The Grand Rehabilitation And Nrsg At Guilderland
Inspection history, citations, penalties and survey trends for this long-term care facility in Altamont, New York.
- Location
- 428 State Route 146, Altamont, New York 12009
- CMS Provider Number
- 335540
- Inspections on file
- 22
- Latest survey
- March 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Grand Rehabilitation And Nrsg At Guilderland during CMS and state inspections, most recent first.
A facility failed to prevent significant medication errors for five residents, including missed psychiatric and antibiotic doses, leading to hospitalizations and untreated conditions. Issues included delayed pharmacy deliveries, staff shortages, and documentation inconsistencies.
The facility failed to meet the required staffing levels from late February to early March 2025, impacting resident care. Residents reported insufficient care, such as missed showers, due to staffing shortages. A nurse highlighted the difficulty of managing multiple units with low staff numbers. Despite these issues, the administration did not recognize significant understaffing, although the facility did not meet the mandated care hours per resident per day.
Two residents reported being treated without dignity and respect in the facility. One resident experienced rough handling and neglect from CNAs, while another, who was partially paralyzed, had their call light turned off without receiving assistance. The RN Regional Clinical Director confirmed that staff were expected to treat residents with dignity and respect.
The facility failed to maintain a clean and comfortable environment, with observations of strong odors, dust build-up, stained ceiling tiles, and soiled floors across three resident units. Chewing gum was found under dining tables, and window blinds were dusty. The administrator acknowledged these issues and planned to address them with the housekeeping and maintenance departments.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical and psychosocial needs. Examples include a lack of care plans for a urinary tract infection, fungal skin rash, pressure ulcer, and gastrostomy tube. Staff interviews revealed challenges in completing care plans, with RNs and LPNs facing difficulties in updating them, and the DON sometimes stepping in to assist.
The facility failed to update comprehensive care plans for several residents, leading to outdated or incorrect information regarding medical conditions, interventions, and goals. For example, a resident's care plan did not reflect a diagnosed urinary tract infection, and another resident's discharge plan was not updated to reflect their long-term care status. Staff interviews revealed challenges in managing care plans due to workload and oversight.
The facility failed to provide appropriate care and monitoring for several residents, including a newly admitted diabetic resident whose blood sugar was not checked as required, a resident with inadequate personal care leading to skin issues, and residents whose vital signs were not consistently monitored or documented. These deficiencies indicate a lack of adherence to care plans and monitoring protocols.
The facility failed to ensure proper physician review and medication management for two residents. One resident received a topical medication without clear instructions, leading to incorrect self-administration. Another resident's high potassium level was not evaluated promptly, despite being reported. Staff interviews revealed confusion over responsibility for monitoring lab results, contributing to the deficiencies.
The facility's governing body failed to ensure proper implementation of policies, resulting in significant medication errors and compromised resident care. Several residents did not receive prescribed medications, leading to hospitalization and incomplete treatments. Interviews revealed communication and documentation breakdowns, with staff unaware of the extent of the issues until the survey.
A facility failed to maintain accurate medical records, with incomplete narcotic count books and repeated or missing vital signs for two residents. Narcotic count records lacked signatures, and vital signs were duplicated or missing for a resident with respiratory issues. Another resident's wound care documentation was inaccurate, as confirmed by staff and the resident. Interviews revealed that staff sometimes signed records days after their shifts, contrary to policy.
The facility failed to implement enhanced barrier precautions for three residents with indwelling medical devices, as observed during a survey. A resident with a hemodialysis catheter, another with a urinary catheter and wound, and a third with a gastrostomy tube did not have the necessary precautions in place. Staff interviews revealed inconsistencies in understanding and implementing these precautions, leading to a deficiency in infection control practices.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and lack of timely follow-up by staff. One resident missed multiple doses of an antipsychotic for schizophrenia, while another did not receive a medication for hyperkalemia for several days. Documentation and staff interviews confirmed the medications were not available and that expected procedures for handling such situations were not consistently followed.
A resident was found with a topical steroid cream in their room without an assessment or physician order for self-administration. The resident, who was cognitively intact, misunderstood the prescription label and applied the cream incorrectly. The facility failed to conduct a required evaluation of the resident's ability to self-administer medications, leading to the resident using the medication without proper guidance.
The facility did not ensure residents were aware of the grievance process, as grievance forms were not readily available, and residents could not file grievances anonymously. During a Resident Council meeting, all residents reported they were unaware of the grievance process and feared retaliation. Staff interviews revealed a lack of awareness about grievance forms and procedures.
A facility failed to report an alleged abuse incident involving two residents, where one resident entered another's room and engaged in a non-malicious altercation. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the New York State Department of Health, as it was deemed playful and not malicious.
The facility failed to provide proper written notification of hospital transfers to the Ombudsman and representatives for two residents. One resident was transferred multiple times without notifying the Ombudsman, while another was sent to the hospital after a fall without notifying the resident, representative, or Ombudsman. Staff interviews confirmed the oversight.
The facility failed to provide written notice of its bed hold policy to two residents or their representatives upon hospital transfer, as required by their policy. Despite multiple hospitalizations for medical reasons, there was no documentation that the policy was communicated. Staff interviews confirmed the lapse in procedure.
