The Pines Healthcare & Rehab Ctrs Machias Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Machias, New York.
- Location
- 9822 Route 16, Machias, New York 14101
- CMS Provider Number
- 335578
- Inspections on file
- 14
- Latest survey
- February 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Pines Healthcare & Rehab Ctrs Machias Campus during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse, resulting in harm to three residents. A resident with dementia struck another with a walker, causing injuries, while two roommates with cognitive impairments engaged in multiple altercations. Despite known aggression histories, preventive measures were inadequately implemented, and staff concerns were not addressed, leading to repeated incidents.
The facility failed to update its abuse prevention policies and did not conduct the required Nurse Aide Registry Verification for an LPN before employment. The outdated policies did not align with current regulations, affecting multiple residents. The facility's oversight in updating procedures and verifying employee credentials resulted in substandard quality of care.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin within required timeframes, affecting multiple residents. Incidents included inappropriate touching by staff, resident-to-resident altercations, and care plan violations leading to injuries. The facility's outdated policies contributed to these reporting delays, resulting in substandard quality of care.
The facility failed to update its abuse/neglect reporting policies since 2015, despite regulatory changes between 2020 and 2024. The DON and Administrator were unaware of these updates, relying on missed notifications. The outdated policy required incidents to be reported to the Nursing Supervisor and State Health Department within five days, potentially conflicting with current regulations. The Policy and Procedure Team, including the Administrator and DON, did not update the policies, and a governing board member assumed compliance was maintained.
A Life Safety Code survey found improper use of extension cords, power strips, and an electrical adapter on both floors of the facility. Power strips were daisy-chained in the Medical Records office, and extension cords were used in resident rooms and the lobby. The Maintenance Supervisor was unaware of these issues, and inspection logs lacked documentation of checks for such equipment.
The facility failed to maintain its emergency generator and associated systems, including not conducting required monthly load tests, annual inspections of circuit breakers, and testing of emergency lighting. The Maintenance Supervisor was unaware of testing requirements, and logs showed no documentation of these tests. Additionally, the generator was not run under load in a specific month due to staffing issues, affecting resident use floors and the basement.
The facility's fire alarm system was inadequately maintained, with smoke and heat detectors not tested within required intervals, and batteries not load tested semiannually. The Maintenance Supervisor confirmed the lack of documentation for battery testing and unresolved issues from a previous inspection. These deficiencies affected all resident use floors and the basement.
The facility's automatic sprinkler system was inadequately maintained, with numerous sprinkler heads covered in lint, dust, and debris, and some corroded and rusted. The facility lacked documentation for quarterly inspections, and the post indicator valve was seized. Additionally, sprinkler piping was improperly used to support external loads. The Maintenance Supervisor confirmed missing documentation for inspections in 2023 and 2024, and issues from contractor reports were not addressed.
Smoke barrier walls in the facility were found to have unsealed penetrations, compromising their fire resistance and smoke passage prevention. On the second floor in the Cedar Unit, a two-inch by one-inch open penetration was observed, while a 16-inch by three-inch penetration was found on the first floor in the Evergreen Unit. The Maintenance Supervisor confirmed no recent work on these walls and noted that inspections occurred biannually, but lacked documentation.
A resident with anxiety, a fractured humerus, and diabetes experienced a violation of dignity and self-determination when a CNA provided care despite the resident's refusal, leading to feelings of shame and humiliation. The CNA touched the resident inappropriately and insisted on providing personal hygiene care against the resident's wishes. Staff interviews confirmed the actions were inappropriate and violated the resident's rights.
A Life Safety Code survey found that smoke barrier doors on the first floor of the Evergreen Unit had a gap greater than one quarter inch, compromising their ability to prevent smoke passage. Despite monthly checks documented by maintenance staff, the issue was not recorded, affecting one of two resident use floors.
During a Life Safety Code survey, it was found that 73 liters of alcohol-based hand rub (ABHR) were improperly stored on open shelving in the basement's Supplies storage room, contrary to NFPA 30 regulations. The Maintenance Supervisor was unaware of the requirement to store quantities greater than 10 gallons in a flammable liquids storage cabinet.
The facility failed to maintain the kitchen hood extinguishment system as required, with missed six-month inspections due to a contractor transition and a lack of monthly inspections for the manual pull station. The Maintenance Supervisor was unaware of the monthly inspection requirement, and facility records lacked documentation for these inspections.
A hazardous area door in the basement failed to self-close and latch, compromising safety. The clean linen storage room, larger than 50 square feet, contained numerous linen carts and shelving units. The Maintenance Supervisor noted the door's self-closing device had been replaced multiple times, and the top hinge was broken, necessitating door and frame replacement. The facility also lacked documentation for audits of hazardous area doors.
In an LTC facility, three residents suffered minor injuries due to staff failing to follow care plans. A resident with fragile skin was not provided protective sleeves, leading to a skin tear. Another resident with cognitive impairments was found without shorts, resulting in self-inflicted scratches. A third resident sustained a skin tear from a side rail left up against care plan instructions. Staff interviews confirmed the care plans were not followed.
The facility failed to maintain ongoing documentation for the supervision of two employees with pending or negative Criminal History Record Check determinations. The employees, a CNA and a Food Service Helper, lacked proper supervision records despite working during their provisional periods. The Infection Control/In-service Coordinator and the Administrator confirmed the absence of required documentation.
