The Paramount At Somers Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Somers, New York.
- Location
- Route 100, Somers, New York 10589
- CMS Provider Number
- 335261
- Inspections on file
- 21
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Paramount At Somers Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of constipation was repeatedly flagged for not having bowel movements, but the facility failed to initiate its bowel protocol or document interventions as required. Despite ongoing alerts and care plan directives, staff did not consistently follow up or record the effectiveness of administered treatments, leading to the resident's hospital admission for severe constipation and related complications.
A resident's representative reported missing personal items to facility staff, but the grievance was not documented or followed up according to policy. Communication breakdowns and lack of staff awareness of the grievance process resulted in the resident's concern not being properly addressed.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
A resident with a documented diagnosis of constipation did not have a care plan addressing this issue initiated in a timely manner. Despite repeated documentation of constipation and related symptoms, the facility delayed implementing its bowel protocol and did not consistently administer or monitor prescribed interventions. Staff interviews confirmed that care plan initiation and review processes were not followed as required, resulting in the resident being discharged to the hospital with severe complications related to constipation.
A resident with a history of stroke and Parkinson's disease experienced a sudden onset of slurred speech, which was reported by nursing staff to an NP. The NP initially ordered rest and IV fluids, suspecting dehydration, and only arranged for hospital transfer after continued symptoms and at the request of the resident's representative. The resident was later diagnosed with bilateral scattered infarcts. Facility staff and the medical director did not immediately recognize or act on the potential for acute stroke, resulting in delayed hospital evaluation.
Surveyors found that two residents did not have physician-ordered follow-up orthopedic consultations properly documented or scheduled after initial consults for hip fractures. Staff interviews revealed that orders for follow-up visits were not consistently entered into the electronic medical record, and communication about these appointments was often verbal rather than documented. As a result, both residents were discharged without the recommended follow-up care being arranged or recorded.
A nurse crushed and administered an extended-release Morphine tablet, clearly labeled 'do not crush,' to a resident with chronic pain and respiratory conditions. The resident became lethargic and exhibited opioid overdose symptoms, requiring Naloxone to reverse the effects. Facility policy requiring label checks and adherence to administration instructions was not followed, resulting in actual harm.
Two residents experienced falls, but their care plans were not updated to reflect the incidents as required. One resident with severe cognitive impairment fell from a Hoyer lift, and another with muscle weakness and ambulatory dysfunction had an unwitnessed fall resulting in injury. Staff interviews revealed inconsistent understanding of the need to revise care plans after such events.
A resident with severe cognitive impairment and total dependence for transfers fell from a mechanical lift during a transfer by two CNAs. The fall occurred when a strap on the Hoyer pad slipped or detached, causing the resident to strike their head on the lift. Staff interviews revealed inconsistencies in the transfer process, and the facility's investigation found that the equipment was intact but may not have been properly secured or monitored during the lift.
Two residents in an LTC facility were exposed to accident hazards due to inadequate supervision and safety protocol failures. One resident, with a pureed diet order, consumed inappropriate food and required suctioning after aspirating, while another had an uninspected electric air mattress overlay brought in by a private aide. Staff were unaware of supervision responsibilities and safety checks for personal equipment, leading to these deficiencies.
A resident's privacy was compromised due to a broken window shade and torn screen in their room, which faced the staff parking lot. Despite the resident's complaints and the facility's policy to maintain windows, the issue persisted for over a week. Staff were aware but did not report the problem, and the Director of Maintenance was only informed days later. The deficiency was noted during a recertification survey.
A resident with severe cognitive impairment did not receive necessary ADL care from facility staff, as a private duty aide, against facility policy, provided all care. The aide's involvement was not reported by staff, leading to a lack of documented evidence of care. The facility failed to ensure adherence to care plans and proper documentation.
A facility failed to maintain an adequate stock of prescribed gastrostomy tubes, leading to complications in the care of a resident with a feeding tube. The resident required an 18-gauge gastrostomy tube, but the facility ran out of stock, resulting in the use of an incorrect size and a temporary Foley catheter. The inventory management system was inadequate, and the purchasing process was delayed, contributing to the deficiency.
