Taconic Rehabilitation And Nursing At Ulster
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland, New York.
- Location
- One Wingate Way, Highland, New York 12528
- CMS Provider Number
- 335803
- Inspections on file
- 15
- Latest survey
- March 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Taconic Rehabilitation And Nursing At Ulster during CMS and state inspections, most recent first.
The facility did not ensure annual testing of all fire alarm system devices, specifically the magnetic fire/smoke barrier doors' hold open devices and magnetic delayed egress locks, as required by NFPA standards. This was identified during a life safety recertification survey, and the Director of Maintenance confirmed the oversight.
The facility did not ensure its HVAC system was maintained according to NFPA 80 standards. A survey revealed that while fire dampers were inspected and deficiencies noted, the follow-up report for repairs was missing. The Director of Maintenance confirmed that repairs were not done and the vendor would be contacted.
The facility was found to have maintenance deficiencies, including a window in a resident's room that could not stay open without a washcloth and a window shade with a mold-like substance. Additionally, a corridor window was propped open with a glove box. These issues were observed on one of the three resident floors.
The facility did not ensure the linen chute door latched properly, as required by NFPA 82 standards. During a Life Safety recertification survey, it was observed that the self-closing device on the intake door to the linen chute on one resident floor did not latch when closed. The Director of Maintenance confirmed the issue during an interview.
The facility did not ensure compliance with plumbing requirements for hand washing fixtures in the kitchen's food prep areas. During a survey, it was found that the sink adjacent to the refrigerator had 3-inch blade handles instead of the required 4-inch wrist blade handles, affecting 2 of 3 food prep locations. The Director of Maintenance acknowledged the issue.
The facility did not conduct a required facility-based or community-based emergency preparedness drill, as confirmed by the Director of Maintenance. Although tabletop drills were conducted, the necessary drill was missing, leading to non-compliance with 483.73(d).
A resident with significant mobility and cognitive impairments experienced a fall and sustained a facial hematoma and hip fracture. The resident was moved from the floor to bed by an LPN and two CNAs without an RN assessment, contrary to facility policy. No neurological checks or timely physician evaluation were documented, and the resident was not sent to the hospital until after an x-ray revealed a femur fracture, resulting in actual harm.
A resident with severely impaired cognition and dependent on assistance for daily living activities was found with long, stained fingernails, indicating a failure in personal hygiene care. The facility's policy required routine nail care following baths and showers, but there was no documentation of nail care for this resident. A CNA admitted to not noticing the long fingernails, and the LPN Unit Manager confirmed the oversight, highlighting a lapse in the facility's adherence to its hygiene policies.
A facility failed to update a care plan for a resident with pressure ulcers, despite staff observing that the current intervention of floating heels with pillows was ineffective due to the resident's movements. The resident, who required maximum assistance with rolling in bed, was observed with their heels directly on the mattress multiple times, and no alternative interventions were provided. Staff did not report the issue to management, resulting in a deficiency.
The facility failed to document COVID-19 vaccination screening and education for two staff members, a CNA and a Laundry Aide, as required by their policy. The LPN responsible for immunization data collection was unaware of the need to offer the vaccine, and the DON was unsure why documentation was incomplete, leading to a deficiency in infection control practices.
The Assistant Director of Nursing failed to perform proper hand hygiene while serving beverages to residents, wearing disposable gloves without changing them between services and touching various surfaces without sanitizing hands. The staff member admitted to using gloves unnecessarily and acknowledged the lack of soap at the sink, which contributed to the deficiency.
The facility failed to maintain infection control practices, including lack of documentation for pneumococcal vaccination for two staff members, an undated Water Management Plan for Legionella prevention, and improper sanitization of a blood pressure cuff by an LPN. The DON and maintenance staff were unaware of these oversights.
A recertification survey found expired medications in a medication room and cart, and a resident with multiple medications left unattended on their bedside table. Staff acknowledged the errors, noting that expired items should not have been used and medications should have been secured.
The facility failed to provide written notices of the bed hold policy to residents or their representatives during hospital transfers. This deficiency affected five residents, including those with intact and moderately impaired cognition, who were transferred without documented evidence of receiving the required notices. The issue was attributed to a service gap and administrative changes.
The facility failed to provide written transfer or discharge notices to five residents who were sent to the hospital, as required by policy. The deficiency was attributed to a service gap due to recent administrative changes and new staff, resulting in a lapse in following the established procedure for notifying residents and their representatives.
A resident with a history of falls and moderately impaired cognition was found without access to a call system to request assistance, as the call bell was consistently out of reach and sight. Despite facility policy requiring call lights to be within reach, the resident had to yell for help and was observed transferring themselves without assistance. Staff interviews confirmed the expectation for call bells to be accessible.