The facility did not remove a Food Service Helper from direct care after receiving a negative Criminal History Record Check determination. The employee continued to work on several occasions due to the facility's oversight in checking updates only in the morning, violating state regulations and facility policy.
The facility did not remove a Certified Nurse Aide from direct care after receiving a negative Criminal History Record Check determination. The oversight occurred because the facility's authorized person only checked for updates in the morning, missing the disapproval letter, which allowed the employee to continue working with residents.
The facility failed to submit the 105 Termination Form to the CHRC program within the required thirty days after a Certified Nurse Aide was reassigned and no longer had access to residents. The employee was hired in January and last worked in February, but the form was not submitted until October. The Administrator acknowledged issues with CHRC paperwork and lack of audit documentation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. On one occasion, a resident with a history of aggression due to dementia struck another resident in the face with a walker, causing lacerations and bruising. The aggressive resident had a known history of physical and verbal aggression and was supposed to have a stop sign across their door to prevent others from entering, but it was unclear if this was in place at the time of the incident. The injured resident, who was cognitively impaired and had a hearing deficit, was in pain and required medication following the incident. In another series of incidents, two residents who were roommates engaged in physical altercations on multiple occasions. Both residents had cognitive impairments and histories of aggressive behavior. Despite being placed on 15-minute checks after the first altercation, they remained roommates and continued to have conflicts, including slapping each other and being found crawling on the floor after a struggle. The facility was aware of the incompatibility between the two residents but did not have alternative accommodations available on the secure unit. The facility's policies on abuse prevention and reporting were not effectively implemented, as evidenced by the repeated incidents of resident-to-resident abuse. Staff interviews revealed that there were concerns about the aggressive behaviors of certain residents, but these concerns were not adequately addressed to prevent harm. The facility's failure to ensure proper supervision and intervention contributed to the incidents, and there was a lack of documentation regarding preventive measures such as the placement of stop signs.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. As per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. - A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident. - Resident #68: - Assessments by a Registered Nursing and Physician were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there are no ongoing negative psychosocial impact. - Additional signage will be placed on the resident’s door to deter others from wandering into the resident’s room. - Certified Nursing Aide #1, Social Worker #1, Registered Nurse Head Nurse #2 and Licensed Practical Nurse #1 will receive educational counseling on their role to identify potential for abuse and prevent abuse from occurring including ensuring that preventative measures such as stop signs were in place per plan of care. - Resident #17: - An assessment by a Registered nurse was completed on each altercation between resident #17 and #75. No injuries were identified. - Resident #17’s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging. - A Social Services assessment will be completed to ensure there were no negative psychosocial impact due to the altercations and the subsequent room changes. - Resident #75: - An assessment by a registered nurse was completed upon each altercation with resident #17. No injuries were identified. - Resident #75’s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due possessiveness. - Resident #75 was moved to a private room on a different unit. - A Social Services assessment will be completed to ensure there were no negative psychosocial impact related to the resident to resident altercations. - Licensed Practical Nurse #1 and Certified Nursing Aide #1 will be educated on their role to report resident issues including resident to resident verbal altercations immediately. - Registered Nurse #1 will be educated on their role to put interventions into place to prevent/reduce risk of abuse and prevention of recurrence. - The Director of Nursing and Assistant Director of Nursing were educated on their role to investigate reports of verbal altercations between residents as potential incidents of abuse and institute measures to prevent recurrence. II. As per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed to identify any incidents of actual or potential abuse, neglect or mistreatment. - The care plan of any identified resident will be reviewed and updated accordingly for risk Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness and ensure interventions are initiated in an effort to prevent abuse. - Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. III. As per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Abuse/Neglect – Prevention and Reporting Process” has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. - The facility Comprehensive care planning policy was reviewed and updated by the consultant with administration and nursing leadership to include the requirement to revise the care plan with interventions to prevent recurrence of incidents including abuse. - As per the Directed Plan of Correction, the Consultant has developed and will implement an In-service Program to address: - Abuse Identification, Prevention and Reporting: - All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing any staff alleged to be involved immediately to prevent further abuse and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: - The Administrator, Director of Nursing and facility leadership staff (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence and immediate removal of any staff alleged to be involved. - Regulatory Changes: - All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. - Care Planning: - All nursing leadership and social work staff will be educated by the consultant on the care plan policy updates specific to identifying Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, initiating interventions to prevent or reduce the risk of abuse and revising care plan with interventions to prevent recurrence of abuse. - The facility will monitor for increase resident-resident altercations and or injuries of unknown origin that may signal or alert staff that a problem is potentially evolving. - All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: - As per the Directed Plan of Correction, a Quality Assurance Committee meeting was held on (MONTH) 24, 2024, to examine this deficiency. - An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plan updated accordingly. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assurance Committee monthly for three months. The consultant will participate in Quality Assurance for three months. Frequency of ongoing audits will be determined by the Committee based on audit results. - Consultant will participate in the Quality Assurance Committee Meeting monthly x 3 months. The administrator will be responsible to ensure corrective action is implemented.
