The Grand Rehabilitation And Nursing At Barnwell
Inspection history, citations, penalties and survey trends for this long-term care facility in Valatie, New York.
- Location
- 3230 Church Street, Valatie, New York 12184
- CMS Provider Number
- 335565
- Inspections on file
- 40
- Latest survey
- June 20, 2025
- Citations (last 12 mo.)
- 53
Citation history
Health deficiencies cited at The Grand Rehabilitation And Nursing At Barnwell during CMS and state inspections, most recent first.
The facility failed to ensure that narcotics were consistently counted by two licensed staff members at shift changes, resulting in missing Oxycontin tablets for a resident with chronic pain. Documentation on controlled medication records and medication administration records was inconsistent, and narcotic count signature sheets across multiple units lacked required signatures from both oncoming and outgoing nurses. Staff interviews confirmed that required procedures for narcotic counts were not followed, leading to unaccounted controlled substances and incomplete records.
Surveyors found that multiple residents experienced significant medication errors involving controlled substances, including inconsistent documentation between the controlled medication record and eMAR, administration of medications at incorrect times or without proper physician orders, and failures to follow required procedures for witnessing and documenting wastage. These errors involved medications such as Clonazepam, Tramadol, Alprazolam, and Oxycodone, and were confirmed through record review and staff interviews.
Surveyors found widespread housekeeping and maintenance failures, including sticky and soiled floors, trash in corridors, soiled and stained linens, cluttered resident rooms, damaged fixtures, and evidence of mold. A resident reported that their bed linens were not changed for a week, and soiled items were left in their room, contributing to unsanitary and uncomfortable conditions.
Multiple residents and staff reported that inadequate staffing levels led to long wait times for call bells to be answered, delays in receiving care, and missed showers or baths. Staff described frequent short-staffing, increased workloads, and the need to assist with tasks outside their usual roles, while the DON acknowledged ongoing staffing challenges. These issues resulted in residents not consistently receiving timely care and attention.
Nursing staff lacked documented annual education and competencies to care for residents with mental and behavioral health needs, despite a significant population with psychiatric and mood disorders. Staff interviews confirmed the absence of training and challenges in managing residents with difficult behaviors, and the facility's process for staff education on these needs was not implemented.
Surveyors found that multiple residents consistently received meals that were cold, unappetizing, and sometimes undercooked or overcooked. Food temperatures were frequently outside required ranges, and both residents and staff reported ongoing issues with tray delivery delays, lack of insulated carts, and poor food quality. Despite repeated complaints and awareness among staff and management, no effective measures had been taken to ensure meals were served at safe and appetizing temperatures.
Multiple incidents of resident-to-resident physical abuse occurred, involving residents with cognitive and behavioral health diagnoses. Aggressive behaviors, such as entering others' rooms, physical altercations, and wandering, were documented but not consistently managed with one-to-one monitoring or updated care plans. Injuries resulted from these altercations, and staff interviews revealed challenges in supervision and care planning due to staffing limitations and incomplete behavioral histories at admission.
Several residents did not have comprehensive, person-centered care plans developed or updated to address their medical, nursing, and psychosocial needs, including missing or incomplete interventions for elopement risk, new wounds, infection management, pressure ulcers, BiPAP therapy, major depressive disorder, and psychosocial adjustment. These deficiencies were identified through record review and staff interviews, revealing a lack of timely and accurate care planning for residents with significant needs.
Surveyors found that several residents did not have their oxygen tubing labeled or dated as required, and some did not receive oxygen as ordered by their physician. Additionally, BiPAP equipment for two residents was not properly cleaned or maintained, and refusals of BiPAP therapy were not consistently documented or reported. Staff interviews confirmed that these actions did not follow facility policy or professional standards.
Surveyors found that medications scheduled for administration at a specific time were given late to three residents, with one medication not available at the scheduled time. An LPN reported being unable to administer all medications on time due to working alone, and management was aware of the staffing issue. This resulted in a medication error rate significantly above the regulatory limit.
Surveyors observed that the facility's exterior areas were not properly maintained, with crumbling retaining walls, overgrown vegetation, a damaged wooden fence, deteriorating brickwork, water-stained stucco, and littered grounds. These deficiencies resulted in an environment that was not safe, functional, sanitary, or comfortable for residents, staff, and the public.
Surveyors found that several residents were not treated with dignity or respect, as evidenced by reports of rude and unresponsive aides, insufficient staff to assist with transfers and bathing, and a resident being left uncleaned and transported through public areas in a soiled state. Staff interviews confirmed low staffing levels and lack of attention to residents' needs, resulting in compromised quality of life and failure to uphold residents' rights.
A resident alleged inappropriate touching by a physical therapist during a therapy session, which was reported internally but not to the State Survey Agency within the required two-hour window. Facility staff determined the allegation was unfounded and did not report it externally, contrary to regulatory requirements for immediate reporting of all abuse allegations.
A resident with Parkinson's Disease and mild cognitive impairment reported being physically abused by a nurse, but the facility failed to conduct a thorough investigation as required by policy. The investigation lacked interviews with the resident, staff, or witnesses, did not establish a clear timeline, and was closed based only on staffing records and an administrator's statement. Key staff were unaware of the incident, and the resident's care plan was not updated.
A resident with multiple chronic conditions who required a two-person mechanical lift was not consistently assisted out of bed or offered showers, receiving only infrequent bed baths. Staff and the resident reported that insufficient CNA staffing prevented regular transfers and bathing, and the resident's preferred chair was unavailable. The care plan interventions to maintain ADL function were not consistently followed, resulting in unmet care needs.
Surveyors found that three residents were not adequately protected from accident hazards or provided with sufficient supervision. One resident's room door was repeatedly stuck, two residents with cognitive and behavioral impairments eloped from the facility on multiple occasions without proper interventions or care plan updates, and another resident exited the building unnoticed despite being on safety checks, resulting in injury. Staff did not consistently follow facility policies or respond to alarms, and documentation and investigation of these incidents were lacking.
A resident with chronic pain conditions did not receive their scheduled Oxycodone dose on time due to a lack of timely communication between an LPN and an RN Supervisor. The resident, who was in significant pain, informed the LPN about the medication shortage, but the issue was not addressed promptly. The RN Supervisor later obtained the medication from the emergency kit after pharmacy authorization, resulting in a delay of over three hours.