A facility failed to conduct a proper PASARR screening for a resident with schizophrenia, resulting in the omission of a necessary Level II referral. The resident, admitted with serious mental health diagnoses, was not identified as having a serious mental illness on the PASARR form. The Director of Social Work, who was not screen certified, relied on the Regional Admissions Coordinator for assistance if inaccuracies were found, but this process was not followed, leading to the deficiency.
A resident with a stage 3 pressure ulcer on the left heel did not receive wound care as ordered by the provider. The facility failed to document and administer the prescribed treatment consistently, and a care plan was not developed until weeks after the wound was first assessed. Staff interviews revealed a lack of adherence to treatment orders, contributing to the deficiency in care.
The facility failed to provide necessary respiratory care for three residents, including inadequate nebulizer maintenance and improper oxygen administration. A resident's nebulizer was found unplugged with undated tubing, and another resident's oxygen flow rate was set incorrectly, contrary to physician orders. Staff interviews revealed inconsistent procedures for respiratory care, contributing to the deficiencies.
The facility failed to provide appropriate dialysis care for two residents, with deficiencies in communication and documentation. One resident's care plan lacked necessary interventions, and multiple instances of incomplete dialysis communication forms were noted. Another resident's dialysis binder was missing essential documentation, and staff interviews revealed lapses in expected procedures. These issues were identified during a survey and were not previously addressed in Quality Assurance meetings.
The facility failed to ensure that nurses and CNAs had the necessary competencies and skills, as evidenced by incomplete education records and insufficient training. Education records for several staff members were incomplete, and RN #2 lacked proficiency in care plan updates and handwashing protocols. Interviews revealed issues with the training program, high staff turnover, and gaps in orientation paperwork.
The facility's medication error rate exceeded 5%, reaching 6.87%, during a survey. Two residents were involved in errors: one received an incorrect dosage of Tylenol due to distractions, and another received crushed medication without an order. The LPN involved noted unclear orders, and the administrator acknowledged missing documentation for medication issues.
The facility failed to store drugs and biologicals according to professional standards, with undated medications and misplaced insulin pens observed. Narcotic logbooks lacked consistent signatures from two licensed nurses, indicating improper narcotic count procedures. Staff interviews revealed a lack of adherence to medication labeling and storage policies.
A resident with dysphagia and malnutrition was not provided the prescribed therapeutic diet during a meal observation. The resident was served whole chicken instead of ground meat as ordered. Staff interviews revealed a failure to adhere to dietary orders, with the Director of Food Service acknowledging the mistake and the Regional Director of Nursing noting that staff should have verified meal accuracy.
The facility failed to adhere to food safety protocols, with pureed vegetables improperly cooled, a malfunctioning dishwashing machine, and lack of proper sanitizing solution testing. Additionally, two food thermometers were out of calibration, and there was no evidence of staff training on thermometer calibration.
The facility did not properly dispose of garbage and refuse, as the dumpster lid was propped open with a broom handle, exposing kitchen and housekeeping waste. An administrator confirmed that the dumpster should be kept closed.
A resident with multiple chronic conditions did not receive ordered laboratory tests on three separate occasions, and the provider was not notified of the missed tests. Orders were entered and confirmed, but the labs were not completed as scheduled, and results were delayed until after repeated reordering. Staff interviews confirmed ongoing issues with lab order processing and communication lapses.
A resident with multiple chronic conditions had abnormal lab results, including elevated potassium, that were not promptly communicated to the ordering provider. Staff interviews revealed confusion about responsibility for monitoring and notifying providers of lab results, and documentation did not show that the provider was informed or that any new orders were made in response to the abnormal findings.
A resident with diabetes, depression, and bladder cancer received a 30-day discharge notice, but the facility failed to notify the Ombudsman in a timely manner, delaying the notification by nearly a month. The Director of Social Work admitted the oversight and confirmed that the facility's policy for same-day notification was not followed.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting five residents. Resident #47 was not administered their psychiatric medication, Clozapine, for 12 days, leading to psychiatric decompensation and a request for hospitalization. The medication was not delivered to the facility until 12/06/2024, despite being ordered on 11/25/2024. Documentation inconsistencies were noted, as the medication was recorded as given on certain days when it was not available in the facility. Resident #12, diagnosed with a urinary tract infection, was prescribed intravenous Ampicillin due to refusal of oral antibiotics. However, the resident missed 10 out of 20 scheduled doses due to pharmacy delivery delays and staff shortages. This led to a change in medication to Levaquin for better compliance, but the resident still missed doses. Resident #23, also with a urinary tract infection, missed four doses of Augmentin due to unavailability, resulting in the development of pneumonia and the need for intravenous antibiotics. Resident #77, with high potassium levels, did not receive the prescribed medication, sodium zirconium cyclosilicate, until four days after it was ordered, leading to further elevated potassium levels. Resident #327, with pneumonia, did not receive prescribed Azithromycin due to the inability to establish intravenous access, resulting in a hospital transfer for treatment. Interviews with facility staff revealed awareness of medication availability issues and a lack of proper documentation and communication regarding missed doses.