Failure to Update Abuse Prevention Policies and Employee Screening
Penalty
Summary
The facility failed to implement and update its policies and procedures to prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. During a complaint investigation and extended standard survey, it was found that the facility's abuse reporting policy, last revised in December 2015, was outdated and did not align with current regulations. Specifically, the policy did not include a timeline for notifying the New York State Department of Health about alleged violations, which is required to be reported immediately or within 24 hours depending on the severity of the incident. This deficiency affected 10 out of 12 residents reviewed. Additionally, the facility did not conduct the required New York State Nurse Aide Registry Verification for an agency Licensed Practical Nurse (LPN) before their employment. The LPN worked multiple shifts at the facility without this verification, which is a necessary step to ensure that employees are screened for any history of abuse. The lack of verification was confirmed during interviews with the Administrator and the Infection Control/In-Service Coordinator, who acknowledged the oversight and the absence of documentation for the verification process. The Director of Nursing and the Administrator admitted to being unaware of the updated regulations for reporting allegations of abuse and neglect. They relied on the Risk Management Team for investigations and expected to receive updates through official communications, which they missed. The facility's failure to update its policies and procedures in accordance with state guidelines resulted in substandard quality of care, with the potential for more than minimal harm to all residents.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 F-607 – Develop/Implement Abuse/Neglect Policies I. Per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: - Resident #17: - Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. - An assessment by a Registered nurse was completed on each altercation. No injuries were identified. - Resident #17’s care plan was reviewed and updated to include potential for Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging. - A Social Services assessment completed to ensure there were no negative psychosocial impacts due to the altercations and subsequent room changes. - Resident #30: - An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #5 will be re-educated on their role to review the care plan prior to providing care. - Resident #42: - An assessment by a Registered nurse was completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #4 is no longer employed by the facility. - Resident #47: - An assessment by a Registered nurse was completed. No injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - An investigation was conducted and allegation unfounded for sexual abuse. - Certified Nursing Assistant #9 was re-educated and was re-assigned from providing care to resident #47. - Resident #68: - Assessments by a Registered Nursing and Physician were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts. - Additional signage will be placed on the resident’s door to deter others from wandering into the resident’s room. - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be updated to include risk of unsafe wandering, risk for victimization due to wandering and behaviors directed at others along with appropriate interventions to address. - A Social Services assessment will be completed to ensure there are no additional ongoing negative psychosocial impacts related to the incident. - Resident #72: - Assessments by a Registered Nursing were completed. No injuries were identified. - A Social Services assessment will be completed to ensure there were no additional negative psychosocial impacts related to the incident. - Resident #75: - Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. - An assessment by a registered nurse was completed following each altercation. No injuries were identified. - The resident was moved to a different unit on 12/11/24. - Resident #75’s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due to possessiveness. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts related to the resident to resident altercations and the subsequent room change. - Resident #95: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Resident #161: - The resident was discharged from the facility on 7/26/24. - A review of the resident’s medical record indicates no additional injuries or negative psychosocial impacts. - Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. - Certified Nursing Assistant #4’s employment was terminated. - A New York State Nurse Aide Registry Verification report was obtained for the Employee Licensed Practical Nurse #4. No findings were noted. - The Administrator, Director of Nursing, and Assistant Director of Nursing were educated on the State Operations Manual timeframe reporting requirements for abuse reporting by the consultant. - The Administrator, Director of Nursing, Assistant Director of Nursing, and the Infection Control/In-Service Coordinator were educated on the requirement for pre-employment screening for all regular and agency staff via the New York Nurse Aide Registry by the consultant. II. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect, or mistreatment. The care plan of any identified resident will be reviewed and updated accordingly for risk of Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, and ensure interventions are initiated in an effort to prevent abuse. - Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. - All regular and agency staff personnel records will be reviewed to ensure the Nurse Aide Registry screening has been completed. III. Per the Directed Plan of Correction the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Abuse/Neglect - Prevention and Reporting Process” has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. - The facility hiring policy will be reviewed by the consultant with administration and nursing leadership and a checklist provided to ensure all pre-employment procedures including Nurse Aide Registry Checks are completed prior to starting work. - As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address: - Abuse Identification, Prevention and Reporting: All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing staff immediately to prevent further abuse, and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: The Administrator and Director of Nursing and facility leadership (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence, and immediate removal of any staff alleged to be involved. - Nurse Aide Registry: All facility leadership staff will be educated by the consultant on the updated hiring policy/process and checklist specifically to ensure the nurse aide registry is reviewed prior to hiring both regular and agency staff. - Regulatory Changes: All leadership staff will be educated by the consultant on their requirement to keep up to date and maintain compliance with all federal and state regulatory changes and to ensure facility policies/procedures align with those changes and staff are educated accordingly. - All training components will be added to initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. - An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect, or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plans updated accordingly. - An audit tool will be developed, and all new hires will be audited weekly for 4 weeks then monthly for 3 months to ensure pre-employment screening, including the nurse aide registry has been completed before hire. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assessment & Assurance Committee monthly for three months. The consultant will participate in the Quality Assessment & Assurance Committee for three months. Frequency of ongoing audits will be determined by the Committee based on audit results. - The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly for 3 months. Responsibility: Director of Nursing