A resident at high risk for falls experienced multiple falls, including one resulting in a cervical fracture, due to the facility's failure to implement and document necessary interventions. Despite being identified as high risk, the resident's care plan was not updated with preventive measures after each fall, as confirmed by interviews with nursing staff.
The facility failed to maintain resident dignity by serving meals with disposable utensils, affecting several residents with cognitive impairments and medical conditions. Staff interviews revealed a lack of awareness and coordination regarding the use of plastic utensils, with the Director of Food Service citing a shortage of real utensils and the DON unaware of the issue.
The facility failed to develop comprehensive care plans for three residents, including one with oxygen therapy needs, another with PTSD, and a third with depression. Despite documented medical conditions, the facility did not implement person-centered care plans, as confirmed by staff interviews and record reviews.
The facility failed to update comprehensive care plans for three residents, leading to unaddressed fall risks, lack of resident involvement in care planning, and outdated interventions for a discontinued feeding tube. Despite multiple falls and a serious injury, a resident's care plan was not revised. Another resident was not included in care planning, and a third resident's care plan was not updated after enteral feeding was stopped.
The facility failed to ensure proper documentation and reconciliation of controlled substances on two units. Staff did not consistently sign shift-to-shift forms for narcotic counts, and LPNs did not sign out medications when removed or immediately after administration. Discrepancies in medication counts were observed, including a mismatch in Lacosamide tablet counts and an unaccounted Fentanyl patch. The DON confirmed expectations for documentation and monitoring, despite annual competencies.
The facility failed to ensure proper labeling and storage of medications, with issues such as unlabeled open medications, unsecured controlled substances, and pre-poured medications found across multiple floors. LPNs were unaware of guidelines for expiration dates, and the DON confirmed that staff should adhere to policies for medication administration.
The facility failed to provide palatable and appropriately tempered meals to residents, with observations revealing cold and unappealing food served with plastic cutlery due to a shortage of real utensils. Residents expressed dissatisfaction, and staff interviews highlighted issues with meal delivery delays and lack of awareness about cutlery use.
The facility failed to cool ground chicken safely in the main kitchen, with the chicken found at 52°F instead of the required 41°F within the specified time. Additionally, the Unit #1 kitchenette was unclean, indicating non-compliance with food safety standards.
The facility did not ensure proper labeling of food brought in by family or visitors for residents, as well as personal food, in the kitchenette refrigerators on three resident units. Items such as deli sandwiches, lactose-free milk, and orange tonic were not labeled with the resident's name, room number, and date, despite a posted policy requiring such labeling.
A resident was found with medication at their bedside without an assessment to determine their ability to self-administer safely. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which was not conducted. An LPN admitted to leaving the medication unattended, and the DON confirmed no residents were cleared for self-administration.
A resident with a PEG tube did not receive appropriate care after tube feedings were discontinued. Despite staff awareness that the tube should be flushed and skin care provided daily, there were no orders or care plans in place for maintenance. Interviews with staff, including an LPN, RN, and DON, confirmed the lack of orders and care plans for the resident's PEG tube.
A resident with severe malnutrition and other conditions did not receive total parenteral nutrition (TPN) as ordered by their physician. The TPN was not started on time and was not taken down as scheduled, leading to a deficiency finding. Staff interviews revealed inconsistencies in documentation and recollection of events, and the resident was eventually sent to the hospital due to a decline in condition.
The facility failed to provide appropriate respiratory care for two residents. One resident, with chronic conditions, was not provided continuous oxygen therapy as ordered, and their care plan lacked documentation for oxygen and BiPAP use. Another resident received oxygen without a physician's order for several days, contrary to facility policy. Staff interviews revealed communication and documentation issues regarding oxygen therapy orders.
A resident with chronic conditions requiring dialysis did not receive consistent monitoring and documentation of their dialysis treatments. The facility failed to complete the required dialysis communications log, missing vital signs and other critical information. Staff interviews confirmed the expectation for complete documentation, which was not met.
A resident with a history of depression was not assessed by a Social Worker upon admission or readmission, contrary to facility policy. The resident, on antidepressant medication, lacked a person-centered care plan for their depression until expressing suicidal ideation, leading to an emergency room transfer. Staff interviews confirmed the absence of a required social service assessment.
Two residents with severe cognitive impairments were left unsupervised, leading to inappropriate sexual behavior. A CNA observed them together but left the room without redirecting one resident. Previous similar behavior was reported but not addressed. Staff lacked training and documentation was insufficient, resulting in immediate jeopardy and substandard care.
A facility failed to ensure residents were treated with respect and dignity, as evidenced by a CNA's verbal abuse towards a resident with severe cognitive impairment. Multiple witnesses reported the aide's inappropriate behavior, including yelling and cursing. Additionally, another resident felt scared after overhearing a loud altercation between the same CNA and an LPN. The facility's investigation revealed a history of similar issues with the aide, contributing to the deficiency.
A resident with cognitive impairment was verbally abused by a CNA, and the incident was not reported to the administrator or state authorities within the required two-hour timeframe. The abuse was overheard by another resident and reported four days later, leading to a deficiency citation for the facility.
Failure to Maintain Accurate Narcotic Counts and Documentation
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt, disposition, and reconciliation of controlled drugs, specifically narcotics, as required by policy and regulation. On one unit, narcotics were not counted by two licensed staff members at the end of a shift, resulting in the discovery that twenty Oxycontin extended-release 10 mg tablets prescribed for a resident were missing. Documentation revealed that the required dual-nurse narcotic count was not performed, and the controlled medication record did not align with the medication administration record, indicating inconsistencies in documentation and administration practices. The resident involved had diagnoses including fibromyalgia, chronic pain syndrome, and anxiety disorder, and was cognitively intact according to the Minimum Data Set. The resident's medication order for Oxycontin was not properly accounted for, with the last documented administration showing 20 pills remaining, but the next shift discovering the entire blister pack missing. Interviews with nursing staff revealed that narcotic counts were either not performed together as required or were not performed at all, with some staff admitting to taking each other's word rather than conducting the count in person. Signature sheets for narcotic counts across multiple units were inconsistently completed, with missing signatures from both oncoming and outgoing nurses on several shifts. Further review and interviews indicated that this was not an isolated incident, as narcotic count signature sheets on all six nursing units showed similar deficiencies in documentation. Some staff reported receiving education on proper narcotic handling and documentation, while others did not recall such training. Despite the facility's policy requiring dual-nurse counts and immediate reporting of discrepancies, these procedures were not consistently followed, leading to unaccounted controlled substances and incomplete records.