The facility experienced significant staffing shortages, particularly on night shifts and weekends, affecting resident care. Residents reported falls and delayed response times to call bells, while staff confirmed the lack of sufficient aides impacted care quality. Despite efforts to address the issue, including using agencies and offering incentives, the facility remained understaffed on multiple occasions.
The facility failed to maintain proper labeling and expiration management of medications. Unlabeled Ascor was found in a refrigerator on the [NAME] Unit, and expired Nexium was found in a medication cart on the Westminister Unit. Staff interviews revealed a lack of clarity on medication discontinuation and removal processes.
The facility's main kitchen failed to store food properly due to faulty insulation door seals on the walk-in freezer, leading to ice accumulation. The facility's policy required regular maintenance checks, but the seals were not functioning properly, causing a gap and ice formation. The Food Services Director acknowledged the issue and had requested repairs.
A resident with severe cognitive impairment and a history of aggression was physically abused by a CNA in a long-term care facility. The incident, captured on surveillance video, showed the CNA hitting the resident, resulting in an abrasion. The CNA had a prior disciplinary record and was the only aide on duty at the time. The facility's investigation found reasonable cause for abuse, leading to the CNA's termination.
A resident's Designated Representative was not informed about the risks and benefits of a newly prescribed medication, Depakote, or alternative treatment options before administration. The resident, who was severely cognitively impaired and had a history of aggression, began receiving Depakote following a recommendation from a Psychiatry NP. Despite the facility's policy requiring family notification for medication changes, there was no documented evidence of such communication. The Medical Doctor claimed to have discussed the medication regimen with the Designated Representative but did not document the conversation.
A facility failed to maintain a clean and homelike environment in a dementia unit, where a strong urine odor was pervasive. The unit lacked a night housekeeper, leaving nursing staff to manage accidents until morning. Carpets were cleaned weekly, but the odor persisted due to residents' incontinence and humid weather, highlighting a deficiency in environmental maintenance.
A resident with severe cognitive impairment and multiple diagnoses experienced a fall, but the facility failed to update the Comprehensive Care Plan (CCP) as required. The care plan, which included interventions for fall prevention, was not revised after the incident, despite protocols stating that care plans must be reviewed post-fall. Interviews revealed confusion over responsibilities for updating care plans, contributing to the deficiency.
A resident with dementia in an LTC facility exhibited increasing aggression and wandering behaviors, but their care plan was not updated to address these issues. Despite staff awareness and training, the care plan remained unchanged, and the medical doctor was not informed of escalating behaviors. Staffing challenges were noted by the DON.
The facility did not conduct a comprehensive assessment to determine necessary resources for the [NAME] Unit, a specialized dementia care area. The assessment failed to identify the unit's specific needs and appropriate staffing levels. Observations revealed insufficient night shift staffing, with only 2 CNAs and 1 LPN for 40 residents, some requiring two-person assistance. Despite staff concerns, no staffing changes were made.
Failure to Initiate and Document Bowel Protocol for Resident with Constipation
Penalty
Summary
A resident with moderate cognitive impairment and a history of constipation was admitted to the facility with diagnoses including constipation and sepsis. The resident was frequently incontinent of bowel and bladder, and a care plan was in place to monitor and manage bowel movements, including initiating a bowel protocol if no bowel movement occurred in two days. Despite this, the resident was repeatedly flagged on the facility's bowel list report in June, July, and August for not having bowel movements, but the facility's bowel protocol was not initiated as required by facility guidelines. The resident's medication orders for constipation were inconsistently managed. Senna was ordered and then discontinued after the resident declined it, and Colace was started later. There was no documentation that the bowel protocol was initiated during multiple periods when the resident had no bowel movements, as indicated by clinical alerts. When the resident finally received a dose of Milk of Magnesia, there was no documented evidence of its effectiveness. The lack of follow-up and documentation persisted despite the resident being seen by nurse practitioners and other staff, and despite ongoing alerts indicating the absence of bowel movements. After discharge, the resident was admitted to the hospital with severe sepsis and was found to have large amounts of stool in the rectum and rectal mural thickening on imaging, consistent with severe constipation. Interviews with staff revealed inconsistent practices regarding monitoring, documentation, and initiation of the bowel protocol. Staff acknowledged that alerts were available and discussed, but there was no evidence that appropriate interventions were consistently implemented or documented for this resident.
