to Explain Arbitration Agreement in Understandable Manner
Penalty
Summary
The facility failed to ensure that the Arbitration Agreement was explained to residents or their representatives in a manner they could understand, as observed during a recertification survey. This deficiency was identified in three out of 21 residents sampled for arbitration. The facility's policy required the Admissions Director to discuss the Admission Agreement with the resident or their representative, but the Arbitration Agreement was written in legal language and not adequately explained. The Admissions Director admitted to reading the agreement aloud without paraphrasing, acknowledging that it was written for lawyers. Residents and their representatives were not informed that signing the agreement was not a condition of admission, nor were they made aware of their right to refuse to sign. Specific instances included a resident who was mentally intact but unaware of the documents signed during admission, with their family member stating that the agreement was not explained to them. Another resident, also mentally intact, signed the agreement under the impression that it was mandatory to avoid returning to the hospital. A third resident, who was moderately cognitively impaired and visually impaired, refused to sign the agreement as it was not explained to them. The facility's administrator acknowledged that the Admission Agreement should be explained in simple language and that residents should have the opportunity to ask questions.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that each resident was offered the Pneumococcal immunization, as observed during a recertification survey. This deficiency was identified in three out of five residents sampled for immunizations. Specifically, there was no documented evidence that these residents were offered or educated on the Pneumococcal immunization. The facility's policy, effective since 2014, mandates that all residents receive immunizations as recommended by the ACIP, with their vaccination status documented in the electronic medical record. However, the records for the sampled residents did not reflect that the Pneumococcal vaccine was offered or declined, nor was there documentation of any educational efforts. The deficiency was attributed to a lapse in the facility's processes, particularly following an unexpected change in the Infection Preventionist role. The new Infection Preventionist, who assumed the role a few weeks prior to the survey, was unable to produce documentation showing that the vaccination had been offered to residents. The Director of Nursing confirmed the lack of documentation and stated that the vaccination should have been offered during admission and annually thereafter. The Administrator suggested that the lapse might be related to the staff change, as they were unable to locate documentation in the electronic medical record to confirm that the previous Infection Preventionist had been offering the vaccination as per policy.
Inaccurate MDS Documentation for Residents
Penalty
Summary
During a Recertification Survey, the facility was found to have deficiencies in accurately reflecting residents' statuses in their assessments. Specifically, the Minimum Data Set (MDS) 3.0 assessment for two residents was inaccurate. One resident, who had a history of wandering behavior and was observed with a Wanderguard on multiple occasions, was documented in the MDS as not using a Wander/elopement alarm. This discrepancy was noted despite the resident's care plan and physician orders indicating the use of a Wanderguard. Another resident, who was admitted with a diagnosis affecting their ability to communicate, was inaccurately documented in the MDS as having clear speech and the ability to make themselves understood. Observations showed the resident using gestures to communicate due to slurred speech, and staff confirmed the resident's nonverbal status. The MDS Coordinator acknowledged the inaccuracies but could not explain the errors as the responsible MDS Assessor was on medical leave. The Director of Nursing stated that the Nursing Department collaborates with the MDS Department to ensure the accuracy of MDS documentation.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 F 641 483.20 Accuracy of Assessment SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The DNS reeducated the MDS Coordinator submitted a correction of the MDS for Resident #36 and #6 on 1/7/2025. The DNS reeducated the MDS Coordinator regarding responsibilities to ensure the accuracy of MDS data prior to submission. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the same practice. The MDS Coordinator/Designee will review assessments, progress notes, and plan of care to ensure accuracy of MDS completion prior to submission. The MDS Coordinator will review the last submitted MDS assessment for all residents to ensure the assessment accurately reflects the resident's status at the time the assessment was completed. A correction MDS will be submitted as needed. III. The following system changes will be implemented to ensure continuing compliance with regulations: The MDS Coordinator/Designee will develop an audit tool to review all scheduled MDS for accuracy prior to submission. The audit tool will assess residents' plan of care, progress notes, and assessment to ensure accuracy and the same practice does not recur. The Administrator, DNS, and MDS Coordinator reviewed the policy and procedure entitled "Minimum Data Set Assessment Completion." No revision is needed at this time. The DNS/Designee will provide education to the MDS Coordinator regarding the above protocol emphasizing the importance of the MDS including accurate data assessment to ensure the CCP addresses each resident's strengths, care needs, including the use of wander alert devices and resident communication ability as applicable. All IDCPT members responsible for completing sections of the Residents Assessment Instrument (RAI) will be provided with this education and training. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The MDS Coordinator/Designee will monitor the same practice does not recur through weekly audits of scheduled MDS. The audit tool will be utilized to ensure the MDS is accurate prior to submission and monitor compliance with accuracy of MDS data. The audit will occur weekly for six months or until two quarters are at 100% compliance. The RN/MDS Coordinator will audit 15% of completed MDS assessments monthly for six months. All MDS accuracy audit findings will be reported to the Administrator and DNS on a monthly basis. Corrective actions, such as submitting a correction MDS, will be implemented as indicated. The MDS Coordinator will report MDS accuracy audit findings to the QAPI Committee for six months. Responsible: The MDS Coordinator/Designee is responsible to ensure regulation compliance.