A resident with impaired decision-making and memory issues was observed wearing socks with their name visibly labeled, compromising their dignity. Staff interviews revealed a lack of awareness about the visibility of name labels, although the DON recognized it as a dignity issue and took steps to address it.
Two residents at risk for pressure ulcers did not receive necessary treatments as per their care plans. One resident's heels were not floated in bed, and skin prep treatments were not documented as administered multiple times. Another resident did not receive documented wound care treatments for their pressure ulcers on several occasions. Staff interviews confirmed the lack of treatment administration and documentation.
Failure to Test Fire Alarm System Devices Annually
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were maintained and tested annually in accordance with NFPA 101 and NFPA 72 standards. During a life safety recertification survey, it was observed that the facility's maintenance logs did not include documentation of annual testing for the magnetic fire/smoke barrier doors' hold open devices and the magnetic delayed egress locks. The last recorded service by the vendor occurred on three separate occasions, but none included the required testing of these specific devices. This deficiency was confirmed during an interview with the Director of Maintenance, who acknowledged the oversight and stated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Facility contracted fire alarm vendor was contacted via telephone on 3/14/25 and informed that hold open devices and magnetic egress locks are required to be tested annually as per NFPA 101 and NFPA 72 and such testing was not included as part of the vendor conducted inspections. - Facility contracted fire alarm vendor was asked to complete a full house test of all hold open devices and magnetic egress locks. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - The facility policy and procedure on Fire Alarm System Testing and Inspection was reviewed and revised to include testing of all hold open devices, magnetic fire/smoke barrier doors, and magnetic delayed egress locks. - Maintenance staff will be re-educated on the fire alarm system testing requirements by the administrator, and a record of education will be maintained for reference and validation. - Facility contracted fire alarm vendor will include in all inspection reports the location and inspection of all doors with magnetic egress locks and hold open devices that are released upon fire alarm activation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure that fire alarm system testing and inspection documentation is completed and validate that all required doors/magnetic devices are included in the documentation maintained on file. - The Director of Maintenance/designee will audit monthly for 3 months. Negative findings will be immediately reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings, and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Failure to Maintain HVAC System in Compliance with NFPA 80
Penalty
Summary
The facility failed to maintain its heating, ventilation, and air conditioning (HVAC) system in compliance with NFPA 80 standards. During a life safety recertification survey, it was discovered that the facility's fire damper log indicated inspections and tests were conducted by a vendor, and deficiencies were noted. However, the required follow-up report detailing the corrections of these deficiencies was missing and not available at the time of the survey. In an interview, the Director of Maintenance admitted that the repairs had not been completed and stated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Facility fire damper inspection vendor was contacted on 3/24/25 and was contracted to complete a full house fire damper inspection. - Fire Damper vendor will provide a written report of any deficient areas, schedule any required repairs identified in the report, and provide documentation of such after the completion of repairs. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Maintenance staff will be re-educated by the administrator on the testing and maintenance requirements for fire dampers, including ensuring necessary repairs are completed and documentation of repairs are retained. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure that fire damper testing, inspection, and repair documentation is completed every 4 years as required by 2010 NFPA 80. - The Director of Maintenance/designee will conduct an initial audit of fire damper inspection(s) and immediately report any negative findings to the administrator. - Results of additional inspections or repairs will be reviewed during monthly QAPI meetings, and the QAPI committee will determine ongoing audit frequency for continued compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and functional environment as required by regulations. During an offsite post-survey revisit, it was observed that a window in a resident's room was in disrepair, as it could not remain open without being propped up by a washcloth. Additionally, the window shade in the same room was found to have a black mold-like substance. Furthermore, a window in the corridor on the same floor was also in disrepair, being propped open with a glove box. These deficiencies were noted on one of the three resident floors. The Director of Maintenance acknowledged the issues, stating that the facility has central air conditioning for resident rooms and that the window shade would be replaced.
Plan Of Correction
Plan of Correction: Approved May 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - The window shade in room [ROOM NUMBER] was replaced on 3/24/25 by the maintenance department. - The window in room [ROOM NUMBER] and the corridor window were repaired by the maintenance director and maintenance assistant. Repairs included lubrication and replacement of pivot shoes and spiral tilt window balance. - A full house audit of windows and window shades was completed on 3/27/25 and any negative findings will be scheduled for repair. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Maintenance staff will be re-educated on the facility preventative maintenance requirements for windows. A record of education will be maintained for reference and validation. - All staff will be educated on maintaining and providing a safe and functional environment to residents; including reporting any observed repairs needed in the facility to the maintenance department via the facility work order system. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure all facility windows are able to be opened and stay open without any outside intervention and that all window shades are present, clean, and in good repair. - The Director of Maintenance/designee will audit 25% of rooms 1 x week for 4 weeks then monthly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is: 4/18/25.