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin within the required timeframes to the State Agency, as mandated by federal and state regulations. Specifically, incidents involving several residents were not reported within the two-hour window for abuse allegations or the 24-hour window for neglect and non-abuse related injuries. This deficiency was identified during a complaint investigation and extended standard survey, affecting 10 out of 12 residents reviewed. One significant incident involved a resident who reported inappropriate touching by a Certified Nurse Aide during incontinent care. The allegation, considered sexual abuse, was not reported to the State Agency within the required two-hour timeframe. Another incident involved a resident-to-resident altercation resulting in physical injuries, which was also not reported promptly. Additionally, there were multiple instances where care plan violations led to injuries, such as skin tears, which were not reported within the required 48-hour period. The facility's outdated policy and procedures, last updated in 2015, contributed to the failure to comply with current reporting regulations. The Director of Nursing and Administrator were unaware of the updated guidelines, leading to delays in reporting incidents to the State Agency. This lack of timely reporting resulted in substandard quality of care, with the potential to affect all residents in the facility.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 I. Per the Directed Plan of Correction the following actions were accomplished for the residents identified in the sample: - Resident #17: - Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. - An assessment by a Registered nurse was completed on each altercation. No injuries were identified. - Resident #17’s care plan was reviewed and updated to include Physically/Verbally Aggressive behaviors and potential for victimization due to wandering and rummaging care plan with appropriate interventions to prevent recurrence. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Resident #30: - An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #5 will be re-educated on their role to review the care plan prior to providing care. - Resident #42: - An assessment by a Registered nurse was completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #4 is no longer employed by the facility. - Resident #47: - An assessment by a Registered nurse was completed. No injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - An investigation was conducted and allegation unfounded for sexual abuse. - Certified Nursing Assistant #9 was re-educated and was re-assigned from providing care to resident #47. - Resident #68: - Assessments by a Registered Nursing and Physician were completed. No injuries were identified. - The resident’s care plan will be reviewed and updated to include risk for Physically/Verbally Aggressive behaviors and appropriate interventions to reduce risk. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts. - Resident #71: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - The resident’s care plan will be reviewed and updated to include wandering risk, risk for victimization due to wandering and behaviors directed at others. - A Social Services assessment will be completed to ensure there were no additional negative psychosocial impacts related to the incident. - Resident #75: - Reports will be submitted to the Department of Health for the 12/10/24 and 12/11/24 incidents. - An assessment by a registered nurse was completed upon each altercation with resident #17. No injuries were identified. - Resident #75’s care plan will be reviewed and updated to include risk of Physically/Verbally Aggressive behaviors and potential for victimization due to possessiveness. - Resident #75 was moved to a private room on a different unit. - A Social Services assessment will be completed to ensure there were no negative psychosocial impacts related to the resident to resident altercations. - Resident #95: - Assessments by a Registered Nursing and Physician were completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Resident #161: - The resident was discharged from the facility on 7/26/24. - A review of the resident’s medical record indicates no additional injuries or negative psychosocial impacts. - Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. - Certified Nursing Assistant #4’s employment was terminated. - The Administrator, Director of Nursing, and Assistant Director of Nursing were educated by the consultant on the State Operations Manual timeframe reporting requirements for abuse reporting by the consultant. II. Per the Directed Plan of Correction the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect, or mistreatment. The care plan of any identified resident will be reviewed and updated accordingly for risk of Physically/Verbally Aggressive behaviors, risk of victimization, risk of wandering, possessiveness, and ensure interventions are initiated in an effort to prevent abuse. - Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. III. Per the Directed Plan of Correction the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Abuse/Neglect – Prevention and Reporting Process” has been reviewed and revised by the consultant with administration and nursing leadership to align with current regulations including reporting timelines. - As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address: - Abuse Identification, Prevention and Reporting: - All facility staff (including risk managers and investigators) will be educated by the consultant on Abuse Identification, Prevention and Reporting including identifying risk, removing any staff alleged to be involved immediately to prevent further abuse, and implementation of interventions to prevent recurrence. - State and Federal Regulations on Incident and Abuse Reporting: - The Administrator, Director of Nursing, and facility leadership staff (including risk managers and investigators) will be educated by the consultant on federal guidelines on Abuse and Incident reporting and their requirement to ensure all incidents are investigated thoroughly, reported timely to the Department of Health, interventions implemented to prevent recurrence, and immediate removal of any staff alleged to be involved. - All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: - As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. - An audit tool will be developed, and all incidents and progress notes will be reviewed daily by the Director of Nursing/designee for 1 month then weekly for 2 months to identify incidents involving abuse, neglect, or mistreatment and ensure they were reported to the Department of Health within required time frames, investigations completed timely, interventions implemented to prevent recurrence including staff involved are removed from providing care as appropriate and care plans updated accordingly. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assessment & Assurance Committee monthly for three months. - Frequency of ongoing audits will be determined by the Committee based on audit results. - The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly x 3 months. Responsibility: Director of Nursing
Failure to Update Abuse/Neglect Reporting Policies
Penalty
Summary
The facility was found to be non-compliant with regulations regarding the administration and implementation of abuse and neglect reporting policies. The policy titled 'Abuse/Neglect - Reporting Process' had not been updated since December 2015, despite changes in regulations occurring between 2020 and 2024. The Director of Nursing and the Administrator were unaware of these updates, as they relied on notifications through a secure online system, which they missed. The outdated policy required incidents to be reported to the Nursing Supervisor and then to the State Health Department within five working days, which may not align with current regulatory requirements. Interviews revealed that the facility's Risk Management Team was responsible for investigating and ruling out abuse or neglect, but the Director of Nursing was unaware of updated reporting regulations. The Administrator admitted that the Policy and Procedure Team, which includes themselves and the Director of Nursing, should have updated the policies to remain compliant. Additionally, a member of the governing board believed that the Administrator was keeping policies up to date, highlighting a lack of oversight and accountability in ensuring compliance with state guidelines.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 Administration has updated the abuse and neglect reporting policies and procedures to reflect current regulatory language. This updated policy will be consistently implemented so that the facility is administered in a manner that enables it to use its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. Special attention will be paid to reporting time-frames to assure information is conveyed within guidelines set forth. An audit of all policies and procedures related to reporting incidents to the New York State Department of Health will be reviewed to assure they reflect the most current guidance. Administration will review state and federal guidance released within the past six months, as well as new guidance as it is released to assure any changes are implemented as directed and that additional staff are educated. The facility has hired a healthcare consultant to assist in establishing methodologies for ensuring compliance with state and federal regulations. The policy related to reporting abuse and neglect has been updated to reflect the most current guidance and to provide clear language of the procedures to be followed so they specifically align with regulations and reporting time-frames. Administrative staff will subscribe to state and federal long term care list serves, and monitor industry organization updates, like those sent by LeadingAge NY, of which the facility is a member. Administrative staff will receive in-service training on this policy and procedure to assure understanding. Audits of incidents reported to the state department of health will be completed as they occur to assure immediate compliance with reporting guidelines. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Administrator will be responsible for ongoing compliance with these corrective measures.