Failure to Document and Address Resident Grievance Regarding Missing Property
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to voice grievances and to make prompt efforts to resolve them, as required by policy. The representative of a resident with moderate cognitive impairment and multiple care needs reported several missing items, including a fleece blanket and a nail manicure kit, to the Patient Relations Concierge. Despite this report, there was no documented evidence that a grievance was filed or that any follow-up was provided to the resident's representative regarding the missing items. The facility's grievance policy requires that grievances be documented and addressed promptly, but this process was not followed in this instance. Interviews revealed that the Patient Relations Concierge received the complaint and attempted to notify the Assistant Administrator and Director of Social Services via WhatsApp, but did not receive a response and was unaware of the official grievance process. The Director of Social Services, who is designated as the grievance officer, stated they were not informed of the issue until much later and confirmed that no grievance documentation existed in the resident's chart. The Administrator acknowledged that the grievance should have been documented and processed according to policy, but this did not occur. Communication breakdowns and lack of staff awareness of the grievance process contributed to the failure to address the resident's grievance appropriately.
Failure to Provide Complete Discharge Information Delays Home Care Services
Penalty
Summary
The facility failed to ensure that all necessary resident information was conveyed to the home care agency at the time of discharge, resulting in a delay in the initiation of home care services for one resident. The resident, who had a history of right femur fracture, depression, muscle weakness, moderate cognitive impairment, and required significant assistance with activities of daily living, was scheduled for discharge with home care services. The discharge planning documentation indicated that arrangements should be made with community resources to support the resident's independence post-discharge. However, the home care agency did not receive all required documentation, including the resident's demographics and orders specifying needed disciplines, which prevented timely initiation of services. Interviews revealed that the facility typically sends discharge referrals two to three weeks before discharge, but the documentation is not maintained in the electronic medical record and is instead kept in paper form. The home care agency representative confirmed that only clinical information was received, and the absence of demographic and insurance information delayed the start of home care services. As a result, the resident's home care services were not initiated until several days after discharge, contrary to the usual practice of starting services within 48 hours.
Failure to Develop and Implement Timely Care Plan for Constipation
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address constipation for one resident. The resident was admitted with multiple diagnoses, including a documented diagnosis of constipation, but no care plan addressing constipation was in place until more than two weeks after admission. Despite the facility's policy requiring timely care plan development and the presence of a bowel protocol, the resident experienced multiple episodes without a bowel movement, as documented in the facility's bowel alert lists and medication administration records. The bowel protocol was not initiated until much later, and there was no evidence that interventions were consistently implemented or monitored for effectiveness. The resident's medical records showed repeated documentation of constipation, complaints of discomfort, and requests for stool softeners. Orders for medications such as Senna and Colace were made, but there was inconsistency in their administration and follow-up. The medication administration records did not reflect refusals or consistent use of prescribed laxatives, and there was a lack of documentation regarding the effectiveness of interventions when they were eventually provided. Nursing and medical progress notes indicated ongoing issues with constipation, but the facility did not initiate the bowel protocol in a timely manner, nor did they update the resident's diagnosis list to reflect active constipation. Interviews with facility staff, including LPNs and the DON, revealed that care plans are expected to be initiated at admission and reviewed by registered nurses and the interdisciplinary team. However, in this case, the care plan for constipation was delayed, and the diagnosis was not properly carried over or updated in the resident's records. The resident was eventually discharged and admitted to the hospital with severe sepsis, where imaging revealed significant stool retention and colitis. The deficiency was attributed to the facility's failure to ensure timely and effective care planning and intervention for constipation as required by policy and regulation.