Linen Chute Door Latching Deficiency
Penalty
Summary
The facility failed to maintain the linen and trash chutes in accordance with NFPA 82 standards. Specifically, the self-closing device on the intake door to the linen chute did not latch when self-closed. This deficiency was observed during a Life Safety recertification survey on one of the three resident floors. The issue was identified during a tour of the linen chute room on the first floor, where it was noted that the intake door to the linen chute did not properly latch. The Director of Maintenance acknowledged the finding during an interview at the time of the survey.
Plan Of Correction
Plan of Correction: Approved May 2, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - The latches and pistons were replaced on all three laundry chute doors on 3/25/25 by the maintenance director. - A full house audit of laundry chutes will be completed and any negative findings will be immediately corrected. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Maintenance staff will be re-educated on the maintenance requirements for rubbish chutes, incinerators, and laundry chutes NFPA 101 to meet code requirements. A record of education will be maintained for reference and validation. - All staff that routinely use the laundry chutes (nursing, dietary, maintenance, housekeeping) will be educated on the requirements that the linen chute door is required to latch when self-closed and to report negative findings to maintenance director/designee immediately. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance has created an audit tool to ensure that laundry chute doors are operational and that all chute doors close and latch. - The Director of Maintenance/designee will audit 2 x week for 4 weeks then weekly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Non-compliant Hand Washing Fixtures in Kitchen
Penalty
Summary
The facility failed to ensure that hand washing fixtures in the food preparation areas of the kitchen were compliant with regulatory requirements. During a recertification survey, it was observed that the hand washing sink in the food prep area adjacent to the refrigerator was equipped with 3-inch long blade handles instead of the required 4-inch wrist blade handles. This deficiency was noted in 2 out of 3 food prep locations in the kitchen. The Director of Maintenance acknowledged the finding during an interview conducted at the time of the survey.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - 4-inch wrist blade handles were installed on the hand washing sink in the food prep area on 3/24/25. - An audit of the sinks in the kitchen was conducted on 3/25/25 and no other concerns were identified for the hands-free fixtures. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All residents have the potential to be affected; however, no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: - Kitchen and maintenance staff will be educated by the administrator on the wrist blade hand free fixtures and requirement in the event future repairs are needed. A record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Maintenance/designee will audit 1 x week for 4 weeks, then monthly thereafter for 3 months. Negative findings will be corrected immediately and reported to the administrator. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Failure to Conduct Required Emergency Preparedness Drill
Penalty
Summary
The facility failed to ensure compliance with the emergency preparedness requirements as outlined in 483.73(d). During a documentation review and staff interview conducted on March 13, 2025, it was found that the facility did not conduct a required facility-based or community-based emergency preparedness drill. Although tabletop drills were conducted on April 23, 2024, and August 28, 2024, the necessary facility-based or community-based drill was missing. This deficiency was confirmed in an interview with the Director of Maintenance, who acknowledged that the required drill had not been conducted.
Plan Of Correction
Plan of Correction: Approved March 31, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: A facility based or community based drill will be scheduled and completed by 4/18/2025. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: All residents have the potential to be affected, however no residents were negatively impacted. Element #3: The following system changes will be implemented to prevent reoccurrence: Maintenance staff and department heads will be in-serviced by the administrator on the requirements for LTC facilities to conduct exercises at least twice per year including unannounced staff drills and participation in an annual full-scale exercise that is either community based, or a facility based functional exercise. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: The Administrator has created an audit tool to track dates of disaster drills, type of disaster drill completed to ensure continued compliance. The Director of Maintenance/designee will audit 1 x week for 4 weeks then monthly thereafter for 3 months. Negative findings will immediately be reported to the administrator. Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Maintenance/designee. Date of Compliance is 4/18/25.
Failure to Ensure Timely RN Assessment and Appropriate Response After Resident Fall
Penalty
Summary
A resident with a history of seizure disorder, heart failure, and traumatic brain injury, who was non-ambulatory and required maximum assistance for transfers, experienced a fall in the early morning hours. The resident was found on the bathroom floor by a Certified Nurse Aide (CNA), who reported the incident to an LPN. The resident had a hematoma on the face and complained of pain in the right lower back. Despite facility policy requiring assessment by a Registered Nurse (RN) after any accident or injury, there was no documented assessment by an RN or physician prior to the resident being moved from the floor to a wheelchair and then to bed by the LPN and two CNAs. Following the fall, the resident continued to complain of pain and exhibited swelling in the right groin and upper thigh. An x-ray was ordered and performed later that evening, revealing an acute fracture of the right femur. There was no documented evidence of a medical evaluation by a physician on the day of the fall, and neurological checks were not initiated. The resident was not transferred to the hospital until the following morning, after the x-ray results were reviewed and the physician was notified. Interviews with facility staff revealed that the LPN did not notify the RN Supervisor or the Director of Nursing (DON) about the fall or the transfer of the resident from the floor. The DON confirmed that the LPN should not have moved the resident without an RN assessment, as per facility policy. The lack of timely assessment and appropriate response resulted in actual harm to the resident, who ultimately required surgical intervention for the hip fracture.