Staffing Deficiency in Nursing Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as required by New York State Public Health Law and Regulations. From February 22, 2025, to March 6, 2025, the facility did not meet the minimum staffing levels necessary to provide adequate care. Specifically, the facility was unable to maintain the required 3.5 hours of care per resident per day, with at least 2.2 hours provided by certified nurse aides and 1.1 hours by licensed nurses. The staffing sheets revealed that on multiple days, the number of licensed nurses and certified nurse aides scheduled was insufficient to meet the required care hours based on the facility census. Residents and staff reported the impact of the staffing shortages. During a resident council meeting, residents expressed concerns about the lack of staff, and one resident reported receiving fewer showers than scheduled due to staffing issues. A registered nurse also noted the challenges of working with low staffing numbers, indicating that they had to manage care plans for multiple units, which was difficult. The nurse also mentioned the lack of effective staff appreciation and incentives for picking up additional shifts. Despite these observations, the facility's administration did not acknowledge significant understaffing. The administrator and director of nursing both stated that they had not been informed of any tasks that could not be completed due to staffing shortages. However, the documented staffing levels and resident and staff feedback clearly indicated that the facility did not meet the required staffing standards, compromising the care and well-being of the residents.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the experiences of two residents. Resident #39, who was cognitively intact and diagnosed with congestive heart failure, hypertension, and Parkinson's disease, reported having to wait for personal care for up to two hours. The resident described some Certified Nurse Aides as rough, stating they were pushed and shoved during care. Additionally, an aide ignored the resident's request for help, leaving a nightgown on the side of the bed and exiting the room. Resident #61, also cognitively intact and diagnosed with spinal fusion, diabetes mellitus, and hypertension, reported that staff would turn off their call light without providing assistance. The resident, who was partially paralyzed and dependent on staff for all care, stated that staff would speak harshly and tell them to wait. Despite having a call bell device, the resident's needs were not fully addressed, as staff would only inquire about water needs. The Registered Nurse Regional Clinical Director confirmed that staff were expected to treat residents with dignity and respect, and should not turn off call lights without assisting residents.
Deficient Housekeeping and Maintenance Services
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services across three resident units, leading to unsanitary and uncomfortable living conditions. Observations revealed strong urine and fecal odors in various corridors and rooms, indicating inadequate cleaning and ventilation. Trash was found on the floor in one room, and unwashed body odor was detected near another. Additionally, the ventilation grid by the emergency exit was heavily soiled with dust, and stained ceiling tiles were present in multiple areas, including corridors and utility rooms. Further observations highlighted a significant build-up of dirt and dust on floors, particularly where corridor door frames meet the floor and next to walls in the Rehabilitation room. Nurse stations across all wings were also soiled with dirt build-up. Chewing gum was found under dining tables, and window blinds in several rooms were caked with dust. The lobby furniture was worn, and there were multiple instances of chipped paint and damaged wall guards throughout the facility. These conditions were acknowledged by the facility's administrator, who indicated plans to address the issues with the housekeeping and maintenance departments.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for eight residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For instance, a resident diagnosed with a urinary tract infection did not have a care plan for antibiotic treatment, despite being prescribed oral and later intravenous antibiotics due to refusal to take oral medication. Another resident with a fungal skin rash did not have a care plan for the use of Lotrisone Cream, which was administered without specific instructions on where to apply it. Additionally, the facility did not include cultural information and interventions in the care plan of a resident, and another resident's care plan for antibiotics was initiated only after the completion of antibiotic therapy. A resident with a pressure ulcer did not have a care plan addressing its presence or interventions, and another resident with dentures lacked a comprehensive care plan. Furthermore, a resident with a gastrostomy tube did not have a care plan to address its presence and use, highlighting a significant oversight in care planning. Interviews with facility staff revealed challenges in completing care plans, with registered nurses sometimes responsible for multiple units and licensed practical nurses unable to update care plans themselves. The Director of Nursing occasionally had to update care plans, but there was no assurance that care plans were completed promptly. The Regional Director of Clinical Services expressed an expectation for care plans to be initiated for specific medical needs, such as a gastrostomy tube, indicating a gap between expectations and practice.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in response to changes in residents' conditions and needs. Specifically, for eight residents, care plans were not updated to reflect current medical conditions, interventions, and goals. For instance, Resident #20's care plan was not revised to remove a medication that was no longer prescribed. Resident #23's care plan for bladder incontinence did not include a diagnosed urinary tract infection, despite documentation of the infection and a new antibiotic prescription. Resident #28's discharge planning care plan was outdated, still reflecting community discharge goals despite the resident's long-term care status. Similarly, Resident #84's care plan for impaired skin integrity was not resolved even after the wound was documented as healed. Additionally, the care plans for Residents #47, #51, and #328 included medications that were no longer prescribed, indicating a lack of timely updates to reflect current medication regimens. Interviews with facility staff revealed systemic issues in care plan management. Registered Nurse #1 expressed difficulty in managing care plans due to workload, and the Director of Nursing acknowledged the oversight in updating care plans. The Regional Director of Nursing emphasized the expectation for care plans to accurately reflect residents' needs, including falls, wounds, behaviors, medications, and new concerns. The facility's policy required care plans to be revised with any significant change in condition, which was not adhered to in these cases.