Failure to Provide Timely Hospital Transfer for Resident with Acute Neurological Changes
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services provided met professional standards of quality for a resident with a history of stroke, peripheral vascular disease, and Parkinson's disease. The resident, who had moderate cognitive impairment and required significant assistance with activities of daily living, experienced a sudden onset of slurred speech. This change was first noted by an LPN, who notified the nursing supervisor and a nurse practitioner (NP). The NP instructed staff to place the resident in bed for rest. Despite continued slurred speech, the NP initially ordered intravenous fluids and lab work, suspecting dehydration, and later requested a speech evaluation. The resident's symptoms persisted into the following day, with ongoing slurred speech and general weakness. The NP was again notified and, after further discussion and at the request of the resident's representative, ordered the resident to be transferred to the hospital to rule out a stroke. The resident was subsequently admitted to the hospital with a diagnosis of bilateral scattered infarcts. Documentation and interviews revealed that the NP and medical director did not immediately suspect a stroke and opted to treat in place, attributing symptoms to possible dehydration or other non-stroke causes. The medical director indicated that unless symptoms worsened or failed to improve, the standard practice was to continue treatment in the facility rather than transfer to the hospital. Interviews with facility staff and the resident's representative highlighted delays in recognizing the severity of the resident's symptoms and in transferring the resident for appropriate evaluation and treatment. The NP did not consult the medical director regarding the case, and the medical director did not question the NP's decisions. The facility's approach did not align with timely intervention for potential stroke symptoms, as required by professional standards of care.
Failure to Document and Schedule Physician-Ordered Follow-Up Consultations
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians reviewed residents' total programs of care and documented progress notes and orders at each required visit for two out of three residents reviewed for follow-up consultation visits. Specifically, one resident admitted after a right hip fracture had an orthopedic consultation recommending a follow-up visit and x-ray in six weeks. However, there was no documented evidence that a physician's order for the follow-up was entered, nor was the appointment scheduled before the resident was discharged home. The resident's discharge instructions included a recommendation to follow up with orthopedics post-discharge, but the required in-facility follow-up was not arranged or documented. Another resident, admitted after a left hip fracture, was also scheduled for an orthopedic follow-up consultation. The consultation report specified a follow-up appointment, but there was no documented physician's order for this visit. The resident was discharged without having the follow-up orthopedic appointment completed. Review of the medical record and staff interviews confirmed the absence of documentation regarding the follow-up consultation, and it was noted that the resident would sometimes cancel appointments, but this was not consistently documented in the medical record. Interviews with facility staff, including the unit clerk, LPN, nurse practitioner, and medical director, revealed inconsistent practices regarding the scheduling and documentation of follow-up consultations. The nurse practitioner stated that recommendations from consultations were verbally communicated to nursing staff, but orders were not entered into the electronic medical record. The medical director acknowledged that orders and progress notes for consultations should be documented and that the current process allowed for lapses in scheduling and documentation, leading to missed appointments.
Crushed Extended-Release Morphine Administered, Resulting in Harm
Penalty
Summary
A deficiency occurred when a nurse administered a crushed extended-release Morphine Sulfate tablet to a resident, despite the medication being clearly labeled as 'do not crush.' The nurse, who was responsible for medication administration, stated that the resident was known to spit out medications and could become verbally disruptive if pain medication was not given on time. In an effort to ensure the resident received their pain medication, the nurse crushed all of the resident's medications, including the extended-release Morphine, and administered them together. The facility's policy required nurses to check pharmacy labels and follow all instructions, including not crushing medications labeled as such, but this protocol was not followed in this instance. Following administration, the resident was found lethargic in bed by a speech language pathologist, who alerted nursing staff. The resident exhibited decreased responsiveness, decreased respirations, wheezing, and pinpoint pupils. Initial assessments by nursing staff and the physician led to the administration of Solumedrol and Lasix for respiratory symptoms, as the resident had a history of chronic obstructive pulmonary disease and pulmonary hypertension. It was only after further inquiry that the nurse disclosed the error of crushing the extended-release Morphine, prompting the administration of Naloxone to reverse the effects of the opioid overdose. The resident returned to baseline shortly after receiving Naloxone, and the incident was reported to the physician and the resident's representative. Interviews with staff confirmed that the nurse was aware of the 'do not crush' instruction but proceeded due to being in a rush and wanting to address the resident's pain. The facility's policy on narcotic handling and administration was not adhered to, resulting in actual harm to the resident.
Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised following actual falls for two out of four residents reviewed for falls. For one resident with severe cognitive impairment, dementia, and total dependence for mobility and transfers, the care plan was not updated to reflect a fall from a Hoyer lift during a transfer by two CNAs. Although the care plan was later updated with staff education and a physical therapy evaluation, there was no documented evidence that the actual fall event was incorporated into the fall risk care plan as required by facility policy. Another resident, who was cognitively intact but had muscle weakness, ambulatory dysfunction, and required assistance with mobility, experienced an unwitnessed fall in their room resulting in a laceration and skin tears. The care plan for this resident, which identified fall risk due to their physical limitations, was not updated to include the details of the fall incident. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the requirement to update care plans immediately after a fall, with some staff relying on progress notes rather than revising the care plan itself.
Resident Fall During Mechanical Lift Transfer Due to Improper Supervision and Equipment Attachment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and total dependence for transfers fell from a mechanical lift during a transfer. The resident, who was bedridden and required assistance for all activities of daily living, was being transferred by two Certified Nurse Aides (CNAs) using a Hoyer lift. The facility's fall prevention policy required a comprehensive approach to safety, including environmental adjustments and individualized interventions for residents at risk of falls. During the transfer, one CNA was preparing the resident's chair while the other CNA attached the Hoyer pad to the lift. As the resident was being lifted, they fell out of the Hoyer pad and struck their head on the leg of the lift. Upon investigation, it was found that one of the straps on the Hoyer pad had slipped or become detached during the lifting process, resulting in the resident's fall. Interviews with staff revealed inconsistencies in the sequence of actions, with one CNA stating they were not in position when the transfer began and the other indicating they had attached all the necessary clips. Further interviews with nursing staff and administration indicated that the Hoyer pad and equipment were intact, but the incident may have been caused by improper attachment or shifting of the resident during the transfer. The facility's investigation concluded that the strap may have come off due to the resident's movement or contact with the bed rail, but both CNAs believed they had followed proper procedures. The event demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided during the transfer process.
Lack of Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. Resident #631, who had a physician order for a pureed diet with nectar thick liquids due to dysphagia, was able to consume thin liquids and a cookie while in a supervised area. This led to the resident requiring oral suctioning to clear their throat after aspirating. The incident occurred when the resident was left unsupervised in the common area, despite the care plan indicating the need for close supervision during meals. Staff members were unaware of who was responsible for supervising the area, leading to the resident's exposure to inappropriate food and drink. Resident #226 was found to have an electric air mattress overlay on their bed, which had not been inspected by the maintenance department for safety. The air mattress overlay was brought in by the resident's private duty aide without the facility's knowledge. The Director of Nursing and other staff members were unaware that the air mattress overlay was not provided by the facility and had not been checked for safety. The maintenance department was only informed of the equipment after the survey had begun, highlighting a lapse in the facility's protocol for inspecting electrical equipment brought in by visitors. Both incidents demonstrate a lack of adequate supervision and adherence to safety protocols within the facility. The failure to supervise Resident #631 in the common area and the oversight in inspecting Resident #226's air mattress overlay contributed to the deficiencies identified during the survey. These lapses in care and safety protocols put the residents at risk and indicate a need for improved communication and adherence to established procedures within the facility.