Deficiency in Personal Hygiene Care for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Specifically, Resident #29, who had severely impaired cognition and required dependent assistance with showers, was observed on multiple occasions with long, stained fingernails. The facility's policy on nail care, revised in 2011, stated that routine nail care should be done following baths and showers whenever possible. However, there was no documented evidence regarding the trimming or cleaning of Resident #29's fingernails, despite the resident's care plan indicating a need for maximal assistance with upper body bathing. During the survey, Certified Nurse Aide #7 admitted to not paying attention to the resident's fingernails when providing care and did not notice the long fingernails during a previous care session. The Licensed Practical Nurse Unit Manager #4 stated that CNAs were responsible for cutting residents' fingernails unless the resident was diabetic and that the CNA should have informed the nurse if a resident's nails were long. Upon observation, the Unit Manager confirmed that Resident #29's fingernails were indeed long, indicating a lapse in the facility's adherence to its own policies and procedures for maintaining residents' personal hygiene.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident #29 was offered nail care and declined nail care. Residents care plan was updated to reflect to encourage nail care per residents’ preference and as tolerated by the resident. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. Certified nurse aid #7 was educated on the policy of providing nail care to the residents as part of daily ADL’s. The CNA has since been re-audited and successfully demonstrated her understanding. All residents on the CNA's assignment had the potential to be affected by the deficient practice. Full house audit by Nurse Managers/designee will be completed to assure all residents' nails are clean and trimmed and care planned appropriately. Any instances of dirty nails were immediately rectified. Nurses and CNA’s will be educated by the DON/designee on the process of providing nail care during daily ADL’s and ensuring residents' nails are clean and trimmed as outlined in the resident’s plan of care. Weekly audits to be completed by the nurse manager/designee to ensure compliance with proper nail care and that residents' nails are clean and trimmed per care plan. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review the audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the Monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Failure to Update Care Plan for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for a resident with pressure ulcers. Specifically, the care plan for a resident, who had a history of [DIAGNOSES REDACTED] and required maximum assistance with rolling in bed, was not updated to include a new intervention when staff observed the resident moving their legs frequently while in bed. The care plan initially documented an intervention to float the resident's heels, but this was not effective as the resident was observed with their heels directly on the mattress on multiple occasions, and no alternative interventions such as heel booties or an air mattress were provided. During interviews, it was revealed that the nursing staff, including an LPN, were aware that the current intervention of using pillows to float the resident's heels was ineffective due to the resident's movements. However, they did not report this issue to the Nurse Manager or suggest alternative interventions. The facility's policy required that care plans be reviewed and updated regularly, especially with changes in the resident's condition, but this was not adhered to in this case, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident # 68 comprehensive care plan was reviewed and revised on 3/8/25 to reflect an air mattress for pressure relief of her heels. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. Unit manager was educated on the requirement to update the resident care plan to accurately reflect interventions. Full house audits will be completed by the nurse managers for all residents with wounds and ensure that the comprehensive individualized care plan for wounds is reviewed and revised to accurately reflect the residents' needs. All unit managers/supervisors educated by the DON/designee to review and revise comprehensive individual care plan weekly or with noted ineffective interventions. Weekly audits will be completed by the unit managers/designee to ensure all residents with wounds have a comprehensive individualized care plan with effective interventions in place. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Deficiency in COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to maintain infection control prevention practices, specifically regarding COVID-19 vaccinations for staff. During a recertification survey, it was found that the facility did not provide documentation of screening, administration, or declination of the COVID-19 vaccine for two staff members, a Certified Nurse Aide and a Laundry Aide. The facility's COVID-19 policy required that all employees and contracted staff be screened and educated about the vaccine, with documentation maintained to reflect this process. However, the facility was unable to provide such documentation for the two staff members in question. Interviews conducted during the survey revealed that the Licensed Practical Nurse responsible for collecting employee immunization data did not have completed forms for the two staff members, indicating a lack of awareness that the COVID-19 vaccine needed to be offered to staff. The Director of Nursing stated that the responsibility for ensuring forms were signed was delegated to the Licensed Practical Nurse, but they were unsure why the documentation was not completed. This oversight led to a deficiency in the facility's infection control practices as per the regulatory requirements.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Staff #15 and #16 were both offered and declined COVID vaccinations for the year. Consent form was signed on (MONTH) 12, 2025. Staff #17 has been educated on the importance of completion of vaccination forms in its entirety. That Covid vaccinations are available in the facility throughout the year. A full house audit of all staff vaccination status will be conducted by DON/designee. All staff will be offered the Covid vaccines with education and eligibility information. Education provided to Staff #17 all staff can accept or decline all vaccinations throughout the year. Covid vaccinations are available at any time in the facility. Upon request. Covid vaccinations are offered at time of hire and, throughout the year. All vaccinations are available at any time. House wide audit of vaccinations records will be completed by ADON/designee monthly until 100% compliance is attained for 3 consecutive months. Any abnormal findings will be reported to the DON. These findings will be corrected immediately with education provided. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Improper Hand Hygiene During Beverage Service