Significant Medication Errors in Controlled Substance Administration and Documentation
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically regarding the administration and documentation of controlled substances for seven residents. The facility's own Controlled Substance/Narcotic Management Protocol required accurate prescribing, administration, storage, destruction, and documentation of all controlled substances, including dual documentation in both the controlled substance logbook and the electronic medication administration record (eMAR). However, multiple instances were found where the documentation on the controlled medication record was inconsistent with the eMAR, and medications were administered at incorrect times or without proper physician orders. For example, one resident with anxiety and depression received Clonazepam at the wrong time of day on several occasions, with the medication being administered in the morning instead of at bedtime as ordered. The medication was signed out on the narcotic sheet but not properly documented in the eMAR, and the nurse responsible did not have a physician order for those administrations. Another resident with schizophrenia and anxiety received Clonazepam and Tramadol with similar inconsistencies, including doses given outside the prescribed schedule, undocumented administrations, and lack of required witness signatures for wasted medications. In some cases, medications were administered when there was no active physician order, and the records between the controlled substance log and the eMAR did not match. Additional deficiencies were noted with the administration of Oxycodone for pain management, where doses were given and documented on the controlled medication record but not reflected in the eMAR, and vice versa. There were also instances where a resident was told they had received medication when they had not, according to their own account and therapy schedule. Interviews with nursing staff and administration confirmed awareness of these discrepancies, and staff described the required procedures for documentation and witnessing of controlled substance administration and wastage, which were not consistently followed in practice.
Failure to Maintain Clean and Homelike Environment Across All Resident Units
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all six resident units. Specific findings included sticky floors in multiple corridors and resident rooms, trash left in corridors, soiled bathroom toilets and floors, littered bathroom floors with used toilet paper, improperly patched wallpaper, warped baseboards, and stained privacy curtains. In one resident room, the soap dispenser was found ripped off the wall and lying on the floor. Additionally, the surface of a wall near the west stairwell was crumbling and soiled with a black mold-like substance, and a moldy odor was detected on one unit. The floors where door frames met the floor were also soiled in several units. In one resident's room, surveyors found a top bed sheet with dried blood stains, a bottom sheet with a large visible stain that was partially covered, and a soiled brief draped over the waste receptacle. The bed table and nightstand were cluttered with empty and unopened beverage bottles, and the room floor was sticky. The resident reported that the bottom sheet had not been changed all week and was covered with a folded blanket by staff. These observations and resident interviews demonstrate a lack of effective housekeeping and maintenance services, resulting in unsanitary and uncomfortable living conditions.
Insufficient Nursing Staff Resulting in Delays and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from both residents and staff regarding inadequate staffing levels. The facility assessment outlined required staffing numbers for each shift, but interviews revealed that actual staffing often fell below these levels, particularly on certain units and during specific shifts such as evenings, nights, and weekends. Residents consistently reported long wait times for call bells to be answered, delays in receiving care, and instances where staff would turn off call lights without providing the requested assistance. Some residents indicated that they were unable to get out of bed or receive full showers or baths due to the lack of available staff. Staff interviews corroborated these concerns, with certified nurse aides and nurses describing frequent short-staffing, increased workloads, and the inability to provide extra attention to residents who required it. Staff reported that, at times, only two aides were available to care for up to 40 residents on a unit, including several residents who required two-person assistance and mechanical lifts. Nursing staff also reported that short-staffing led to delays in medication administration and required them to assist with direct care tasks outside their usual responsibilities, sometimes resulting in staying late to complete their work. The Director of Nursing acknowledged ongoing staffing challenges, particularly on the most demanding units, and confirmed that staffing was reviewed daily and incentives were being used to attract additional staff. Despite these efforts, both staff and residents reported that insufficient staffing persisted, leading to delays in care and unmet needs. The deficiency was cited under 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) for failing to ensure adequate nursing staff to assure resident safety and well-being.
Lack of Staff Competency in Mental and Behavioral Health Care
Penalty
Summary
Nursing staff, including licensed nurses and Certified Nurse Aides, did not possess the necessary competencies and skills to care for residents with mental and behavioral health needs. The facility assessment documented a significant population of residents with psychiatric and mood disorders, including anxiety, bipolar disorder, depression, schizophrenia, schizoaffective disorder, borderline personality disorder, traumatic brain injury, and psychosis. Despite this, there was no documented evidence of annual educational competencies or training for staff regarding the care of residents with mental health or behavioral needs. The facility's process for assessing and addressing the needs of residents with such conditions included referral to the Nursing Educator for staff education, but this was not implemented in practice. Interviews with staff confirmed the lack of training and education on mental and behavioral health care. A Certified Nurse Aide reported insufficient staffing to monitor and provide care for residents with difficult behaviors. The Director of Social Work acknowledged the challenge of managing a large population of residents with behavioral and mental health issues, making care planning and supervision difficult. The Administrator noted the high number of residents with mental health diagnoses and the need for staff education in de-escalation and behavior management, which had not been provided. The Nurse Educator confirmed that no orientation or annual education on mental or behavioral health needs was in place.