Failure to Provide Appropriate Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for five residents. Resident #6, who was newly admitted with diabetes, did not have their blood sugar checked as required by discharge paperwork until the following day, despite being insulin-dependent. The Director of Nursing acknowledged that assessments, including vital signs and finger sticks, should be completed during the shift of admission, but this was not done in a timely manner. Resident #14's care was inadequate as their bed clothes were not changed effectively, and the mattress was found covered with dead skin. This indicates a failure to adhere to the resident's comprehensive care plan, which required supervision and assistance for personal care and maintaining skin integrity. Similarly, Resident #20 did not receive proper foot care, resulting in elongated toenails and blisters. The resident had informed staff about their condition, but there was no documented evidence of a care plan addressing foot care. For Residents #23 and #77, the facility failed to monitor vital signs as ordered, and there was a lack of documentation regarding the residents' conditions. Resident #23 had orders for daily vital signs and monitoring for changes in condition, but there were repeated instances of missing or duplicated vital sign entries without notifying the medical provider. Resident #77 also had orders for daily vital signs, but there were multiple occasions where vital signs were not documented, and the medical provider was not informed. These deficiencies highlight a systemic issue in the facility's ability to monitor and document resident conditions effectively.
Deficiencies in Physician Review and Medication Management
Penalty
Summary
The facility failed to ensure that the physician reviewed the residents' total program of care, including medications and treatments, at each visit for two residents. For one resident, a topical medication was prescribed without clear instructions on where it should be applied or the duration of use. The resident, who was a registered nurse, applied the medication incorrectly to their face instead of under the breast as intended, due to a lack of clear instructions and a formal assessment for self-administration. The physician was unaware of the fungal infection under the breast and had prescribed the medication for a facial rash. Another resident with chronic kidney disease and other conditions had a high potassium level reported, which was not evaluated by a provider in a timely manner. The laboratory results indicating the high potassium level were accessible to the provider, but there was no documentation that the provider was notified of the critical results. The high potassium level was not addressed until several days later, despite the provider being in the facility and having access to the results. Interviews with staff revealed a lack of clarity regarding the responsibility for monitoring and acting on laboratory results. Registered nurses believed that providers should monitor test results themselves, while the facility's administration indicated that nurses should notify providers of critical results. This lack of communication and responsibility led to delays in addressing the residents' medical needs, contributing to the deficiencies noted in the survey.
Medication Errors and Quality of Care Deficiencies
Penalty
Summary
The facility's governing body failed to ensure that residents received appropriate quality of care, as evidenced by significant medication errors and compromised resident care. The facility was cited for deficiencies under F760 and F684, indicating that established policies regarding the management and operation of the facility were not implemented effectively. This resulted in multiple residents not receiving their prescribed medications, which placed them at risk for serious harm. Several residents experienced medication errors, including a resident who did not receive prescribed psychiatric medication for 12 days, leading to decompensation and hospitalization. Other residents received only partial doses of their prescribed antibiotics, and one resident did not receive medication to lower potassium levels until four days after it was prescribed. Additionally, there were failures in monitoring vital signs and providing personal care assistance, further compromising resident care. Interviews with facility staff revealed a lack of communication and documentation regarding medication availability and administration. The Director of Nursing and the Administrator were unaware of the extent of the medication issues until the survey, indicating a breakdown in the facility's quality assurance processes. The Medical Director acknowledged communication breakdowns and was only notified of significant problems, highlighting systemic issues in the facility's operations.
Inaccurate and Incomplete Medical Records in LTC Facility
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards, as evidenced by incomplete and inaccurate documentation across three units. Narcotic count record books for Units A, B, and C were found to have numerous missing signatures from both on-coming and off-going nurses, indicating a lack of proper documentation during narcotic counts. Interviews with nursing staff revealed that some nurses were signing the narcotic count book days after their shifts, contrary to the facility's policy that requires signatures at the time of the count. Resident #23's medical records showed repeated and missing vital signs, suggesting inaccuracies in documentation. The Treatment Administration Record for January, February, and March 2025 documented identical vital signs on multiple days, which is highly unusual and was acknowledged as such by the nursing staff and a nurse practitioner. Additionally, there were several days with no vital signs recorded at all, further indicating incomplete documentation. For Resident #53, wound care documentation was found to be inaccurate. Despite a wound assessment note indicating that a wound on the left buttocks was healed, the March 2025 Treatment Administration Record documented that dressing was completed. Interviews with the resident and nursing staff confirmed that there were no open areas requiring a dressing, highlighting discrepancies in the documentation of care provided. The Regional Clinical Director emphasized that staff should not document care that was not provided, underscoring the importance of accurate medical records.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed for three residents with indwelling medical devices, as observed during a recertification survey. Specifically, Residents #110, #115, and #231 did not have enhanced barrier precautions implemented, which are necessary to prevent the spread of multi-drug resistant organisms. Resident #110, who had a hemodialysis catheter, did not have signage or setup for enhanced barrier precautions in their room, and there was no documented physician's order for such precautions. Similarly, Resident #115, with an indwelling urinary catheter and a wound on the right lateral ankle, and Resident #231, with a gastrostomy tube, also lacked signage, setup, and documented orders for enhanced barrier precautions. Interviews with facility staff revealed inconsistencies in understanding and implementing enhanced barrier precautions. Registered Nurse #2 incorrectly stated that indwelling medical devices like urinary catheters and gastrostomy tubes did not require enhanced barrier precautions, while Licensed Practical Nurse #7 and Registered Nurse #1 indicated that such precautions should be initiated for residents with wounds or external medical devices. The Regional Clinical Director also expected residents with indwelling medical devices and wounds to be placed on enhanced barrier precautions, highlighting a discrepancy between policy expectations and actual practice.