Improper Use of Extension Cords and Power Strips
Penalty
Summary
During a Life Safety Code survey, it was observed that extension cords, power strips, and an electrical adapter were improperly used to supply power to various equipment on both the first and second floors of the facility. On the second floor, a power strip was plugged into another power strip to supply power to two computer tablets in the Medical Records office. The Maintenance Supervisor was unaware of this setup. On the first floor, an electrical adapter was used to power two phone chargers in the Nursing Supervisor's office, and an extension cord was used in a resident's room to power two phone chargers. Additionally, another extension cord was used to power a holiday tree in a resident's room, and yet another extension cord supplied power to a string of lights wrapped around the handrail of the open staircase connecting the first and second floors. The Maintenance Supervisor stated that residents' rooms were supposed to be inspected for extension cords and power strips during monthly bed inspections. However, a review of the monthly Bed Inspections logs revealed that the last inspection occurred in 2024, and there was no documentation indicating that residents' rooms were checked for extension cords and power strips. This lack of awareness and documentation contributed to the deficiency, as the facility failed to maintain electrical safety standards as required by the relevant codes and regulations.
Plan Of Correction
Plan of Correction: Approved March 1, 2025 The power strips, extension cords and adapter found during survey were immediately removed from use. An audit of the entire facility to include resident rooms, offices and common areas will be conducted to assure no other power strips, extension cords and adapter are being utilized with exception to those found to meet the UL and life safety code standards. Any found to be non-compliant will be removed. A review of the facilities policy related to use of power strips, extension cords and adapter has been completed and found to be in compliance with the standards set forth by life safety codes. Maintenance staff will receive education and in-servicing to review this policy and procedure. Random audits of resident rooms, offices and common spaces for non-approved power strips, extension cords and adapters will be completed weekly, for six weeks, to assure ongoing compliance. A new audit form that includes bed inspections, and inspections for extension cords, power strips, and electrical adapters, will be created to document these audits. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Emergency Generator Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its emergency generator and associated systems, as observed during a Life Safety Code survey. Specifically, the facility did not conduct monthly load tests, annual inspections of the main and feeder circuit breakers, or monthly and annual testing of emergency lighting associated with the emergency power supply equipment. During an observation in the basement, the transfer switch for the emergency generator was found in the Electrical room, and the emergency battery backup lighting fixture did not illuminate when tested. The Maintenance Supervisor was unaware of the requirement to test the battery backup lighting fixture monthly for 30 seconds and annually for 90 minutes. Review of logs from 2023 and 2024 showed no documentation of these tests being conducted. Additionally, the Maintenance Supervisor confirmed that there was no documentation of inspections for the main and feeder circuit breakers in 2023 and 2024. The contractor responsible for inspecting, testing, and maintaining the facility's emergency generator also did not conduct these inspections. Furthermore, the emergency generator was not run under load in a specific month of 2024 due to staffing issues, and the transfer switch was not exercised. These deficiencies affected both resident use floors and the basement, indicating a lack of compliance with the required safety standards.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 The following items noted during survey as being deficient: conducting monthly generator load tests, annual inspection of the main and feeder circuits breakers, monthly and annual testing of emergency lighting associated with emergency power supply equipment, and proper function of emergency lighting associated with emergency power supply equipment have all been completed and repaired to meet the life safety code standards. The emergency light fixture is scheduled to be replaced. The facility will complete a facility-wide audit to ensure there are no other battery-powered emergency light fixtures that require testing. The 30 second and 90 minute testing of the emergency light fixtures will occur with the routinely scheduled generator load tests. A contractor has been hired to complete the inspection of the main and feeder circuits breakers and annually going forward. An audit of all generator inspection documents will be completed to assure that routine load tests are completed within the standards of the life safety code. These inspections will be added to existing schedules. A review of the facilities policy related to generator inspections will be completed to assure it contains language that outlines the procedures for proper inspection. The audit documents used for generator inspections will also include the language specific to the monthly generator load tests and testing of the emergency light fixtures. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of generator inspection documents to include the main and feeder circuits breakers, the annual testing of emergency lighting associated with emergency power supply equipment, and emergency lighting associated with emergency power supply equipment, monthly generator load tests, and the monthly 30-second testing, will be completed and documented monthly, for three months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Fire Alarm System Maintenance Deficiencies
Penalty
Summary
The facility's fire alarm system was found to be inadequately maintained during a Life Safety Code survey. Specifically, the smoke detectors were not inspected and tested annually, and the heat detectors and smoke detectors located in elevator shafts were not inspected and tested every 18 months. Additionally, the batteries associated with the fire alarm panel and fire alarm system were not load voltage tested semiannually, and the Notification Appliance Control Panel (NACP) batteries failed load testing. These deficiencies affected both resident use floors and the basement of the facility. Interviews with the Maintenance Supervisor revealed that the contractor responsible for inspecting, testing, and maintaining the fire alarm system did not provide documentation of semiannual load voltage testing of the batteries. Furthermore, issues identified in the fire alarm system inspection and testing report from April 2024 were not addressed, and the contractor did not return to correct these issues. The report also noted that several resident rooms were not tested due to COVID restrictions, and the elevator shaft devices were only simulated for functionality without the elevator company present. The smoke and heat detectors in the elevator shafts had not been tested for 21 months, exceeding the maximum interval allowed by the National Fire Protection Association (NFPA) standards.