Deficiencies in Hand Hygiene and Expired Supplies
Penalty
Summary
The facility was found to have deficiencies in food service safety and infection control practices during a recertification survey. A Certified Nursing Assistant (CNA) was observed assisting multiple residents with hand hygiene in preparation for dining without performing hand hygiene between residents. The CNA used bare hands and gloves inconsistently, failing to change gloves or sanitize hands between assisting different residents. This was observed for ten residents, indicating a lapse in following the facility's hand hygiene policy, which requires hand hygiene before and after resident contact and between handling food items. Additionally, the facility failed to ensure that disinfecting germicidal wipes and hand sanitizing solutions were discarded by their expiration dates. Expired hand sanitizers and disinfecting wipes were found in various locations, including the medication room, pantry, and central supply room. The Central Supply Representative admitted to not checking expiration dates, and the Infection Preventionist acknowledged that expired supplies would not be as effective. The Director of Plant Operations and Maintenance stated that the central supply person is responsible for checking the expiration of supplies. Interviews with staff, including the CNA, Registered Nurse, and Infection Preventionist, revealed a lack of adherence to infection control practices and oversight in monitoring the expiration of supplies. The CNA admitted to forgetting to change gloves and not performing hand hygiene between residents, while the Infection Preventionist and other staff did not identify concerns related to hand hygiene during their observations. The facility's policies on hand hygiene and inventory control were not effectively implemented, leading to these deficiencies.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 880 483.80 Infection Prevention & Control SS=D I. The following actions were accomplished for the resident(s) identified in the sample: On [DATE], the Certified Nursing Assistant #4 who was assigned on the second-floor dining room was re-educated on the Facilities’ policy entitled “Hand Hygiene.” On [DATE], the hand sanitizer with an expiration date of [DATE] in the medication room on the second floor was immediately removed and replaced. On [DATE], the disinfecting wipe that was found on the 3rd floor panty room was immediately removed and replaced. On [DATE], the three sealed boxes containing expired disinfecting wipes that were found in the central supply with expiration dates of [DATE] were immediately removed and discarded. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially affected by the same practice. All Certified Nursing Assistants were educated on the facility policy entitled “Hand Hygiene” to ensure proper hand hygiene is practiced in between residents to prevent cross contamination. All hand sanitizer in the entire building were checked by housekeeping staff, including in the central supply, to ensure there were no other expired hand sanitizer. No additional expired hand sanitizer was identified. All disinfecting wipes in the entire building were checked by central supply, including within the central supply department, to ensure there were no other expired disinfecting wipes. No additional expired disinfecting wipes were identified. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Infection Control Preventionist provided an education to all nursing staff on hand hygiene, emphasizing its importance during direct contact with residents in the dining room. This education focused on ensuring the staff members practice proper hand hygiene between residents and when donning or removing gloves, thereby minimizing the risk of cross contamination. The Director of Nursing and the Infection Control Preventionist reviewed the facility’s policy entitled “Hand Hygiene” and all regulatory components were outlined with no revision needed. The Infection Control Preventionist will continue to monitor hand hygiene protocols during meals times in the dining room to ensure all staff members adhere to compliance standards. All Housekeeping staff responsible for monitoring and changing hand sanitizers throughout the facility received education on the critical importance of routinely checking expiration dates. This education ensured that all hand sanitizers remain effective and safe for use, thereby maintaining a high standard of hygiene within the facility. All Central Supply staff/representative responsible for distributing supplies and managing procurement and inventory control within the facility received education on the vital importance of routinely checking expiration dates. This education specifically emphasized hand sanitizer and disinfecting wipes, ensuring that these products remain effective and safe for use, thereby supporting the overall health and safety of the facility. The Executive Director/Administrator and the Director of Plant Operations and Maintenance reviewed the facility’s policy entitled Purchasing, Stocking Inventory Control and Order Points Procedure was revised to incorporate comprehensive inventory control measures and monitoring protocols, ensuring that all supplies are routinely checked for expiration dates. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Director of Nursing and Infection Control Preventionist will develop an audit tool to assess compliance with hand hygiene practices during mealtimes in the dining room. This audit tool will specifically focus on ensuring the staff members perform hand hygiene both during direct contact with residents and between residents. Quality Assurance Monitoring will be conducted by the Director of Nursing/Designee using a standardized audit tool titled “Hand Hygiene Compliance in Dining Room.” The audits will be conducted weekly for six months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. The Executive Director/Administrator and the Director of Plant Operations and Maintenance will develop an audit tool to monitor compliance with inventory control measures and monitoring protocol ensuring that all supplies are routinely checked for expiration dates. Quality Assurance Monitoring will be conducted by the Director of Plant Operations and Maintenance/Designee using a standardized audit tool titled “Supply Inventory and Monitoring of Expiration Dates.” The audits will be conducted weekly for six months and/or until two quarters are at 100% compliance. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Plant Operations and Maintenance. Responsible: Executive Director/Administrator, Director of Nursing, Infection Preventionist and Director of Plant Operations are responsible for ensuring all above is in compliance.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that residents or their designated representatives were appropriately notified at the termination of Medicare Part A benefits. This deficiency was identified during a recertification survey, where it was found that the facility did not mail the Notice of Medicare Non-Coverage to the residents' representatives on the same day that telephone notifications were made. Specifically, for two residents, the facility left voice messages for their representatives but did not follow up with mailed notices as required by the facility's policy and CMS instructions. The policy mandates that notices be mailed on the same day as the phone call, but this was not adhered to in these cases. The Minimum Data Set Coordinator acknowledged that while they informed representatives by phone, they did not mail the notices unless requested by the representatives, which was contrary to the policy. The Coordinator also stated that they mailed notices with certified mail receipt only if they could not reach the representative by phone. However, there was no documented evidence of the representatives' refusal to receive the notices. The Administrator confirmed that the Coordinator was responsible for ensuring the notices were provided and that proof of receipt should be maintained, but this was not done in these instances.
Plan Of Correction
Plan of Correction: Approved January 31, 2025 F582 483.10 Medicaid/ Medicare Coverage/ Liability Notice SS=D TAG I. The following actions were accomplished for the resident(s) identified in the sample: The facility mailed the Beneficiary Notification to the designated representatives of resident #36 and #55. On 1/8/25, the Beneficiary Notification was mailed certified to the designated representative of Residents #36 and #55. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents on Medicare are potentially affected by the same practice. The MDS Coordinator will audit residents who received Beneficiary Notification for the last six months. If any deficient practice is identified, immediate corrective action will be implemented and findings reported to the Administrator and Quality Assurance Committee. The Administrator educated the MDS Coordinator on the facility policy entitled “Advanced Beneficiary Notice of Medicare Non-Coverage Benefit Exhaust Letters” to ensure compliance with regulations. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Facility reviewed the policy and procedures “Advanced Beneficiary Notice of Medicare Non-Coverage Benefit Exhaust Letters” to ensure regulation compliance and no revision needed. The MDS Coordinator/Designee will keep a log of all residents receiving the Beneficiary Notification. The log will indicate the date the resident/designated representative was notified, and the Beneficiary Notification was mailed to the designated representative. The MDS Coordinator/Designee will maintain a log for all residents who receive the Beneficiary Notification of Medicare Non-Coverage. The log will also indicate the date of mailing with certified tracking receipt and notification. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The corrective action will be monitored weekly through audits and the findings will be presented to the quality assurance committee for six months to ensure deficient practice will not recur. Compliance with this regulation will be assessed utilizing an audit tool developed by the MDS Coordinator. The findings from the audit will be reported to the Quality Assurance Committee for six months by the MDS Coordinator. Responsible: The MDS Coordinator/Designee is responsible for compliance.