Failure to Ensure Timely Availability and Administration of Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring the timely availability and administration of prescribed medications. For one resident with schizophrenia, chronic obstructive pulmonary disease, and type 2 diabetes, there was a physician's order for Clozapine to begin on a specific date. However, the medication was not available for administration on multiple days, with documentation indicating delays in pharmacy delivery and the medication not being dispensed until nearly two weeks after the initial order. The Medication Administration Record and pharmacy reports confirmed missed doses and late delivery, with staff documenting the issue but not ensuring the medication was on hand as ordered. Another resident with chronic kidney disease, cerebral infarction, and chronic obstructive pulmonary disease had a high potassium level identified by laboratory testing. The provider ordered Lokelma to address the hyperkalemia, but the medication was not available in the facility for several days after the order. Nursing notes indicated the pharmacy could not deliver the medication until the following afternoon, and there was no documentation that the provider was notified of the ongoing unavailability or that the medication was administered on the days following the order. The Medication Administration Record and nursing notes lacked evidence of timely administration or provider notification regarding the missed doses. Interviews with facility staff, including the DON and Administrator, revealed awareness of ongoing issues with pharmacy deliveries, particularly with an out-of-state pharmacy, and a lack of consistent documentation and reporting of missed medications. Staff described expected procedures for handling unavailable medications, but there was no evidence these procedures were consistently followed in the cases reviewed. The deficiency was identified through record review and staff interviews during the recertification and abbreviated survey.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Resident #23, who was cognitively intact and had a history of chronic obstructive pulmonary disease, congestive heart failure, and type 2 diabetes, was observed with a topical steroid cream in their room without an assessment or physician order for self-administration. The facility's policy required an evaluation of the resident's mental and physical abilities to self-administer medications, which was not conducted for Resident #23. During an observation, Resident #23, a former registered nurse, was found using antifungal powder and a tube of cream for a rash under their breast and on their face. The resident stated that the nurse left the cream for them to apply themselves, although the prescription label indicated it was to be applied under the breast. The resident misunderstood the label and applied the cream to their face, unaware it was intended for the breast. The physician's progress note indicated the cream was prescribed for a rash on the face, but the resident was not formally assessed for self-administration. Interviews with the physician and facility staff revealed discrepancies in the instructions for the cream's application. The physician stated the cream was intended for the nurse to apply, not the resident, and was unaware of the prescription instructions to apply it under the breast. The facility's Registered Nurse Regional Clinical Director confirmed that a self-administration form should have been completed, and a physician's order was necessary to leave medications at the bedside. The lack of assessment and clear instructions led to the resident self-administering the medication incorrectly.
Residents Unaware of Grievance Process and Forms Unavailable
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, as evidenced by the lack of readily available grievance forms and the absence of an option to file grievances anonymously. During a Resident Council meeting, all 12 residents present reported they were unaware of the process to file a grievance and did not know who the Grievance Officer was. Some residents expressed fear of retaliation if they made a complaint. The facility's policy, dated November 2016, stated that grievances could be made orally or in writing without fear of retaliation, and a designated Grievance Officer was responsible for investigating grievances. Interviews with staff revealed a lack of awareness and availability of grievance forms. The Activity's Director was unaware of the existence of grievance forms, while the Director of Social Work, who served as the Grievance Officer, had forms in their office but was unsure if they were available on the units. The Director of Social Work also reported an open-door policy for informal complaints but was uncertain about the possibility of filing grievances anonymously. The Regional Clinical Director of Nursing acknowledged the process for addressing complaints, involving the Social Worker, Administrator, and Director of Nursing, but corrective actions were only taken after the survey raised concerns.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged violation involving abuse within the required timeframe. Specifically, an incident occurred where a resident reported that another resident entered their room, knocked off their hat, and tapped them on the cheek. This incident was documented in an Incident Report, but the facility did not report it to the New York State Department of Health as required by regulations. The facility's policy mandates that all reports of resident abuse, neglect, exploitation, and other related incidents be promptly reported to the appropriate authorities. The residents involved had distinct medical conditions. One resident was admitted with Alzheimer's disease and was severely cognitively impaired, while the other had alcoholic cirrhosis of the liver, acute kidney failure, and hypotension, but was cognitively intact. The facility's investigation concluded that the incident was playful and not malicious, leading to the decision not to report it. However, this decision was contrary to the facility's policy and state regulations, which require immediate reporting of such incidents, regardless of intent.