Failure to Maintain Resident Privacy Due to Broken Window Shade
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #66, by not maintaining the window in their room in a functional state. The window, which faced the staff parking lot, had a broken shade that could not be pulled down, and a torn insect screen. This situation persisted for over a week, during which Resident #66 expressed dissatisfaction and a desire for privacy. The resident's roommate also confirmed the issue, stating that the broken shade allowed light to shine through the room continuously, necessitating the use of a curtain between the beds for some privacy. Despite the facility's policy requiring windows to be maintained in a safe and functional order, the broken shade and screen were not addressed promptly. Certified Nurse Aide #21 acknowledged awareness of the issue but failed to report it for repair. The Director of Maintenance was unaware of the problem until several days later, at which point the shade was repaired. The Director of Nursing confirmed that residents should be provided privacy upon request, including having window shades closed during care. The deficiency was identified during a recertification survey, highlighting a failure to uphold the resident's right to a dignified existence and privacy.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. The resident, who had severe cognitive impairment and required total assistance with eating, toileting, and personal hygiene, did not receive the required ADL care on multiple shifts as documented in the October 2024 Certified Nurse Aide documentation. A private duty aide, who was not permitted to provide care according to facility guidelines, stated they provided all care for the resident during their 8-hour daily shifts. Observations and interviews revealed that the private duty aide was performing tasks such as feeding, bathing, and applying protective cream, which were supposed to be done by the facility staff. Certified Nurse Aide #27 admitted that they documented care as provided even when it was not done by them, and they did not report the private duty aide's involvement to the nurses. The Director of Nursing and Licensed Practical Nurse Manager #22 confirmed that private duty aides were not allowed to provide care and that staff should have reported any non-compliance. The facility's failure to ensure proper documentation and adherence to care plans resulted in the resident not receiving the necessary care from the facility staff. The private duty aide's involvement, despite being against facility policy, was not adequately addressed by the staff, leading to a lack of documented evidence of care being provided by the certified nurse aides. This deficiency highlights a breakdown in communication and adherence to facility policies regarding the provision of care by private duty aides.
Failure to Maintain Adequate Stock of Prescribed Gastrostomy Tubes
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not have the physician-prescribed gastrostomy tube size available for Resident #182, who was admitted with diagnoses including aphasia, respiratory failure, and gastrostomy status. The resident's care plan required a specific size of gastrostomy tube, but the facility ran out of the necessary 18-gauge gastrostomy tubes, leading to complications in the resident's care. On July 20, 2024, the resident's g-tube balloon broke, and the g-tube came out. The facility did not have the prescribed 18-gauge gastrostomy tube available, and attempts to use a 20-gauge tube were unsuccessful. As a temporary measure, an 18 French Foley catheter was inserted, and the resident was sent to the hospital for a new tube. On July 22, 2024, a 14-gauge gastrostomy tube was inserted because the facility still did not have the correct size in stock, which may have caused the resident's abdominal opening to become smaller. Interviews with facility staff revealed that the inventory management system was inadequate, as the Director of Housekeeping and Central Supply did not maintain records of inventory levels, leading to a shortage of the necessary gastrostomy tubes. The staff was unaware of how long the stock had been depleted, and the facility's purchasing process was delayed, contributing to the deficiency in care for Resident #182.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Multiple residents and staff members reported that the facility was short-staffed, particularly on night shifts and weekends. The facility's staffing sheets from October 1 to October 31, 2024, revealed that the facility was understaffed on 19 out of 31 days, with only one Certified Nurse Aide scheduled on various units during night shifts. This staffing shortage led to delayed response times to call bells, with residents experiencing falls and other care issues as a result. Interviews with residents and staff highlighted the impact of the staffing shortages. One resident reported experiencing falls due to lengthy response times to call bells, while another resident noted that staff seemed rushed and took about 15 minutes to respond. Staff members, including Certified Nurse Aides and a Licensed Practical Nurse, confirmed the staffing issues, stating that the lack of sufficient aides affected the quality of care, resulting in skin issues and longer wait times for residents. The facility attempted to address the staffing challenges by utilizing agencies, offering incentives, and running a Certified Nurse Aide Training Program, but continued to struggle with maintaining adequate staffing levels.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were maintained in accordance with accepted professional standards, specifically regarding labeling and expiration dates. During an observation of the medication storage room refrigerator on the [NAME] Unit, two boxes of Ascor were found in a plastic bag without a resident name or pharmacy label, while another bag containing three boxes of Ascor was properly labeled. A Licensed Practical Charge Nurse confirmed that all Ascor was ordered for the same resident and should have been in the labeled bag. Additionally, on the Westminister Unit, a blister pack containing 27 capsules of Nexium DR 40 mg was found in a medication cart. The blister pack was labeled for a resident who was no longer receiving the medication, and it had an expiration date of 6/6/24, with a handwritten date of 10/28/24. A Registered Nurse stated that the medication had been discontinued, but they were unsure when. They explained that discontinued or expired medications should be removed from the cart, scanned by the Director of Nursing, and returned to the pharmacy. The Director of Nursing confirmed that the Pharmacy Consultant checks medication carts monthly, and Unit Managers and Charge Nurses conduct weekly checks.