Plan Of Correction
Plan of Correction: Approved March 2, 2025 The smoke detectors missed on the annual inspection will be inspected per life safety code standards. The heat and smoke detectors in the elevator shaft not inspected and tested within the last 18 months will be inspected. This test will be coordinated with the vendors who provide elevator service and fire detection services. The batteries associated with the fire alarm panel and fire alarm system that were not load voltage tested semiannually have been tested per life safety code standards. The Notification Appliance Control Panel batteries that failed the load testing have been replaced and now operate per life safety code standards. An audit of the most recent inspection reports has been completed to assure no other heat or smoke detectors were missed and require inspection. Any areas identified as lacking inspection have been inspected per life safety code standards. A review of the facility's policy related to routine testing of building systems, to include fire systems, has been reviewed and updated to include language that clearly outlines the frequency and scope of inspections, as well as who is to complete them. The facility maintenance and administrative staff will utilize electronic calendar reminders to assist in assuring that inspection dates are occurring within the regulatory time frames. All maintenance staff will receive education and in-servicing on this new policy and procedure. An audit of the inspection reports will occur monthly, for any vendor-provided services related to smoke head testing and related fire system tests, for three months, to assure no areas are missed or that vendors return to address any missed items. The maintenance supervisor, or designee, will complete the audits. These audits will be reviewed for proper completion by the maintenance director. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Inadequate Maintenance of Sprinkler System
Penalty
Summary
The facility's automatic sprinkler system was found to be inadequately maintained during a Life Safety Code survey. Observations revealed that numerous sprinkler heads across the facility, including those in the Cedar Unit Tub room, dining room, lounge, Therapy Suite, and various other locations, were loaded and covered with lint, dust, and debris. Some sprinkler heads were also corroded and rusted, requiring replacement. Additionally, an escutcheon was missing from a sprinkler head in the walk-in freezer. The facility lacked documentation verifying that quarterly inspections, testing, and maintenance of the sprinkler system had been completed, and the post indicator valve was seized in the open position. Further inspection above the ceiling tiles on both the first and second floors revealed that sprinkler piping and pipe hangers were improperly used to support external loads, such as temporary lighting, electrical wiring, and junction boxes. These items were attached to the sprinkler system using metal wires and plastic ties, which is not compliant with safety standards. The Maintenance Supervisor acknowledged that the facility did not have documentation for checks conducted on the sprinkler piping when maintenance work was performed above the ceiling tiles. Interviews with the Maintenance Supervisor revealed that the facility had no documentation for the inspection and testing of the automatic sprinkler system for the second quarter of 2023 and the third quarter of 2024. The contractor responsible for inspecting, testing, and maintaining the system did not perform these tasks during the specified periods. Additionally, issues documented in the contractor's inspection reports from October 2024 and January 2025, such as dirty and corroded sprinkler heads in the kitchen, were not addressed, and the contractor did not return to correct these issues.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The sprinkler heads noted in the inspection to not be free of foreign materials were properly cleaned per life safety code standards. The sprinkler heads noted in the inspection to be corroded or rusted have been replaced per life safety code standards. The escutcheon noted in the inspection as missing has been replaced. The sprinkler piping and pipe hangers noted to have been exposed to external loads during inspection have had the loads removed. The quarterly inspection, testing and maintenance of the automatic sprinkler system noted as lacking has been verified and documented. The post indicator valve that was found during inspection to have been seized in the open position will be repaired to proper function. An audit of all of the facilities sprinkler heads will be completed to assure they are free of foreign materials, not corroded or rusted and have escutcheons to meet the life safety code standards. An audit of all ceiling areas containing sprinkler piping and pipe hangers will be completed to confirm they have not been exposed to external loads. There are not other post-indicator valves in the facility. The quarterly inspection, testing and maintenance of the automatic sprinkler system will be audited for completion to assure the facility remains compliant with timely quarterly inspections. Any and all areas found during these audits to be non-compliant will be cleaned, repaired or replaced to assure compliance with life safety code standards. A review of the facilities policy related to sprinkler system inspections will be completed to assure it contains language that outlines the requirements of quarterly sprinkler inspections, to include frequency, scope, documentation, individuals responsible and follow-up procedures on identified issues. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of sprinkler inspection documents, as well as inspection of sprinkler heads and sprinkler piping will be completed monthly, for three months to assure ongoing compliance. These audits will include checking for lint/dust on sprinkler heads, corrosion on sprinkler heads, proper escutcheon placement, checking sprinkler piping for external load, and visual inspection of the post indicator valve. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