Failure to Notify Ombudsman and Representatives of Resident Transfers
Penalty
Summary
The facility failed to ensure proper written notification of transfer or discharge was sent to the resident, the resident's representative, and the Office of State Long-Term Care Ombudsman for two residents reviewed for hospitalization. For Resident #112, the facility did not provide written notification to the Ombudsman for three out of four hospital admissions. The resident, who was cognitively intact, was transferred to the hospital on multiple occasions for reasons including missed dialysis, pain control, unresponsiveness, and critical lab values. Interviews with facility staff revealed that the required notifications were not documented as sent to the Ombudsman. For Resident #123, the facility did not provide written notification of the transfer to the hospital to the resident, the resident's representative, or the Ombudsman. The resident, who had mild cognitive impairments and required substantial assistance with daily activities, was sent to the hospital after a fall. The Director of Social Work admitted that discharge notifications were not sent for hospital transfers, and the Administrator acknowledged the oversight. The facility's policy required such notifications, but they were not followed in these instances.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives upon transfer to a hospital, as required by their policy. This deficiency was identified during a recertification survey for two residents who were hospitalized. Resident #112, who was cognitively intact and had multiple health conditions including metabolic encephalopathy, type 2 diabetes, and end-stage renal disease, was transferred to the hospital on several occasions for various medical reasons. However, there was no documented evidence that the bed hold policy was communicated in writing to the resident or their representative during these transfers. Similarly, Resident #123, who had acute kidney failure, absolute glaucoma, and type 2 diabetes, was transferred to the hospital following a fall. The facility's social work and nursing staff acknowledged that the bed hold policy should have been provided at the time of transfer, but there was no documentation to support that this occurred. Interviews with facility staff, including the social worker and the administrator, confirmed that the bed hold policy was not reviewed or documented as having been provided to the residents or their representatives, indicating a lapse in following the facility's established procedures.
Failure to Conduct Proper PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident was properly screened for a mental disorder or intellectual disability prior to admission, as required by the Preadmission Screening and Resident Review (PASARR) process. Specifically, the PASARR form for a resident with a diagnosis of schizophrenia incorrectly documented that the resident did not have a serious mental illness, and a Level II referral was not made. The facility's policy required the admissions coordinator to obtain and review the PASARR for all new residents and to ensure a Level II screen was completed when necessary. However, this process was not followed for the resident in question. The resident, who was admitted with diagnoses of schizophrenia, generalized anxiety disorder, and major depression disorder, was later hospitalized for bacterial pneumonia and transitioned to a psychiatric unit due to suicidal ideation. Despite the resident's history of schizophrenia and multiple inpatient hospitalizations, there was no documented evidence of a Level II referral. The Director of Social Work, who was not screen certified, stated that they would check the resident's diagnoses for the need for a Level II referral and would contact the Regional Admissions Coordinator if a screen was found to be inaccurate. This oversight in the screening process led to the deficiency identified during the recertification survey.
Failure to Follow Wound Care Orders for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. Specifically, the wound care treatment ordered by the provider for a resident with a pressure ulcer on the left heel was not followed. The treatment administration record did not document the wound care provider's treatment orders as prescribed, and there were inconsistencies in the administration of the treatment. The ordered foam dressing was not included in the treatment administration record, and there were days when the treatment was not administered as required. The resident, who was admitted with diagnoses including urinary tract infection, acute kidney failure, and age-related physical disability, had a stage 3 pressure ulcer on the left heel. The wound care provider's orders specified cleansing the wound and applying specific dressings on designated days, but these instructions were not consistently documented or followed. Additionally, a care plan to address the pressure ulcer was not developed and implemented until several weeks after the wound was first assessed, delaying necessary interventions to promote healing and prevent infection. Interviews with facility staff revealed a lack of adherence to the prescribed wound care regimen. Licensed Practical Nurse #8 acknowledged that wound care should be performed according to physician orders and noted that blanks on the treatment record indicated missed treatments. The Registered Nurse Regional Clinical Director stated that if a nurse could not complete a treatment during their shift, they should notify the provider and ensure a handoff to the next shift. These lapses in following treatment orders and developing a timely care plan contributed to the deficiency in care for the resident's pressure ulcer.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with professional standards for three residents. For two residents, the facility did not ensure proper documentation and maintenance of nebulizer equipment. Specifically, Resident #23's nebulizer was found unplugged with undated tubing, and there was no record of nebulizer maintenance in the Treatment Administration Record. Similarly, Resident #231's nebulizer tubing was not dated, and there was no documentation of maintenance, despite the resident receiving nebulizer treatments. Additionally, the facility did not adhere to physician orders for oxygen administration for Resident #51. The resident's oxygen concentrator was observed set at 4 liters per minute, but during another observation, the portable oxygen flow rate was set at 2 liters per minute, contrary to the physician's order of 4 liters per minute to maintain oxygen saturation above 88%. This discrepancy indicates a failure to follow the prescribed oxygen administration protocol. Interviews with staff revealed a lack of consistent procedures for nebulizer maintenance and oxygen administration. Licensed Practical Nurse #5 admitted to inadequate labeling and maintenance of nebulizer tubing, while the Regional Director of Nursing acknowledged that licensed staff were responsible for ensuring proper respiratory care but did not consistently document or follow through with the necessary procedures. These lapses contributed to the deficiencies observed during the survey.