Medical Director's Inconsistent Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) committee included the Medical Director's participation in at least four quarterly meetings as required. Specifically, the Medical Director did not attend two out of the four required quarterly meetings. The facility's policy mandates that the QAPI committee must include the Medical Director, among other key personnel, and meet at least quarterly. However, the review of attendance sheets revealed that the Medical Director did not sign in for several meetings throughout the year, and there was no documented evidence of their attendance via Microsoft Teams or in person for two of the quarterly meetings. Interviews conducted during the survey revealed discrepancies in the Medical Director's attendance. The Medical Director claimed to attend meetings monthly, often via Microsoft Teams, and stated that a Clinical Assistant would attend in their place if they were unavailable. However, the Clinical Assistant, who primarily performs administrative tasks and is not deeply familiar with the facility's policies, confirmed that they occasionally attended meetings on behalf of the Medical Director. The Administrator corroborated that the Medical Director was invited to meetings via email and that the meetings were accessible in person, by phone, or via Microsoft Teams. Despite these arrangements, the lack of consistent attendance by the Medical Director at the required quarterly meetings led to the deficiency citation.
Plan Of Correction
Plan of Correction: Approved February 3, 2025 F 868 483.75 QAA Committee SS=D I. The following actions were accomplished for the resident(s) identified in the sample: The Medical Director received an Inservice from the Administrator on Regulation Compliance and the importance of attendance at Quality Assurance Committee Meetings. The Medical Director will attend facility QAPI meetings minimally once every quarter. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected. The facility reviewed the Quality Assurance Policy and Procedures to ensure regulation compliance. No revision is needed. The Medical Director/ Designee will meet with Quality Assurance Performance Committee at least quarterly to coordinate and evaluate activities such as identifying issues with respect to quality assessment and assurance activities. The Medical Director is required to attend the meeting in person to foster effective communication, collaboration, and engagement with the quality improvement team. If unable to attend in person, the Medical Director/ Designee will attend via TEAMS or Telephonically. III. The following system changes will be implemented to ensure continuing compliance with regulations: The Medical Director / Designee will audit the attendance at Quality Assurance Meeting to ensure compliance of minimally quarterly attendance. The Audit will occur monthly for one year. The Medical Director will be responsible for reporting key data metrics during each meeting. In order to ensure an appropriate quality review for 2024 related to this deficient practice, the Medical Director will review all reports that were presented in the 2024 QAPI meetings. This will develop an understanding of Quality in 2024 in order to continue to improve for 2025 and thereby enhancing quality care for residents at this facility. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The Medical Director/ Designee will report findings monthly to the Quality Assurance Committee on the compliance with the regulation for one year. Attendance, along with these reports, will be documented by the Medical Director and provided to the quality improvement coordinator. A log of attendance will be maintained by the administrator. Non-compliance will be reviewed and addressed during performance evaluations with the organization’s Medical Director. Responsible: The Medical Director/ Administrator, organization’s Medical Director are responsible for audit compliance.