Penalty
Summary
The facility failed to ensure food was distributed and served in accordance with professional standards for food service safety during a recertification survey. The Assistant Director of Nursing was observed serving beverages to multiple residents in the main dining room without performing proper hand hygiene. The staff member wore disposable gloves while serving but did not change them between serving different residents. Additionally, the Assistant Director of Nursing touched various surfaces, such as the beverage cart handle and a resident's walker, without changing gloves or sanitizing hands, and continued to serve beverages to residents. The Assistant Director of Nursing also touched their own face with bare hands while taking a beverage order and proceeded to serve a resident without washing or sanitizing hands. The staff member admitted to wearing gloves to prevent contamination of the ice but acknowledged that gloves were not necessary and that hand hygiene should have been performed. The surveyor confirmed that the sink was out of soap, which contributed to the lack of proper hand hygiene during the beverage service.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident # 93 had no ill effects from the deficient practice noted during the meal service on 3/5/25. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. ADON was educated on proper hand hygiene while serving in the main dining room. She has since been re-audited and successfully redemonstrated understanding. All facility residents have the potential to be affected by the alleged practices. A meal service audit was conducted on all units to verify that disposable gloves were not being used during meal pass and that hand hygiene was performed properly. No further issues were identified. All nursing staff will be in-serviced regarding proper hand hygiene in accordance with professional standards for food service safety while serving meals. Weekly audits will be completed across all 3 meals in each dining room on a rotating basis by DON/designee to assure proper hand hygiene during meal service. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Infection Control Deficiencies in Vaccination, Water Management, and Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by three specific deficiencies. Firstly, the facility did not provide documentation of pneumococcal vaccination screening, administration, or declination for two staff members, a Certified Nurse Aide and a Laundry Aide. The Licensed Practical Nurse responsible for collecting immunization data admitted to not having completed forms for these staff members, indicating a lapse in ensuring that employees were educated and had the opportunity to consent to or decline the vaccine. The Director of Nursing acknowledged the oversight and attributed it to the delegation of vaccine tasks to the Licensed Practical Nurse. Secondly, the facility's Water Management Plan, crucial for preventing and controlling Legionella, was found to be undated with no evidence of annual review or updates. The Director of Maintenance was unaware of the oversight. Lastly, during a medication pass observation, an LPN was seen placing an unsanitized blood pressure cuff back into the medication cart after use, contrary to the facility's policy requiring sanitization between uses. The Director of Nursing confirmed that shared equipment should be sanitized with alcohol or sanitizing wipes after each use.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Nurse Aide #15 and laundry aide #16 were offered the pneumococcal vaccine on 3/12/25; both declined and signed a declination form. - Education provided to LPN #17 on the requirements for all employees to have documented immunization status; including eligibility, education and administration of vaccines and that signed consents/declinations are maintained on file. - The water management plan was reviewed and updated on 3/5/2025 and verbal education was provided to the Maintenance Director on the documentation requirements for the water management plan which includes, at minimum, an annual documented review of the water management plan. - Licensed practical nurse #18 was educated on the requirement to sanitize blood pressure cuffs after use, prior to being placed in the medication cart. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All Residents have the potential to be affected; however, no residents have been negatively impacted. - Staff Educator/designee completed an audit of all employee vaccination status, and the pneumococcal vaccine will be offered to any employee identified as needing such based off of audit findings. Element #3: The following system changes will be implemented to prevent reoccurrence: - The facility policy and procedure titled “Pneumococcal Vaccination Program for Employees” was reviewed and found to be appropriate. - The staff educator/designee will provide education to all employees upon hire and at least annually on the pneumococcal vaccine and will obtain a signed consent or declination for the vaccine. Consent/declination forms will be retained on file. - The staff educator/designee will provide education to all licensed nurses on the requirement to properly sanitize blood pressure cuffs after use and prior to placing in medication cart for storage. - The administrator provided verbal education to the Maintenance Director on 3/5/2025 on the requirement to complete and update the water management plan on an annual basis. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Nursing has created an audit tool to ensure that all employees were offered the pneumococcal vaccine upon hire and annually and that a consent/declination form is signed by the employee. - The Director of Nursing has created an audit tool to ensure that licensed staff are properly sanitizing blood pressure cuffs after use. - ADON/Designee will complete a full house audit of employee vaccination records monthly until 100% compliance is attained for 3 consecutive months. Negative findings will be corrected and reported to the Director of Nursing. - Unit managers/designee will audit once a week to ensure that blood pressure cuffs are properly sanitized in between residents until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected and reported to the Director of Nursing. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency for blood pressure cuffs after 4 weeks of 100% compliance; and for employee vaccinations after 3 months of 100% compliance. Element #5: The person responsible for the corrective actions is the Director of Nursing/designee. Date of compliance is 4/18/25.