Deficiencies in Dialysis Care Documentation and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents, Resident #11 and Resident #110, as identified during a recertification and abbreviated survey. For Resident #11, the facility did not ensure ongoing communication and collaboration with the dialysis facility, nor did it conduct ongoing assessments in January and February 2025. The care plan for Resident #11 lacked interventions for assessing and monitoring the resident before and after dialysis. Additionally, multiple instances were noted where the dialysis treatment communication forms were incomplete, missing vital signs, and lacked signatures from the nursing staff. Resident #110 also experienced deficiencies in dialysis care. The facility did not consistently complete, review, and log dialysis communication sheets between February 18, 2025, and February 26, 2025. Observations revealed that Resident #110's dialysis binder contained only an incomplete sheet dated February 18, 2025, and the sheets for subsequent dates were missing. Interviews with the resident and staff indicated that the dialysis book had been lost, and there were no progress notes documenting the resident's condition before or after dialysis on specific dates. Interviews with nursing staff and the Regional Registered Nurse Clinical Director highlighted expectations for completing dialysis communication sheets and maintaining communication with the dialysis center. However, these expectations were not met, as evidenced by the incomplete documentation and lack of communication logs. The facility's administrator acknowledged that issues regarding dialysis documentation were not previously discussed in Quality Assurance meetings, and these deficiencies were identified through the survey process.
Inadequate Staff Training and Competency in LTC Facility
Penalty
Summary
The facility failed to ensure that licensed nurses and Certified Nurse Aides (CNAs) possessed the necessary competencies and skills to meet the needs of residents, as evidenced by incomplete education records and insufficient training. Specifically, the education records for CNAs #3 and #4, Licensed Practical Nurses (LPNs) #11 and #12, and Registered Nurse (RN) #4 were found to be incomplete. Additionally, RN #2 lacked the knowledge required to perform assigned tasks, as they were not proficient in updating care plans and were unaware of proper handwashing protocols. The facility's assessment outlined specific training and competency requirements for staff, including mandatory annual training and orientation topics such as infection control, resident rights, and person-centered care. However, the records showed that these requirements were not consistently met. For instance, CNA #3's file lacked evidence of annual education after a year of employment, and CNA #4's orientation checklist and competency evaluations were unsigned. Similarly, LPNs #11 and #12 did not have documentation of annual education, and RN #4's file was missing signatures and evidence of completed education. Interviews with staff revealed further issues with the facility's training program. RN #2 reported that the orientation was insufficient and that staff turnover was high, leading to a workforce of mostly new and inadequately trained individuals. LPN #13, the facility educator, acknowledged gaps in orientation paperwork and stated that competencies were reviewed annually, with additional training provided as needed. The Regional Director of Nursing and the facility Administrator were both new to their positions and expressed intentions to improve training processes, but were not fully aware of the existing deficiencies.
Medication Error Rate Exceeds 5% During Survey
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.87% during a recertification survey. This deficiency was identified through observations and interviews involving two residents. Resident #47, who has a history of metabolic encephalopathy, type 2 diabetes, and breast cancer, was involved in a medication error when an LPN attempted to administer an incorrect dosage of Tylenol. The LPN acknowledged the error, attributing it to distractions at the medication cart. Resident #67, with diagnoses including diabetes, stroke, and hyperlipidemia, was also involved in a medication error. The LPN administered Tylenol Extra Strength without a specified milligram dosage on the order and crushed the medication without a documented order to do so. The LPN admitted to knowing the correct dosage but noted that several orders were unclear and required clarification. The facility's administrator acknowledged the lack of documentation for missing medications and the absence of specific reports on medication issues.
Medication Storage and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards of practice, as observed during a recertification survey. On Unit A cart 2, multiple stock medications were not dated, and two bottles of resident-specific eye drops lacked opening dates. Additionally, a bottle of insulin was found without a label indicating resident ownership or the date it was opened, and a bottle of Valproic Liquid was not stored in a biohazard bag as required. On Unit B cart 2, a stock medication was not dated, and on Unit C cart 1, an insulin pen for a resident was misplaced and should have been in a different cart. The survey also revealed inconsistencies in the narcotic count logbooks across multiple units. Five out of six narcotic logbooks lacked consistent signatures from two licensed nurses, as required by law, to document a two-person narcotic count between shifts. Specific instances of missing signatures were noted on various dates for Units A, B, and C, indicating a failure to adhere to proper procedures for narcotic counts. Interviews with nursing staff revealed a lack of awareness and adherence to medication labeling and storage policies. Registered Nurse #2 and Licensed Practical Nurse #9 were unable to explain why medications were not labeled with dates or why narcotic sheets were not consistently signed. The Regional Director of Nursing confirmed that stock medications and insulin should be dated when opened, and narcotic counts should be conducted with two licensed nurses signing the log sheet. The Administrator acknowledged that these issues were not previously addressed in Quality Assurance meetings and were only identified through the survey process.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a therapeutic diet as prescribed by a physician for a resident with a history of cerebral infarction, dysphagia, and malnutrition. During a lunch observation, the resident was served whole portions of chicken parmesan instead of the prescribed ground meat. The resident's meal ticket indicated a regular, chopped diet with ground meats, but the meal did not comply with these specifications. The resident, who was significantly cognitively compromised, was observed attempting to cut the meat with a fork, and their roommate noted that meals usually consisted of pureed foods. Interviews with facility staff revealed a lack of adherence to dietary orders. The Director of Food Service acknowledged the error, stating that the meat should have been ground as per the speech therapy's determination. The responsibility for ensuring meal accuracy was attributed to the staff member who delivered the tray. Additionally, the Regional Director of Nursing indicated that nurses and Certified Nurse Aides should have verified the trays before serving them to residents, highlighting a lapse in the facility's protocol for meal distribution.