Improper Food Storage Due to Faulty Freezer Seals
Penalty
Summary
The facility failed to ensure proper storage of food in accordance with professional standards for food service safety in the main kitchen. During a recertification survey, it was observed that the walk-in freezer had ice accumulation on the inside door surface, the freezer's floor, and the inner plastic curtain. The facility's policy, dated 8/21/20, required daily maintenance tasks, including door seal inspections to ensure proper functioning, and monthly insulation inspections. However, the freezer's insulation door seals were not attaching properly, leaving a gap between the door and the door's frame, which led to the formation of ice inside the freezer. The Food Services Director confirmed the issue and stated that a request had been placed with a contractor to fix the door seals.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as evidenced by an incident captured on surveillance video. On the night of the incident, a Certified Nursing Assistant (CNA) was observed approaching a resident from behind and subsequently hitting the resident on the shoulder, which led to a physical altercation between the two. The CNA continued to hit the resident with a closed fist, causing the resident to fall to the floor and sustain an abrasion to the nose. This incident resulted in actual harm to the resident, although it was not deemed immediate jeopardy. The resident involved in the incident was admitted to the facility with diagnoses of Lyme disease and unspecified dementia without behavioral disturbance. The resident was assessed as severely cognitively impaired and had a history of physical aggression towards others. The facility had a comprehensive care plan in place for the resident, which included interventions for managing physical aggression and wandering behavior. However, on the night of the incident, the resident was agitated and wandering into other residents' rooms, requiring constant redirection. The CNA involved in the incident had a previous disciplinary record for not appropriately handling a resident-to-resident altercation. On the night of the incident, the CNA was the only aide on the floor, as the other CNA was on break. The Licensed Practical Nurse (LPN) on duty had informed the Nursing Supervisor about the resident's escalating behavior but did not receive a timely response. The LPN later activated a code to request assistance, but by that time, the altercation had already occurred. The facility's investigation concluded that there was reasonable cause to believe that abuse had occurred, leading to the termination of the CNA involved.
Failure to Inform Designated Representative of Medication Changes
Penalty
Summary
The facility failed to ensure that a resident's Designated Representative was informed in advance about the risks and benefits of a newly prescribed medication, Depakote, and alternative treatment options. This deficiency was identified during a survey conducted from July 23, 2024, to July 24, 2024. The resident, who was severely cognitively impaired and had a history of physical aggression, was administered Depakote without the Designated Representative being notified. The facility's policy required family notification regarding changes in medication, but there was no documented evidence that this occurred prior to the administration of Depakote. The Designated Representative had previously expressed concerns about medication changes and had refused an antidepressant due to inadequate explanation from the Psychiatrist. Despite this, the resident began receiving Depakote on July 13, 2024, following a recommendation from a Psychiatry Nurse Practitioner. The Medical Doctor involved stated they discussed the medication regimen with the Designated Representative but did not document the conversation or recall the exact date. The Assistant Director of Nursing indicated that both the Medical Doctor and the unit nurse should notify the Designated Representative of medication changes, but this did not happen in this case.