During a Life Safety Code survey, it was observed that smoke barrier walls in the facility were not maintained as required. Specifically, the smoke barrier walls on both the first and second floors were found to have unsealed penetrations, which compromised their ability to resist the passage of smoke and maintain a 30-minute fire resistance rating. On the second floor in the Cedar Unit, a two-inch long by one-inch wide open penetration was found above the smoke barrier doors. Similarly, on the first floor in the Evergreen Unit, a 16-inch long by three-inch wide open penetration was observed. The Maintenance Supervisor confirmed that no recent work had been conducted on these walls and stated that the facility's smoke barrier walls were inspected twice a year, although no documentation of these inspections was available.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 Q1. Per the Directed Plan of Correction, the following actions were accomplished for the residents identified in the sample. - No residents were negatively impacted. - Penetrations were sealed in the smoke barrier wall above the smoke barrier doors separating Cedar Unit from the second floor corridor. - Penetrations were sealed in the smoke barrier wall above the smoke barrier doors separating the Evergreen Unit from the first floor corridor. Q2. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - A visual inspection of the facility will be conducted to ensure all visible penetrations are properly sealed. Q3. Per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: - The facility fire protection policy was reviewed by the consultant with Administration and the Director of Maintenance without changes. - As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program to address - All maintenance staff will be re-educated on the policy specific to ensuring thorough inspection of the facility to ensure all areas of penetrations are identified and properly sealed by the consultant. - All training components have been added to the initial orientation and annual education for facility maintenance staff. Q4. The facility’s compliance will be monitored utilizing the following quality assurance system: As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. - The Director of Maintenance will inspect any areas of contractor work for potential areas of penetrations immediately following the conclusion of scope of work. - The Director of Maintenance will provide quarterly reports on contracted work and subsequent inspections to the Quality Assurance Performance Improvement committee for the next 12 months. - Frequency of ongoing audits will be determined by the Committee based on audit results. - The consultant will participate in the Quality Assessment & Assurance Committee Meeting monthly x 3 months. Responsibility: The Director of Maintenance
Violation of Resident Dignity and Rights
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination, as evidenced by an incident involving a certified nurse aide (CNA) and a resident with diagnoses including anxiety, a fractured right humerus, and diabetes. The resident, who was cognitively intact, experienced an inappropriate interaction with CNA #4. The CNA provided care despite the resident's refusal, leading to feelings of shame and humiliation. The incident occurred when CNA #4 touched the resident in the genital area without announcing their presence and continued to do so even after the resident asked them to stop. Later, the CNA insisted on providing personal hygiene care despite the resident's preference to perform their own care, further violating the resident's dignity. Interviews with other staff members, including a registered nurse, a licensed practical nurse, and a social worker, confirmed that CNA #4's actions were inappropriate and violated the resident's rights. The resident was visibly upset and embarrassed by the incident, which was reported to have occurred in the early hours of the morning. The facility's policy on resident choice and rights emphasizes the importance of respecting residents' decisions and maintaining their dignity, which was not upheld in this case. The Director of Nursing acknowledged the dignity concern, and the CNA involved denied the allegations, stating they would not force care on a resident who refused it.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The resident noted to be adversely affected by an employee’s action which denied them their right to be treated with respect and dignity was assured that employee would no longer provide them care. The resident was seen by the social worker post incident but declined to discuss the incident further. The resident has since discharged. The employee cited in the deficient practice was immediately removed from duty upon notification of the event, did not return to work post incident and is no longer employed at the facility. All residents have the potential to be affected. All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify any incidents of actual or potential abuse, neglect or mistreatment. Any identified incident will be reviewed to ensure each has been thoroughly investigated, reported timely to the Department of Health, staff alleged to have committed abuse immediately removed from contact with residents, care plans updated, and measures have been initiated to prevent recurrence. The facility policy for Resident Rights has been reviewed and remains appropriate. Resident Rights in-servicing is mandatory yearly for all facility staff and is part of the orientation program for new hires. Printed versions of the New York State Resident Rights Handbook are readily available on all units and in common areas. The facility completes satisfaction surveys quarterly with responsible parties and monthly with a random selection of long-term residents and new admissions. All facility staff will receive additional in-service training, specific to the residents' right to refuse care, and to always be treated with dignity and respect. These corrective actions will be monitored via random unannounced resident-care audits to assure all physical care interactions and verbal communications are conducted in a manner that affords the resident dignified, respectful care. Ten compliance audits will be completed by nurse managers/their designees, weekly for six weeks. These audits will include completion with families or responsible parties of those cognitively impaired to ensure treatment of [REDACTED]. These audit results will be placed on the agenda of both the monthly (for the next three months) and the quarterly Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Nursing will be responsible for ongoing compliance with these corrective measures.