Failure to Provide Palatable and Safe Temperature Meals
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable, attractive, and at safe and appetizing temperatures for all residents reviewed. Multiple residents and their family members reported that meals were frequently served cold, unappetizing, and sometimes appeared undercooked or overcooked. During a resident council meeting, residents described food as cold, hard, and uncooked, and noted that staff did not always reheat food when requested. There were also complaints about inconsistencies between the meal ticket and what was actually received on the tray. Direct observations and tray testing confirmed that food temperatures were often outside the required ranges, with hot foods below 135°F and cold foods above 41°F. For example, one resident's lunch tray included a beef taco at 114.1°F, vegetables at 108°F, and jello at 56.5°F, with the ice cream already liquefied. Another test tray showed beef tacos at 112.6°F and 113.5°F, peas and carrots at 103.1°F, and several cold items such as yogurt, cottage cheese, and salad dressing well above the safe cold temperature threshold. Staff interviews corroborated these findings, with several CNAs and LPNs stating that food was often cold by the time it reached residents, and that delays in tray delivery were common due to slow elevators and staffing issues. Residents with various medical conditions, including chronic obstructive pulmonary disease, congestive heart failure, diabetes, end stage renal disease, and cognitive impairments, were affected by these deficiencies. Some residents reported that they often ate cold food rather than wait for a replacement, while others relied on family members to bring in outside food. Staff and management acknowledged ongoing complaints about food temperature and quality, citing issues with open carts, lack of insulated delivery systems, and logistical challenges in distributing trays promptly. Despite awareness of these problems, no effective changes had been implemented to ensure meals were consistently served at safe and appetizing temperatures.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents of resident-to-resident physical altercations involving four residents. One resident with diagnoses including schizophrenia, traumatic brain injury, and epilepsy exhibited repeated aggressive behaviors, including entering other residents' rooms, physical altercations, and wandering. Despite documentation of these behaviors in nursing progress notes and care plans, the resident was not consistently placed on one-to-one monitoring at the time of the incidents, and interventions were not sufficiently updated to address the ongoing risk. Several specific incidents were documented: one resident was injured after being struck in the face by another resident who entered their room, resulting in lacerations that required emergency medical care. Another incident involved a resident being punched in the face while an item was taken from their walker, causing injury. Additional altercations included a resident being punched after attempting to prevent another from entering their room, and a forceful push that resulted in two residents falling to the floor. These events occurred despite existing care plans that identified behavioral symptoms and interventions such as medication management, safety checks, and environmental modifications. The facility's policies required immediate action to stop abuse and prompt reporting, as well as comprehensive care planning for residents at risk. However, there was no documented evidence of a care plan specifically addressing risk for abuse for at least one resident before or after a significant incident. Staff interviews indicated challenges in providing adequate supervision due to staffing issues and a high population of residents with behavioral health needs. The facility also faced difficulties in discharging residents to more appropriate settings, and there were gaps in communication regarding residents' behavioral histories upon admission.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulation. In multiple cases, care plans were either missing, incomplete, or not updated to reflect changes in residents' conditions. For example, one resident at high risk for elopement did not have their electronic monitoring device checks reinstated or documented after returning from a hospital stay, despite a continued high risk assessment. The care plan was not revised to address this change, and there was no evidence of ongoing monitoring as previously required. Another resident developed a new open area on the coccyx, but the care plan was not updated to document this wound or to include specific interventions for its treatment. Although staff provided wound care and interventions such as turning, positioning, and topical treatments, these actions were not reflected in the resident's care plan. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the care plan should have been updated to address the new wound, but this was not done. Additional deficiencies included a resident with an infection on intravenous antibiotics whose care plan did not include any interventions, and a resident with a stage III pressure ulcer whose care plan was delayed and incorrectly documented the ulcer as stage II. Other residents lacked care plans for significant issues such as BiPAP therapy, major depressive disorder, and adjustment to the facility following admission with complex psychosocial needs. These omissions were identified through record review and staff interviews, demonstrating a pattern of incomplete or missing care plans for residents with identified needs.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received services in accordance with professional standards of practice. Surveyors observed that for several residents receiving supplemental oxygen, the oxygen tubing was not labeled or dated to indicate when it had last been changed, despite facility policy and physician orders requiring weekly changes and labeling. This was noted repeatedly for multiple residents during different observations, and staff interviews confirmed that labeling was expected but not consistently performed. In addition, one resident did not receive supplemental oxygen as ordered by the physician, with discrepancies noted between the prescribed oxygen flow rate and the amount actually being delivered. Documentation was also incomplete, with missing records for oxygen administration on certain shifts. Staff interviews acknowledged that the delivery of oxygen must match physician orders and that documentation lapses could indicate missed care. Furthermore, the facility did not ensure that BiPAP equipment used by two residents was appropriately cleaned and maintained to prevent respiratory infections. There were no documented interventions or orders for cleaning and maintenance of the BiPAP equipment until after surveyor observations, and refusals of BiPAP therapy by a resident were not consistently documented or communicated to the physician. Staff interviews confirmed that cleaning protocols and documentation were required but not followed as per facility policy.
Medication Error Rate Exceeds Regulatory Threshold Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5%, as required by policy and regulation. During a recertification survey, observations, record reviews, and interviews revealed that three out of four residents observed during a medication pass experienced medication administration errors, resulting in an error rate of 59.26%. Specifically, medications scheduled for administration at 9:00 AM were instead given between 10:23 AM and 10:55 AM. In one instance, a prescribed medication was not available for administration at the scheduled time. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified. The residents involved had various medical conditions, including epilepsy, chronic obstructive pulmonary disease, hypertension, orthopedic aftercare, anemia, atherosclerosis, schizoaffective disorder, and chronic pain syndrome. The LPN responsible for administering the medications acknowledged being aware that the medications were late but stated that it was not possible to pass all medications on time while working alone on the unit. The LPN also indicated that management staff were aware of the need for additional help. These findings were based on direct observation and interviews conducted by surveyors.
Failure to Maintain Safe and Sanitary Facility Grounds
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed multiple deficiencies in the exterior areas, including crumbling blocks in the retaining wall on the west end of the property, an overgrown propane tank area with a wooden fence in disrepair, crumbling brickwork in the loading dock wall, black water staining on the east exterior wall stucco, and grounds along the west exterior wall that were littered and had a build-up of leaves and overgrown vegetation. These conditions were directly observed during the recertification survey and confirmed through interviews.