Deficiency in Maintaining a Clean Environment in Dementia Unit
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents in the [NAME] Unit, as evidenced by a strong pervasive odor of urine throughout the unit, including in resident rooms. Observations were made on multiple occasions, noting the intense odor upon entering the unit and specific rooms, as well as a sticky wooden floor and a musty damp smell in each resident room. The unit, which houses residents with dementia, had both carpeted and wooden floors, and the odor was particularly strong in certain rooms. Interviews with staff revealed that the unit did not have a housekeeper at night, and nursing staff attempted to clean floors when residents had accidents. However, deep cleaning was only performed when housekeeping staff arrived in the morning. The carpets were cleaned weekly, but the unit's condition was exacerbated by the residents' incontinence and the humid weather. The housekeeping director noted that the unit required constant cleaning due to the residents' conditions, and the administrator stated that carpets were shampooed weekly, with spot cleaning available as needed. Despite these efforts, the odor persisted, indicating a deficiency in maintaining a clean and homelike environment.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner for a resident who was at risk for falls. Specifically, the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and Bipolar Disorder, was not updated following a fall incident. The resident had a history of falls, and the care plan included interventions such as encouraging the resident to stay in supervised settings, wearing non-skid footwear, and providing reality orientation. However, after a fall on April 2, 2024, where the resident hit their head, there was no documented evidence that the care plan was reviewed or revised. Interviews conducted during the survey revealed a lack of clarity regarding responsibilities for updating care plans. A Licensed Practical Nurse (LPN) stated that they were not responsible for initiating or updating care plans, which was the responsibility of the unit managers. The Assistant Director of Nursing confirmed that LPN Unit Managers are responsible for initiating and updating care plans, but they must be reviewed and signed by a Registered Nurse. Despite this protocol, the care plan for the resident in question was not updated following the fall incident, indicating a lapse in the facility's adherence to its care plan policy.
Failure to Update Dementia Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency was identified during a survey, where it was found that the resident's comprehensive care plan was not reviewed and revised to address increasing dementia-related behaviors. The resident, who was admitted with diagnoses of Lyme disease and unspecified dementia, exhibited physical aggression and wandering behaviors, which were not adequately addressed in their care plan. The resident's care plan, initiated in May and updated in July, included goals and interventions to manage behavioral symptoms and impaired cognition. However, despite documented episodes of aggression, wandering, and agitation, there was no evidence that the care plan was reviewed or revised to include individualized approaches to these behaviors. Nursing notes and psychiatric consultations documented the resident's ongoing agitation, restlessness, and exit-seeking behaviors, yet the care plan remained unchanged. Interviews with staff revealed that while they were aware of the resident's behaviors and had received dementia care training, they were not responsible for updating care plans. The medical doctor responsible for the unit was not alerted to any escalation of behaviors, and the facility's staffing issues were acknowledged by the Director of Nursing. Despite these challenges, the facility did not take the necessary steps to update the resident's care plan to address their changing needs.
Inadequate Facility Assessment and Staffing on Dementia Unit
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care, particularly on the [NAME] Unit, a specialized dementia unit. The assessment did not identify the unit as a specialized dementia care area nor did it define the staffing assignments required for its day-to-day operations. The facility's policy on facility assessment was intended to guide decisions on budget, staffing, training, equipment, and supplies, but there was no documented evidence that these needs were addressed for the [NAME] Unit. During the survey, it was observed that the night shift staffing on the [NAME] Unit was insufficient, with only 2 Certified Nursing Assistants and 1 Licensed Practical Nurse for 40 residents, some of whom required two-person assistance and others who wandered at night. The lack of housekeeping staff during the night shift led to nursing staff having to manage cleaning tasks, which was not ideal. Despite concerns raised by staff about the need for more personnel, no changes were made to the staffing schedule. The Administrator acknowledged responsibility for managing the Facility Assessment but relied on the Director of Nursing for insights into resident acuity and staffing needs.
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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