Kitchen Illumination Deficiency
Penalty
Summary
The facility failed to ensure continuous illumination in the kitchen area, as manual switches were observed that could disable all lighting. This deficiency was noted during a Life Safety Code Survey on one of the four resident units. Specifically, on the first floor kitchen area wall, manual switches were found that, when tested, turned off all illumination in the kitchen area. This was confirmed through observation and an interview with the facilities director, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved January 22, 2025 K291 Plan of Correction for affected areas: The facility reconfigured the manual switches on the first-floor kitchen wall allowing for continuous illumination in the kitchen area when switches are turned off. Work completed 01/12/24. Plan of Correction to identify other areas potentially affected: The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Plant Operations inspected all kitchen areas throughout the facility for similar deficiencies. No deficiencies were identified. Work completed by 01/21/24. Plan of Correction for system measures to prevent reoccurrence: All maintenance staff will receive additional education, and all participants will understand the life safety issues relating to continuous illumination in the kitchen. The Director of Plant Operations has been assigned the responsibility for the education of staff. The facility will check for continuous illumination in the kitchen on a monthly basis. The Director of Plant Operations will utilize an audit tool to document and report kitchen continuous illumination lighting findings. Plan of Correction for monitoring corrective actions: The Director of Plant Operations or Designee will review monthly Kitchen continuous illumination audit for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of the kitchen continuous illumination lighting audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. Responsibility: Director of Plant Operations
Failure to Timely Report Resident Injury
Penalty
Summary
The facility failed to report an incident involving a resident with injuries of unknown source to the New York State Department of Health within the required two-hour timeframe. The incident involved a resident who was found lying on the floor with swelling on the left side of the face and limited movement in the left arm. The resident was subsequently transferred to the hospital, where a fracture was confirmed. Despite the facility's policy requiring immediate reporting of such incidents, the report was not submitted until nearly 24 hours later. The resident involved had a history of falling, difficulty walking, hypotension, and generalized muscle weakness, and was assessed to have moderately impaired cognition. At the time of the incident, the resident was on fall precautions, including a low bed position and access to a call bell, which was not activated. The incident was unwitnessed, and the resident was unable to provide a consistent account of what happened. The facility's staff, including the RN and CNA on duty, were aware of the incident but did not report it in a timely manner. Interviews with facility staff revealed confusion and a lack of clarity regarding the reporting process for incidents involving injuries of unknown source. The Director of Nursing and the facility Administrator both indicated uncertainty about the reporting requirements, particularly for falls with injury. The incident was ultimately reported after the hospital confirmed the resident's fracture, but this delay constituted a failure to comply with state regulations for timely reporting of such incidents.
Deficiency in Posting Survey Results
Penalty
Summary
The facility failed to ensure that the last three years of survey results were posted in a location readily accessible to residents, family members, and legal representatives, as required by their policy. During the recertification survey, it was observed that the survey results were posted at the resident courtesy phone, which was not in plain view, and not in a location where individuals could examine them without having to ask. This deficiency was evident for five out of eleven residents attending the Resident Council meeting, who stated they did not know where to find the survey results without asking. The facility's policy on posting and availability of survey results and complaint investigations, effective January 2025, mandates transparency and regulatory compliance by posting the most recent survey results in accessible locations and making past reports available upon request. However, observations on multiple units revealed that the survey results from 2022 were not posted, and there was no documented evidence in the Resident Council Meeting Minutes that the location or postings of the survey results were discussed. Interviews with the Administrative Coordinator and the Director of Nursing confirmed that the survey results should have been posted since 2022, and the Administrator stated that the survey results are discussed in resident council meetings and on admission.
Plan Of Correction
Plan of Correction: Approved February 4, 2025 F577 483.10 Rights to Survey Results / Advocate Agency Information SS=C TAG I. The following actions were accomplished for the resident(s) identified in the sample: The social worker met with each resident identified and informed of the facility survey results posting location which is located on the first-floor lobby near the security desk. The facility ensured all 3 years of facility survey results were in the binder readily accessible to residents: #15, #49, #96, #29, #42. All residents indicated were informed by the social worker on 1/28/25. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: The facility identified all residents, families, and legal representatives as having the potential to be affected. The residents will receive information of the location of the facility’s survey posting during resident council, care plan meeting and upon admission which is located on the first-floor lobby near the security desk. The facility has posted the location of the facility’s survey posting on the units, vestibule entrance and lobby. The Staff Educator will provide education of staff re: location of the survey posting. III. The following system changes will be implemented to ensure continuing compliance with regulations: The facility reviewed the Policy and Procedure titled Posting and Availability of Survey Results and Complaint Investigation to ensure compliance with regulations. The policy was revised on 1/8/2025. The Administrator provided in-service to the Director of Recreation, Director of Social Service on the facility’s policies and procedures entitled “Posting and Availability of Survey Results and Complaint Investigation” to ensure compliance. The facility will post the location of the facility’s survey findings on all units, the vestibule entrance of the lobby and by security desk. The residents will be offered to review the facility survey results during Resident Council. The facility’s survey binder will be reviewed quarterly by the Director of Therapeutic Recreation, Director of Social Services or Designee to ensure three years of facility’s survey results are posted and the residents are aware of survey results location. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: The corrective actions will be monitored through quality assurance to ensure the same practice will not recur. The Director of Therapeutic Recreation and Social Services or Designee will develop an audit tool to monitor compliance with facility's survey posting results and ensure accessibility to all residents, families/designated representative. The audits will be conducted monthly for six months or until two quarters are at 100% compliance. The Directors of Therapeutic Recreation and Social Services or Designee will monitor monthly for six months ensuring three years of facility survey results are posted and accessible to all residents, families/designated representative is aware of survey result location on the first-floor lobby near the security desk. The Director of Therapeutic and Social Services/Designee will utilize an audit tool to assess compliance monthly and report findings to the Quality Assurance Committee for six months. Responsible: Executive Director/Administrator will be responsible for ensuring compliance.