Expired Medications and Improper Storage in LTC Facility
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with professional standards for expiration dates and storage. During a recertification survey, it was observed that one of the medication rooms contained an open box of expired [MEDICATION NAME] 1.5 Cal, which was being used for a resident's feeding. Additionally, expired nicotine patches were found in a medication cart without proper labeling. Interviews with nursing staff revealed that the expired items should not have been in use, and it was the responsibility of the medication nurses to check and dispose of expired items. Furthermore, a resident was found with multiple medications left unattended on their bedside table, despite not having documented permission to self-administer medications. The medications included Carvedilol, an anti-depressant, Aspirin, Apixaban, Folic Acid, Levetiracetam, a stool softener, and an anti-acid. A nurse had left the medications with instructions for the resident to wait for water, which was against facility policy. The nurse acknowledged that the medications should have been secured in the medication cart while retrieving water.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The expired [MEDICATION NAME] feed and nicotine patches were immediately discarded. Resident #60 received appropriate medications on [DATE] and resident has been discharged from the facility. Resident’s preference was to have all medications administered by the nursing department and not to self-administer medications. Resident #90 was assessed and had no negative outcome related to tube feed. MD made aware. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs, and a medical record review was completed with no abnormal findings. All nursing staff who administered the expired [MEDICATION NAME] and did not discard the expired nicotine patches were re-educated on checking of expiration dates and discarding as appropriate. Nurse manager #6 was re-educated on med pass policy to not leave residents' medications at the bedside and to assure medications are consumed. She has since been re-audited and successfully redemonstrated her understanding. All residents receiving tube feed and medication have the potential to be affected by practice. DNS and Maintenance Director completed a full house audit of tube feeding expiration dates. Additionally, all medication rooms and medication carts were checked to verify that no medications were expired. Any additional medications/feeds that were found to be expired were immediately discarded. All residents who self-administer medications were audited to verify that a Self Administration evaluation was completed and appropriate. Residents that do not have a care plan for self-administering medications will have medications provided by nurses. The nurses will not leave medications unattended. All Nurses and the Maintenance Director were educated by DON/designee to check expiration dates on all tube feed and medications administered items used. Prior to use, dates will be checked. All Nurses will be re-educated by DON/designee pertaining to proper medication administration. All licensed nurses will be re-educated on the facility procedure for residents that request to self-administer medication. Nursing and Maintenance will monitor expiration of tube feeding and supplies. Weekly audits by Unit Manager/designee of tube feeding will be conducted. Medication cart checks will continue to be checked by Pharmacy Consultant monthly. Tube feed will be checked by maintenance before being brought to the unit to ensure that tube feeding has not exceeded expiration date. Tube feeding will be checked by the nurse prior to hanging it. Audits will be ongoing. Weekly audits on med passes by Unit Managers will ensure medication is not left at the bedside. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is [DATE].
Failure to Provide Written Bed Hold Policy Notices
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during transfers to the hospital. This deficiency was identified for five residents who were reviewed for discharge. Specifically, these residents were transferred to the hospital, and the facility could not provide evidence that written notice of the bed hold policy was given to the residents or their representatives. The facility's policy requires that the bed hold policy be communicated both verbally and in writing at the time of admission and transfer. Resident #50, who had intact cognition and was dependent on staff for all activities of daily living, was transferred to the hospital due to respiratory issues. Similarly, Residents #202 and #203, both with moderately impaired cognition and requiring staff assistance, were transferred to the hospital following incidents that necessitated evaluation. In each case, there was no documented evidence that the residents or their representatives received written notice of the bed hold policy. Interviews with the Director of Social Work and the Administrator revealed that there was a service gap and inconsistency in providing these notices, attributed to recent administrative changes.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: ò Review of identified residents revealed that Residents #50, 69, 68 experienced transfers to the hospital and all were readmitted to the facility after completion of acute hospital stay and are current residents. Resident #202 was transferred to the hospital for acute needs and expired in the hospital. Resident #203 was scheduled for discharge to ALF prior to hospital admission and was directly discharged to ALF from acute care hospital. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: ò All residents who were transferred have the potential to be affected, however no residents were negatively impacted. ò An audit of the last 30 days of resident hospital transfers was completed to ensure that a notice of bedhold was given. Element #3: The following system changes will be implemented to prevent reoccurrence: ò The facility policy and procedure on ‘Bed Hold and Notice’ was reviewed and found to be appropriate. ò Social Work staff, medical records, and admissions will be reeducated on the facility policy and requirement for Bed hold notification for all residents and a record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: ò The Director of Social Work has created an audit tool to ensure that Notice of Bed Hold documentation is accurately completed for all hospital transfers/discharges and validate that all required documentation is uploaded to the facility eMAR system. ò The Director of Social Work/designee will audit, and audits will continue until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected immediately and reported to the administrator. ò Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Social Work/designee. Date of Compliance is [DATE].