Food Safety Protocols Not Followed
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the main kitchen, pureed vegetables stored in the walk-in refrigerator were found to be at 52 degrees Fahrenheit, despite being prepared the previous day. This indicates improper cooling practices, as the facility's training documentation required foods to be cooled to 41 degrees Fahrenheit within six hours. Additionally, the automatic dishwashing machine was not functioning correctly, with a final rinse temperature of 150 degrees Fahrenheit, below the required 180 degrees Fahrenheit, and the water pressure gauge was not operational. Further deficiencies were noted in the facility's lack of a test kit for checking the concentration of the sanitizing solution used for food contact equipment, which should be between 150 and 400 parts per million. Moreover, two out of four food temperature thermometers were found to be out of calibration, reading 27 and 25 degrees Fahrenheit in a standard ice-bath test. There was no documented evidence that dietary staff had been trained on how to adjust or calibrate these thermometers. These deficiencies were identified during a recertification survey, highlighting significant lapses in food safety protocols.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a recertification survey. Specifically, the lid of the garbage dumpster was found propped open with a broom handle, allowing kitchen and housekeeping waste to be exposed. This condition was noted during an observation, and it was confirmed through an interview with an administrator who acknowledged that the dumpster should be kept closed.
Failure to Provide Timely Laboratory Services as Ordered
Penalty
Summary
The facility failed to provide timely laboratory services as ordered for a resident with chronic kidney disease, cerebral infarction, and chronic obstructive pulmonary disease. The provider initially ordered laboratory tests, including a complete blood count, procalcitonin, and B-type natriuretic peptide, to be completed on a specified date. However, these tests were not completed as ordered, and there was no documentation that the provider was notified of the missed tests. The provider subsequently reordered the same laboratory tests on two additional occasions, but the tests were again not completed in a timely manner, and the provider was not informed of the delays. Documentation shows that the laboratory orders were entered and signed by the providers and confirmed by nursing staff, but there were repeated failures in ensuring the laboratory draws were performed as scheduled. The laboratory results were not available in the resident's chart for the dates ordered, and there was no evidence in the nursing notes that the provider was notified about the uncompleted tests. It was only after the third order that the laboratory specimens were collected and resulted several days later. Interviews with facility staff revealed that there were known issues with laboratory orders not being completed on the day they were ordered, and that communication lapses occurred regarding unsigned or unconfirmed orders. Staff also indicated that routine labs were only drawn on certain days unless marked as stat, which may have contributed to the delays. The deficiency was identified through record review and staff interviews, confirming that the facility did not ensure timely laboratory services to meet the needs of the resident.
Failure to Promptly Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering nurse practitioner or on-call provider of abnormal laboratory results for one resident. Specifically, a resident with chronic kidney disease, cerebral infarction, and chronic obstructive pulmonary disease had a basic metabolic profile collected, which revealed several critical or abnormal values, including a high potassium level. There was no documented evidence in the nursing notes that the provider was notified of these abnormal results when they were reported. Interviews with staff revealed confusion regarding responsibility for monitoring and communicating laboratory results, with some staff believing it was the provider's responsibility to check the results directly in the electronic medical record, while others stated that nurses should notify the provider. The resident's medical record showed that abnormal laboratory results, including a high potassium level, were present on multiple occasions, but there was no documentation of provider notification or new orders addressing these findings. Interviews with the nurse practitioner and other staff indicated ongoing issues with laboratory orders not being completed as requested and a lack of clarity about who was responsible for following up on abnormal results. The deficiency was identified through record review and staff interviews, which confirmed the lack of timely provider notification for abnormal laboratory findings.
Failure to Timely Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility did not ensure timely notification to the Office of the State Long-Term Care Ombudsman regarding the discharge of a resident. Specifically, Resident #52, who was admitted with diagnoses of diabetes mellitus type 2, depression, and bladder cancer, received a 30-day discharge termination notice on 11/7/2023. However, the Ombudsman was not notified until 12/4/2023, which is a delay of nearly a month. The facility's policy, dated 3/2018, mandates that the Ombudsman should be notified at the time of the discharge notice, but this was not adhered to in this case. During an interview, the Director of Social Work acknowledged that it was the Social Work Department's responsibility to send out discharge notification letters and admitted that the delay in notifying the Ombudsman was an oversight. The Director also confirmed that the facility had a policy in place for same-day notification, which was not followed in this instance. This deficiency was identified during a record review of facility-initiated discharges from 9/1/2023 to 1/30/2024, where it was found that only one 30-day notice of discharge was issued, and it was not properly communicated to the Ombudsman in a timely manner.
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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