Failure to Ensure Resident Dignity and Adequate Assistance Due to Staff Conduct and Insufficient Staffing
Penalty
Summary
Surveyors identified deficiencies in the facility's compliance with resident rights to dignity, respect, and quality of life, as evidenced by observations, record reviews, and interviews with residents and staff. One resident, who was cognitively intact, reported that several certified nurse aides were rude, had 'sharp' tongues, and sometimes ignored requests for help. The resident also stated that after complaining about a nurse's behavior, the nurse was terminated, but other staff continued to display similar negative attitudes and lack of care. Another resident, with chronic medical conditions and requiring a two-person mechanical lift for transfers, reported that due to insufficient staffing, they were rarely able to get out of bed and had not been offered the opportunity to do so for about ten days. The resident also stated that staff no longer asked if they wanted to get out of bed and that showers or tub baths were not provided due to the lack of available staff, resulting in infrequent bed baths instead. Staff interviews confirmed that only two to three aides were available for 40 residents, and that several residents did not get out of bed as a result. A third resident, with Parkinson's disease and mild cognitive impairment, was observed in a lethargic state, drooling, and with food smeared on their face, hands, and clothing while eating in a common area. The resident was not cleaned up after eating and was subsequently transported through public areas in this condition. Staff confirmed that care instructions were available to aides, and the DON stated that all residents should be treated with dignity and respect, but the observed care did not reflect this standard.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to the appropriate authorities within the required timeframe. Specifically, a resident reported to an occupational therapist that a physical therapist had inappropriately touched them during a therapy session. The occupational therapist relayed this allegation to the Director of Physical Therapy, who then informed the Director of Nursing. The Director of Nursing conducted an internal investigation and determined the allegation was unfounded, documenting that no abuse had occurred within the two-hour reporting window. However, the facility did not report the allegation to the New York State Department of Health within two hours as required by regulation, based on their internal conclusion that the claim was false. Interviews with facility staff confirmed that the abuse allegation was not reported to the State Survey Agency because the internal investigation concluded it was unsubstantiated. The Director of Nursing stated that, since the allegation was determined to be untrue within the two-hour window, they believed reporting was unnecessary. This action was not in accordance with facility policy and state regulations, which require all alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation is made, regardless of the outcome of the initial internal investigation.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with Parkinson's Disease, major depressive disorder, and bipolar disorder, who was assessed as having mild cognitive impairment and being able to communicate effectively. The resident reported that a staff member was rough with them in September 2024, and later alleged being hit in the face three times by a registered nurse. The initial investigation was closed without interviewing the resident, staff, other residents, family, or visitors, and without establishing a clear timeline of the event. The specific date of the alleged incident was not determined, and there was no documentation in the electronic medical record regarding the allegation. The facility's policy required that all allegations of abuse or neglect be promptly reported and thoroughly investigated, including interviews with the resident, staff, witnesses, and others who may have relevant information. However, the investigation consisted only of reviewing staffing sheets and a statement from the administrator, which concluded the allegation was unsubstantiated because the accused nurse was not scheduled to work at the time. No supporting interviews or statements were obtained, and the resident's care plan was not updated to reflect the alleged incident. Interviews with facility staff revealed that key personnel, including the DON and Activities Director, were not aware of the incident, and the administrator acknowledged that the investigation was not thorough and should have been reported to the state health department. The lack of a comprehensive investigation and failure to follow facility policy resulted in the deficiency cited by surveyors.
Failure to Provide Necessary ADL Assistance Due to Staffing and Equipment Limitations
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, congestive heart failure, and morbid obesity was not provided with the necessary care and services to prevent avoidable decline in activities of daily living (ADLs). The resident required a two-person mechanical lift for transfers and was dependent on staff assistance to get out of bed and for bathing. Over multiple observed dates, the resident was not assisted out of bed and was not offered showers, only receiving infrequent bed baths. The resident reported that staff did not ask if they wanted to get out of bed due to insufficient staffing, and that they had not been out of bed for approximately ten days. The care plan indicated the need to encourage participation in ADLs and to use assistive devices, but these interventions were not consistently implemented. Staff interviews confirmed that there were typically only two to three Certified Nurse Aides available for 40 residents, making it difficult to provide the required assistance for residents needing two-person transfers. The resident's preferred seating option, a Broda chair, was no longer available, and therapy services were being provided at bedside due to the resident not being transferred out of bed. The facility's policy emphasized promoting dignity and quality of life, but the lack of staff and resources resulted in the resident not receiving care in accordance with their needs and preferences.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
Surveyors identified deficiencies in the facility's ability to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for three residents. For one resident with peripheral vascular disease, hypertension, and glaucoma, the corridor door to their room was repeatedly observed to be stuck or unable to be freely opened or closed while the resident was present in the room. Multiple staff interviews confirmed the issue was not previously noticed, but the door was later found to be functioning properly after the observations. Another resident with schizophrenia, traumatic brain injury, and epilepsy, who was identified as an elopement risk, experienced two separate elopement incidents. The resident was not wearing a wander guard and was able to leave the facility on both occasions. Staff failed to update the care plan or document interventions after these incidents, and interviews revealed that the resident would not keep a wander guard on and required close monitoring, which was not consistently provided due to staffing challenges. The facility's own policies for elopement were not followed, and the incidents were not properly investigated or documented at the time. A third resident with hemiplegia, major depressive disorder, and severe cognitive impairment eloped from the facility while on 30-minute safety checks. The resident exited through a side door by holding the release for fifteen seconds, triggering an alarm that was not responded to by unit staff. The resident was found outside by staff, sustained a laceration after a fall, and was sent to the hospital. There was no documented investigation into how the resident was able to exit unnoticed, and staff interviews indicated a lack of awareness and follow-up regarding the alarm and the resident's absence.
Delayed Pain Management for Resident
Penalty
Summary
The facility failed to provide timely pain management for a resident, leading to a deficiency in care. On 3/31/2024, a resident with chronic pain conditions, including inflammatory spondylopathies and hidradenitis suppurativa, did not receive their scheduled dose of Oxycodone at 12:00 PM. The resident, who was cognitively intact, reported their pain level as 7 or 8 on a scale of 0-10 due to the delay in medication administration. The resident informed the assigned LPN before 12:00 PM that they were out of Oxycodone and that previous doses had been obtained from the emergency kit. The LPN, who was not regularly assigned to the resident's unit, did not notify the RN Supervisor in a timely manner about the unavailability of the medication. Consequently, the RN Supervisor only became aware of the issue later and had to obtain authorization from the pharmacy to dispense the medication from the electronic medication dispensing system. The resident eventually received their medication at 3:15 PM, over three hours past the scheduled time, causing significant discomfort. Interviews with staff revealed systemic issues in the medication ordering process. The RN Supervisor noted that the physician had renewed the Oxycodone order on 3/29/2024, but it was not signed, leading to a delay in pharmacy authorization. Additionally, the charge nurse on the night shift was responsible for ensuring narcotic medications were ordered and available, a task that was not consistently performed. This lack of coordination and communication among staff contributed to the delay in pain management for the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of multiple falls, experienced a witnessed fall on July 1, 2023, while ambulating without a walker. Despite being identified as high risk for falls, no interventions were documented or implemented following this incident to prevent further accidents. Subsequently, the resident experienced another fall on September 26, 2023, resulting in a cervical 1 vertebrae fracture. The fall occurred when the resident tripped on an intravenous pole and struck their head. The resident was transported to the hospital and returned with a cervical collar. Despite these incidents, there was no documented evidence that the resident's care plan was updated with interventions to prevent further falls. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that interventions were expected to be added to the care plan after each fall. However, they acknowledged that interventions were not documented for the falls on July 1, 2023, and September 26, 2023. The lack of documented interventions and updates to the care plan contributed to the resident's repeated falls and subsequent injury.