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to the hospital for five residents, as required by their policy and regulations. Residents involved had varying levels of cognitive impairment and required assistance with activities of daily living. For instance, one resident with intact cognition and dependent on staff for all activities was transferred to the hospital due to respiratory issues, but there was no documented evidence of written notification to the resident or their representative. Similarly, other residents with moderately impaired cognition were transferred to the hospital without documented written notice being provided. The Director of Social Work acknowledged the lack of documented evidence for providing written notices, attributing it to a service gap caused by recent administrative changes. The facility's Administrator, who had recently started, identified the issue during an audit and noted that the facility had not been issuing discharge notices in writing for some time. This deficiency was recognized as a result of new staff and changes in administration, which led to a lapse in following the established procedure for notifying residents and their representatives in writing about transfers or discharges.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: ò Review of identified residents revealed that Residents #50, 69, 68 experienced transfers to the hospital and all were readmitted to the facility after completion of acute hospital stay and are current residents. Resident #202 was transferred to the hospital for acute needs and expired in the hospital. Resident #203 was scheduled for discharge to ALF prior to hospital admission and was directly discharged to ALF from acute care hospital. ò Education provided to social workers on the requirement for notice of transfer/discharge to accompany all residents transferred/discharged from the facility. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: ò All residents who were transferred/discharged had the potential to be affected, however no residents were negatively impacted. ò An audit of past 30 days of discharges was conducted to ensure Notice of Transfer/Discharge was provided and to ensure the resident or the resident's representative were notified in writing of the reason for transfer/discharge to the hospital in a language they understood and to notify the Ombudsman for discharge or transfer and hospitalization. Negative findings will be immediately corrected. Element #3: The following system changes will be implemented to prevent reoccurrence: ò The facility policy and procedure on 'Discharge Notice' was reviewed and found to be appropriate. ò Social Work staff, medical records and licensed nursing staff will be reeducated on the facility policy and requirement for discharge/transfer notification for all residents and a record of education will be maintained for reference and validation. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: ò The Director of Social Work has created an audit tool to ensure that Notice of Transfer/Discharge documentation is accurately completed for all planned and unplanned discharges and validate that all required documentation is uploaded to the facility eMAR system. ò The Director of Social Work/designee will audit, and audits will continue until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected immediately and reported to the administrator. ò Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after three months of compliance. Element #5: The person responsible for the corrective action is the Director of Social Work/designee. Date of Compliance is [DATE].
Inaccessible Call System for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that Resident #30 had access to a call system to request staff assistance, as required by their policy. The call bell for Resident #30 was consistently found out of reach and out of sight, placed on a stationary chair in the corner of the room. This was observed multiple times over several days, and the resident expressed difficulty in calling for help, stating they had to yell for assistance. The resident, who had a history of falls and was at risk for further falls, was observed transferring themselves to the toilet without assistance, indicating a lack of available support due to the inaccessible call system. The facility's policy mandates that call lights be within reach of residents at all times to ensure their safety and ability to communicate needs. Despite this, the call bell for Resident #30 was repeatedly found in an inaccessible location, and staff interviews confirmed that call bells should be within reach. The resident's care plan highlighted the need for supervision with transfers and ambulation, yet the lack of an accessible call system compromised their ability to request necessary assistance, potentially increasing their risk of falls.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident #30 was immediately provided with her call bell, and the call bell has been kept within reach. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. All residents had the potential to be affected by the deficient practice. Unit Managers completed a Full house audit of residents to assure call bells are within reach. No further call bells not within reach were found. The Staff educator/Designee provided reeducation for all staff to place call bell within reach for all residents, while in bedroom. Weekly call bell placement audits will be conducted by Unit Manager/designee and reported to DON. All issues will be corrected immediately. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits. For compliance, any negative findings will result in immediate education. The audit's results will be reported to QAPI monthly meetings. Then quarterly, the frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Resident Dignity Compromised by Visible Name Labels on Clothing
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, which compromised the maintenance or enhancement of their quality of life. This deficiency was identified during a recertification survey, where it was observed that a resident, who had severely impaired decision-making and memory problems, was ambulating independently in the hallway wearing socks labeled with their name on the top of the foot. This labeling was visible to other residents, staff, and visitors, which is contrary to the facility's policy on dignity, respect, and privacy in treatment and care. Interviews conducted during the survey revealed a lack of awareness among staff regarding the visibility of name labels on residents' clothing. The LPN Unit Manager stated that the labels were intended to ensure clothing items were returned to the correct resident after laundry, and they were not aware that such labels should not be visible. Similarly, the Social Worker did not perceive the visibility of the name label as a problem. However, the Director of Nursing acknowledged that visible clothing labels were a dignity issue and took steps to address the situation by requesting the relabeling of the resident's socks.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident #65’s socks were immediately removed. Resident #65 was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs, and a medical record review was completed with no abnormal findings. LPN #14 and the Social Worker were reeducated by ADON/Designee on resident dignity and privacy, as well as policy and procedure for clothing labeling. All residents to have clothing labeled in a non-visible area. Both the LPN and Social Worker state their understanding. All residents who have clothing labeled had the potential to be affected by the deficient practice. A full audit of each unit’s resident clothing was conducted by unit managers/designee to identify other potential residents affected by deficient practices. Any instances where clothing labels were found to be visible were rectified immediately. The Staff Educator/designee will conduct educational sessions for all nursing and laundry staff on resident dignity and the use of clothing labels, and policy and procedure for labeling clothing for residents, to ensure all residents are treated in a dignified manner, keeping labels private. Weekly audits will be completed by unit manager/designee to assure residents' rights are observed and policy and procedure is adhered to, with no name labels being visible. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.