Failure to Notify Resident's Representative of UTI Diagnosis and Treatment
Penalty
Summary
The facility failed to ensure timely notification of a resident's medical condition and treatment changes to the resident, their physician, and the resident's representative. On August 7, 2024, a urine test was ordered for a resident to rule out a urinary tract infection (UTI). The test results, which were positive for Escherichia coli, were reported to the facility on August 11, 2024, but the attending physician was not informed until September 4, 2024. Consequently, antibiotic treatment was delayed until September 5, 2024. The resident's family was not notified of the positive test results or the subsequent antibiotic treatment order. The facility's policy requires immediate communication of changes in a resident's condition or treatment to the resident, their representative, and the attending physician. However, there was no documented evidence that the nursing staff notified the physician or the resident's representative about the positive urine test results. Interviews with staff revealed a lack of clarity regarding responsibility for notifying the physician and family, with some staff believing it was the unit manager's responsibility, while others thought it was the charge nurse's duty. The Director of Nursing confirmed that the facility's protocol was not followed, as the resident's representative was not informed of the abnormal test results or the antibiotic treatment. The attending physician also acknowledged that the resident's representative should have been notified. The failure to communicate these critical changes in the resident's condition and treatment plan represents a significant deficiency in the facility's adherence to its notification policy.
Delayed Treatment for UTI Due to Communication Failure
Penalty
Summary
The facility failed to ensure timely treatment and care for a resident diagnosed with a urinary tract infection (UTI). On August 7, 2024, a medical doctor ordered a urine test to rule out a UTI for a resident with severe cognitive impairment and other medical conditions. The urine test, conducted on August 8, 2024, showed a positive result for Escherichia coli, which was reported to the facility on August 11, 2024. However, the results were not reviewed by a medical doctor until September 4, 2024, leading to a 26-day delay in initiating antibiotic treatment. The facility's policy required that laboratory results be promptly reviewed and acted upon by medical staff. Despite this, there was no documented evidence that nursing staff followed up on the urine test results between August 8 and September 4, 2024. Interviews with nursing staff revealed a lack of awareness and follow-up on the test results, with responsibilities for checking and notifying medical staff about lab results not being fulfilled. The delay in treatment was attributed to a failure in communication and procedure adherence among the nursing staff and medical doctors. The Director of Nursing and medical staff acknowledged the oversight, noting that the results should have been reviewed and acted upon sooner. The facility's procedure required that the charge nurse or manager on duty receive lab results, notify the doctor, and anticipate any necessary orders. However, this process was not followed, resulting in a significant delay in addressing the resident's UTI, which was only treated after the family insisted on action being taken.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bronxcare Special Care Center | 1 mi | ★★★★★ | 22 | 0 |
| Triboro Center For Rehabilitation And Nursing | 1.2 mi | ★★★★★ | 5 | 0 |
| Concourse Rehabilitation And Nursing Center, Inc | 1.5 mi | ★★★★★ | 0 | 0 |
| Bronx Center For Rehabilitation & Health Care | 1.9 mi | ★★★★★ | 16 | 0 |
| Highbridge Woodycrest Center | 1.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.