Deficiency in Resident Dignity Due to Use of Disposable Utensils
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the use of disposable utensils during meals for several residents. This deficiency was observed in multiple dining rooms, affecting five residents with varying degrees of cognitive impairment and medical conditions, such as chronic obstructive pulmonary disease, metabolic encephalopathy, and Alzheimer's disease. The facility's policy stated that residents should be provided with a diet that considers their preferences, yet observations showed meals served on plastic trays with plastic utensils, lacking knives, which hindered residents' ability to eat comfortably. Interviews with staff revealed a lack of awareness and understanding regarding the use of plastic utensils. A resident expressed confusion about the consistent use of plastic utensils, and a Licensed Practical Nurse was unaware of any care plans or safety risks necessitating their use. The Director of Food Service admitted that the facility ran out of real utensils and had to order them frequently, while the Director of Nursing was unaware of the issue and assumed it was due to safety concerns. This lack of coordination and communication among staff contributed to the deficiency in maintaining residents' dignity during meals.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, as identified during a recertification survey. Resident #108, who was admitted with chronic osteomyelitis, morbid obesity, and paraplegia, was receiving oxygen therapy and BiPAP for sleep apnea. Despite these needs, there was no comprehensive care plan addressing the resident's oxygen use, as confirmed by interviews with the resident, a registered nurse unit manager, and the director of nursing. Resident #118, diagnosed with post-traumatic stress disorder (PTSD), did not have a care plan addressing this condition. The director of social work acknowledged that a trauma-centered care plan should have been developed, given the resident's PTSD diagnosis. The absence of such a plan was confirmed by the director of nursing, who stated that a person-centered care plan should have been implemented for the resident's PTSD. Resident #376, who had a history of depression and was on antidepressant medication, did not have a person-centered care plan for their depression until after they expressed suicidal ideation. The resident's depression was documented in the medical provider's admission history, yet the care plan only addressed psychotropic medication administration without a focus on the resident's psychosocial needs. Interviews with the director of social work and social worker revealed a lack of awareness of the resident's depression diagnosis, which contributed to the deficiency.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs by the interdisciplinary team after each assessment for three residents. Resident #64, who was identified as high risk for falls, experienced multiple falls, including a witnessed fall on 7/01/2023 and another on 9/26/2023, which resulted in a cervical vertebra fracture. Despite these incidents, the care plan for falls was not updated to include new interventions to prevent further accidents. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that interventions were not documented in the care plan following these falls, contrary to the facility's policy. Resident #75 was admitted with chronic systolic heart failure, end-stage renal failure, and type 2 diabetes mellitus. Despite having no cognitive impairment, the resident was not involved in care planning and did not have a care plan meeting during the comprehensive assessment. The Director of Social Work acknowledged that the resident should have had a care plan meeting by the time of the survey and was unsure why there was a delay in the initial meeting with the social worker. Resident #200, who had a history of dysphagia following a stroke and was previously on enteral feeding, had their tube feeding discontinued on 5/02/2024. However, the comprehensive care plan was not updated to reflect the discontinuation of enteral feedings, and there were no current care plan interventions for the maintenance and care of the feeding tube. Interviews with an LPN and the Director of Nursing confirmed that the care plan was not updated, and the existing interventions were resolved instead of being revised.
Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of controlled substances on Units #5 and #6, as observed during a recertification survey. The shift-to-shift staff signature form for controlled drugs was not consistently signed by staff members at each shift change, which is necessary to validate the correct narcotic count. Specifically, on Unit #6, there were three consecutive days with missing staff reconciliation for controlled drugs. Additionally, during medication administration observations, two Licensed Practical Nurses (LPNs) failed to sign out controlled medications when removed from the blister pack and did not immediately sign the administration record after administering the medication. Further discrepancies were noted in the medication administration documentation. One LPN administered a Lacosamide tablet to a resident without signing the controlled substance log, resulting in a mismatch between the blister pack count and the logbook. Another LPN documented an incorrect count of Fentanyl patches, with one patch unaccounted for in the medication cart. The Director of Nursing confirmed that nurses are expected to sign the shift-to-shift documentation form at each shift change and that unit managers are responsible for monitoring narcotic count sheets and resolving discrepancies. Despite annual competencies for medication administration and controlled substance handling, these deficiencies were observed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that six out of six medication carts and two out of three medication storage rooms did not comply with labeling and storage requirements. Specifically, opened medications lacked open and expiration dates, controlled substances were not secured in a double-locked cabinet, loose pills were found in medication carts, and medications were pre-poured on one medication cart. Observations revealed several instances of non-compliance. On the 5th floor, medication cart B contained loose pills and multiple opened medications without proper labeling, including eye drops, nasal spray, and insulin pens. The narcotic lock box in the 5th floor medication room was found unlocked. Similar issues were noted on the 6th floor, where medication cart A had opened medications without open and expiration dates, and the medication room refrigerator contained an open vial of tuberculin without an open date. Further observations on the 2nd, 3rd, and 4th floors showed similar deficiencies, with medication carts containing unlabeled pre-poured medications and insulin vials without expiration dates. Interviews with LPNs revealed a lack of awareness regarding pharmacy or manufacturer guidelines for expiration dates, and the Director of Nursing confirmed that staff should follow policy and procedure when administering medications. The facility's policies required labeling of medications upon opening and prohibited pre-pouring of medications.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for several residents. During a recertification survey, it was observed that residents on multiple floors received meals that were cold, unattractive, and not palatable. Specifically, residents expressed dissatisfaction during a resident council meeting, noting that their meals were often cold and unappealing. Observations confirmed that food temperatures were below acceptable levels, with items such as hamburgers and baked beans served at temperatures significantly lower than recommended. The facility's policy on Food and Nutrition Services, dated January 2024, stated that residents should receive a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs. However, during meal observations, it was noted that staff served beverages without wearing gloves, and residents were provided with plastic cutlery, lacking knives, which was not in line with any care plan or safety assessment. Interviews with staff revealed that the use of plastic utensils was due to a shortage of real cutlery, which was not being returned to the kitchen after meals. Additionally, the facility's elevator system contributed to delays in meal delivery, resulting in cold food. Residents with various medical conditions, such as sepsis, chronic obstructive pulmonary disease, and orthopedic aftercare, were affected by these deficiencies. For instance, one resident reported that their breakfast was cold upon delivery, with congealed fat on the ham slices, and temperatures of the food items were recorded well below the desired levels. Interviews with the Director of Food Service and the Director of Nursing indicated a lack of awareness and communication regarding the issues with cutlery and meal temperatures, contributing to the ongoing problem.