Failure to Administer and Document Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers and those with existing pressure ulcers received necessary treatment and services consistent with professional standards of practice. Resident #68, who had a history of [DIAGNOSES REDACTED], was not provided with the required interventions to float their heels in bed, as documented in their care plan. Observations revealed that Resident #68's heels were directly on the mattress without any heel booties or pillows to float them, and there was no air mattress in place. Additionally, there was no documented evidence that skin prep treatments were administered as ordered on multiple occasions in February and March. Resident #352, who had [DIAGNOSES REDACTED], was also not provided with the necessary wound care treatments for their Stage 3 and Stage 4 pressure ulcers. The Treatment and Medication Administration Records showed no documented evidence that treatments were completed on several dates in May and June. Interviews with staff, including Licensed Practical Nurses and the Director of Nursing, confirmed that the treatments were not signed off, indicating they were not administered, and there was no documentation explaining the omissions. The facility's policy required daily monitoring and documentation of pressure ulcers and chronic wounds, but this was not adhered to for the residents in question. The lack of adherence to care plans and treatment orders, as well as the failure to document treatment administration, contributed to the deficiency in providing adequate care for residents with pressure ulcers.
Plan Of Correction
Plan of Correction: Approved April 11, 2025 Element #1: The following actions were accomplished for the resident(s) identified in the deficient practice: - Resident #68’s heels were immediately floated and the attending physician was notified of the missed treatments. The resident’s care plan and treatment protocol was reviewed and revised to reflect the use of an air mattress. Resident #68 was monitored for 5 consecutive days with no issues noted. A medical record review was completed and no abnormal findings were identified. - Resident #352 was discharged from the facility on 7/2/2024. A medical record review was completed with no additional abnormal findings. Element #2: The following actions will be implemented to identify other residents who have the potential to be impacted by the deficient practice: - All Residents at risk for skin breakdown as per facility skin risk assessment have the potential to be affected. All residents identified as being at risk based on documented skin assessment were reviewed with no issues noted and care plan is in concert with the resident needs. No deficient practice noted. - ADON/designee completed an audit of all residents with skin breakdown to ensure all devices and treatments are in place and are being signed for by the licensed nurses. Element #3: The following system changes will be implemented to prevent reoccurrence: - The facility policy and procedure titled “Documentation of Pressure Ulcer and Chronic Wounds” was reviewed and found to be appropriate. - The staff educator/designee will provide education to all licensed nurses on documentation of pressure ulcers and chronic wounds policy; including closely monitoring the effectiveness of treatments, daily documentation of treatments provided, as well as documenting an explanation when a treatment is not completed. Additionally, education will be provided to all licensed nurses on updating the resident(s) care plan to accurately reflect interventions in place; such as floating heels and use of air mattress. Element #4: The facility’s compliance with the corrective action will be monitored using the following quality assurance system: - The Director of Nursing has created an audit tool to ensure that all residents with pressure ulcers/chronic wounds have proper treatment orders in place that are signed for by licensed nurses and that proper interventions are in place. - Unit managers/designee will audit once a week until 100% compliance is attained for 4 consecutive weeks. Negative findings will be corrected and reported to the Director of Nursing. - Results of audits will be reviewed during monthly QAPI meetings and the QAPI committee will determine ongoing audit frequency after 4 weeks of 100% compliance. Element #5: The person responsible for the corrective actions is the Director of Nursing/designee. Date of compliance is 4/18/25.
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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