Improper Food Cooling and Unclean Kitchenette
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the recertification survey. Specifically, ground chicken was not cooled safely in the main kitchen. Observations revealed that the ground chicken, which was cooked on the previous day, was found in the walk-in refrigerator at a temperature of 52 degrees Fahrenheit, which is above the safe cooling temperature. According to the facility's Hazard Analysis Critical Control Points (HACCP) Cooling Step by Step Process, cooked food should be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours and then to 41 degrees Fahrenheit within 4 hours. However, the chicken had been placed in the refrigerator at 7:00 AM and had not reached the required temperature by 10:54 AM. Additionally, the Unit #1 kitchenette was found to be unclean, further indicating a lack of adherence to food safety standards. Interviews with the Assistant Director of Food Service and the Chef confirmed the timeline of events, and the Director of Food Service acknowledged the issue, leading to the disposal of the improperly cooled chicken. The Regional Manager of the food service vendor and the facility Administrator were informed of the deficiency, highlighting the need for staff training on proper food cooling procedures.
Improper Labeling of Resident and Personal Food
Penalty
Summary
The facility failed to ensure that food brought in by family or visitors for residents was stored safely and properly labeled in the kitchenette refrigerators on three of six resident units. Specifically, deli sandwiches for a resident were not dated, and lactose-free milk and orange tonic brought in by family members were not labeled with the resident's name, room number, and date. Additionally, personal food found in a green reusable lunch bag was not labeled. The facility had a posted document on the refrigerators stating that all food must be labeled with the resident's name and date, but this policy was not followed.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that an interdisciplinary team assessed a resident's ability to safely self-administer medication, as required by their policy. Resident #35, who was cognitively intact and had diagnoses including chronic diastolic congestive heart failure, morbid obesity, and bipolar disorder, was observed with a cup containing seven pills and a cup of medicine mixed in water at their bedside. There was no documented evidence in the resident's electronic medical record that an assessment had been conducted to determine their ability to self-administer medications safely, nor was there a physician order or care plan in place for self-administration. During interviews, it was revealed that the facility's protocol was not followed. A Licensed Practical Nurse (LPN) admitted to mistakenly leaving the medications at the resident's bedside when they left the room to answer a call light. Another LPN and the Director of Nursing confirmed that no residents on the floor were cleared to self-administer medications, and that a physician's assessment and order were required for a resident to self-medicate. The facility's policy stated that residents had the right to self-administer medications if deemed clinically appropriate and safe by an interdisciplinary team, but this process was not followed for Resident #35.
Failure to Maintain Care for Resident with Discontinued PEG Tube
Penalty
Summary
The facility failed to ensure appropriate care and maintenance for a resident with a percutaneous endoscopic gastrostomy (PEG) tube after enteral feedings were discontinued. The resident, who had a history of dysphagia following a stroke and moderate cognitive impairment, was initially receiving tube feedings as per a physician's order. However, the order for tube feeding was discontinued, and there were no subsequent orders for the maintenance of the PEG tube or skin care at the insertion site. This lack of orders and care plan led to the deficiency identified during the survey. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, revealed that they were aware that a PEG tube not in use should still be flushed daily and require skin care. Despite this knowledge, there were no current orders or care plans in place for the resident's PEG tube maintenance. The Director of Nursing acknowledged that the order for flushes was discontinued along with the feeding order, and there were no policies addressing the care of an unused feeding tube.
Failure to Administer TPN as Ordered
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards and physician orders for a resident who was admitted with pneumonia, severe malnutrition, and a stroke. The resident was cognitively intact and had a physician's order for total parenteral nutrition (TPN) to be administered in a 16-hour cycle starting at 5:00 PM and ending at 9:00 AM. However, the TPN was not started on time on one occasion and was not taken down as ordered the following morning. This deviation from the physician's order was documented in a late entry by a Nurse Practitioner, who noted that the TPN was not removed at the scheduled time, and advised the Registered Nurse to contact the pharmacy for the next infusion. Interviews with facility staff revealed inconsistencies in the documentation and recollection of events. The Assistant Director of Nursing acknowledged that the physician's orders should have been followed, and any deviation should have been communicated to the provider. The Director of Nursing noted a problem with documentation, suggesting that the incident likely occurred on a different date than initially reported. The resident's condition deteriorated, and they were sent to the hospital, further complicating the timeline of events. The failure to adhere to the physician's orders for TPN administration was identified as a deficiency during the survey.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident #108 and Resident #473, as observed during a recertification survey. Resident #108, who was admitted with chronic osteomyelitis, morbid obesity, and paraplegia, was ordered to receive continuous oxygen therapy at 4 liters per minute via nasal cannula and BiPAP at bedtime. However, observations on multiple dates revealed that Resident #108 was not wearing supplemental oxygen as ordered. Interviews with the resident and staff indicated that the resident only wore oxygen at night or when in bed and rarely used the BiPAP due to discomfort. The care plans for Resident #108 did not document the use of oxygen or BiPAP, and there was no evidence of a care plan addressing non-compliance or refusal to wear oxygen. Resident #473, diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, and emphysema, was observed wearing 3 liters of oxygen via nasal cannula on several occasions without a physician's order documented in the medical record. The comprehensive care plan for Resident #473 indicated a need for oxygen, but there was no order in the medical record until after the surveyor's inquiry. Interviews with staff revealed a lack of communication and documentation regarding the oxygen therapy, with staff expressing uncertainty about the orders and the need to verify them in the system. The facility's policy on oxygen administration required verification of physician orders before initiating oxygen therapy, except in emergencies. However, this policy was not followed for Resident #473, who received oxygen without an order for at least five days. The lack of proper documentation and adherence to physician orders for both residents highlights deficiencies in the facility's respiratory care practices, as evidenced by the observations and interviews conducted during the survey.
Inadequate Dialysis Care Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. Specifically, the resident, who had multiple diagnoses including chronic systolic heart failure, end-stage renal failure, and type 2 diabetes mellitus, was not consistently monitored for complications before and after dialysis treatments. The facility's policy required the use of a communications log to document the resident's needs and response to dialysis treatments, but this was not adhered to. The dialysis communications log was found to be incomplete on multiple occasions, with missing entries for pre- and post-dialysis vital signs, dialysis access site condition, medication changes, infections, acute condition documentation, and nurse signatures. Interviews with facility staff, including a Registered Nurse Unit Manager and the Director of Nursing, confirmed that the expectation was for these forms to be completed and documented, but they were not consistently filled out. This lack of documentation and communication with the dialysis center represents a deficiency in the care provided to the resident.
Failure to Provide Social Services Assessment for Resident with Depression
Penalty
Summary
The facility failed to provide medically related social services to a resident with a documented history of depression, as required to maintain their mental and psychosocial well-being. The resident, who was admitted with diagnoses including depression, did not receive an assessment by a Social Worker upon admission or during subsequent readmissions. This lack of assessment was contrary to the facility's policy, which mandates that the Care Planning/Interdisciplinary Team, including a Social Worker, develop an individualized comprehensive care plan based on a comprehensive assessment. The resident was on an antidepressant medication, but there was no documented person-centered care plan addressing their depression until after they expressed suicidal ideation. The deficiency was highlighted when the resident verbalized suicidal thoughts and a plan to harm themselves, leading to their transfer to the emergency room for psychiatric evaluation. Interviews with facility staff revealed that the initial social service assessment, which includes screening for depression, was not completed for the resident. The Director of Social Work and the Director of Nursing confirmed that a Social Worker should have conducted an assessment around the time of admission, but this did not occur, resulting in a failure to address the resident's mental health needs adequately.
Inadequate Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents with severe cognitive impairments from abuse, specifically inappropriate sexual behavior, due to inadequate supervision. On the day of the incident, a Certified Nurse Aide (CNA) observed the two residents sitting together on a bed in one of the resident's rooms. Despite noticing the situation, the CNA left the room to gather cleaning supplies without redirecting one of the residents out of the room. Upon returning approximately 7 to 8 minutes later, the CNA found the residents engaged in inappropriate sexual behavior, with one resident partially undressed. Prior to this incident, there were indications of inappropriate interactions between the two residents, as reported by another CNA who had observed similar behavior and informed a manager. However, there was no documented evidence of any follow-up or intervention to prevent further occurrences. The facility's policies on abuse prevention and reporting were not effectively implemented, as the care plans for the residents were not updated to reflect the need for increased supervision or interventions to prevent such incidents. Interviews with various staff members revealed a lack of consistent training and awareness regarding the handling of residents with wandering behaviors and potential for inappropriate interactions. The staff did not receive specific training following the incident, and there was a general lack of communication and documentation regarding the residents' behaviors and the necessary precautions to prevent abuse. This oversight resulted in a situation that posed immediate jeopardy and substandard quality of care for the residents involved.
Verbal Abuse and Disrespectful Behavior by Staff
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of Certified Nurse Aide #8 towards Resident #2. Resident #2, who had severe cognitive impairment, was subjected to verbal abuse by the aide. Multiple witnesses reported that the aide yelled and cursed at the resident, telling them to "get the fuck away" and "get into your room," among other disrespectful remarks. This incident was corroborated by several staff and residents who overheard the altercation, indicating a pattern of inappropriate behavior by the aide. Additionally, Resident #6 reported feeling scared after overhearing a loud verbal altercation between Certified Nurse Aide #8 and an LPN during a night shift. The altercation involved shouting and aggressive language, which was confirmed by other staff members who witnessed the incident. This behavior contributed to an environment that was not conducive to the residents' right to a dignified existence and self-determination. The facility's investigation revealed that Certified Nurse Aide #8 had a history of inappropriate interactions with residents and staff, including being moved between units due to similar issues. Despite these known issues, the aide continued to exhibit behavior that violated the residents' rights to be treated with respect and dignity. The facility's failure to address these ongoing issues in a timely manner led to the deficiencies identified during the survey.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident and a Certified Nurse Aide (CNA) within the required two-hour timeframe. The incident occurred during the night shift when a resident, who was cognitively impaired and had a history of cerebral infarction, anxiety disorder, and major depressive disorder, was verbally abused by a CNA. The abuse was overheard by another resident, who reported it to a Licensed Practical Nurse (LPN) four days later. The LPN then informed the Assistant Director of Nursing, who subsequently reported it to the Director of Nursing and the Administrator. The facility's policy mandates immediate reporting of abuse allegations to the administrator and state authorities, defined as within two hours. However, the incident was not reported to the New York State Department of Health until four days after it occurred. Multiple staff members, including another CNA and a Resident Assistant, witnessed or were aware of the incident but did not report it immediately. Some staff members cited fear of job loss or perceived the CNA's behavior as typical, which contributed to the delay in reporting. Interviews with staff revealed that the CNA involved had a history of similar behavior, and the incident was not considered unusual by some staff members. The Director of Nursing confirmed that they were unaware of the incident until four days later, at which point it was reported to the necessary authorities. The facility's failure to adhere to its abuse reporting policy resulted in a deficiency citation.
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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