Smoke Barrier Doors Not Properly Maintained
Penalty
Summary
During a Life Safety Code survey, it was observed that the smoke barrier doors on the first floor of the Evergreen Unit did not close properly, leaving a gap greater than one quarter inch between them. This gap compromised the doors' ability to prevent the passage of smoke, affecting one of the two resident use floors. The Maintenance Supervisor confirmed that the facility's maintenance staff conducted monthly checks on the smoke barrier doors, as documented in the Security Door Checks logs from February 2023 through January 2025. However, these logs did not record any issues regarding the gap between the doors, indicating a failure to identify and address the deficiency during routine inspections.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The unit smoke barrier doors found during survey not close the opening between them, leaving more than the minimum clearance necessary to prevent the passage of smoke have been repaired with vertical door seals to assure they meet life safety code standards. An audit of all facility smoke barrier double-doors will be completed to assure they do not contain vertical gaps that would allow passage of smoke. Any areas identified as not properly closing and allowing an opening between them will be repaired per life safety code standards. A review of the facilities policy related to door inspections will be completed to assure it contains language that outlines the procedures for proper inspection to include closing, latching, and not having a gap in the opening between them if they are double doors. The audit documents used for door inspections will also include the language specific to the procedure. All maintenance staff will receive education and in-servicing on this new policy and procedure. Random audits of smoke barrier doors will be completed monthly, as part of the security door check audits, for three months to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Improper Storage of Alcohol-Based Hand Rub
Penalty
Summary
During a Life Safety Code survey, it was observed that alcohol-based hand rub (ABHR) was improperly stored in the facility's basement. Specifically, 73 liters (equivalent to 19.28 gallons) of ABHR were stored in the Supplies storage room on open shelving, which is located across from the Boiler room. This storage method did not comply with the 2012 edition of the National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code, which requires that quantities greater than 10 gallons be stored in a flammable liquids storage cabinet. During an interview, the Maintenance Supervisor admitted to storing the ABHR in the Supplies room and was unaware of the regulations regarding the storage of ABHR in quantities exceeding 10 gallons.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The excess (greater than 10 gallons) volume of alcohol-based hand sanitizer noted during the survey has been removed and redistributed to meet life safety code standards. An audit of other housekeeping storage areas has been completed to identify any other areas that had quantities beyond those allowed by regulation. No other areas were identified to be in violation of this life safety code standards. A review of the facility's storage procedures has been completed to assure proper storage of alcohol-based hand sanitizers. The facility will also reduce on-site inventory of hand sanitizer to avoid the potential for excess storage in potentially hazardous areas. All maintenance and housekeeping staff will receive education and in-servicing on this new policy and procedure. Random audits of housekeeping storage areas will be completed weekly, for six months, to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Deficiency in Kitchen Hood Extinguishment System Maintenance
Penalty
Summary
The deficiency identified during the Life Safety Code survey pertains to the maintenance of the kitchen hood extinguishment system in the facility's basement kitchen. The system was not inspected every six months as required. The Maintenance Supervisor revealed that the contractor responsible for inspecting, testing, and maintaining the system was scheduled to perform an inspection in 2023. However, due to a transition between companies, the inspection was not completed as scheduled. The system was last inspected on March 9, 2023, and October 6, 2023, with issues cited in the October report being corrected by a re-inspection on October 16, 2023. Additionally, the manual pull station for the kitchen hood extinguishment system was not inspected monthly, as required. During an observation in the basement kitchen, it was noted that the tag attached to the manual pull station lacked documentation for monthly inspections for October, November, and December of 2024. The Maintenance Supervisor admitted to being unaware of the requirement for monthly inspections of the manual pull station, and there was no documentation available for these inspections in the facility's records. This oversight was confirmed by reviewing the Fire Extinguisher Monthly Checklist, which also lacked documentation for the required monthly inspections.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The hood extinguishment system identified during survey as having not been inspected every six months, has had timely inspections since the occurrence in 2023, per life safety code standards. The manual pull station for the hood extinguishment system pull station identified as lacking the required monthly inspection has been inspected and is working properly. The facility has only one hood extinguishment system, so there is nothing further affected by the deficient practice. An audit of the facilities pull-stations will be completed to identify any others that may have lacked monthly inspections. Any identified as having been missed will be inspected per life safety code standards. A review of the policy related to inspections of the hood extinguishment system and pull stations has been completed with updates made to specify frequency and documentation of inspections. All maintenance staff will receive education and in-servicing on this new policy and procedure. Audits of the monthly pull-station inspection will be completed to assure all pull-stations are inspected, including the hood extinguishment system, for three months to assure ongoing compliance. Audits of the hood extinguishment system’s six-month inspections will occur via electronic calendar reminders to the maintenance supervisor and administration, as a mechanism to assure scheduled inspections are not missed. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Failure to Maintain Hazardous Area Door in Basement
Penalty
Summary
A hazardous area in the basement of the facility was not maintained properly, as observed during a Life Safety Code survey. The door to the clean linen storage room, which is a hazardous area, failed to self-close and latch into its door frame. This room was larger than 50 square feet and contained multiple clean linen carts and shelving units filled with clean linen. During the observation, the Maintenance Supervisor acknowledged that the door's self-closing device had been replaced multiple times and that the top hinge was broken. The Maintenance Supervisor also mentioned that both the door and its frame required replacement. Additionally, the facility lacked documentation for audits of hazardous area doors, as stated by the Maintenance Supervisor during a subsequent interview.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The door identified during the survey as not self-closing and latching into its door frame has been repaired to and is currently working properly and per regulation. The facility is in the process of obtaining quotes to ultimately replace the door, which will occur post survey compliance date. An audit and review of all facility self-closing doors has been completed to assure that they are also closing and latching fully into their frames. Any other doors found to be malfunctioning will be repaired to assure they self-close and latch fully into the door frame. A review of the facility's policy related to the routine inspection of self-closing and latching doors has been completed to assure it contains language specifying the frequency and scope of such checks. Door audits will be documented and maintained in a binder within the maintenance department. All maintenance staff will receive education and in-service training on this updated policy and procedure. An audit of all self-closing and latching doors will be completed weekly for six weeks to assure all doors are operating per regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Failure to Implement Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to implement care plans as intended for three residents, resulting in minor injuries. Resident #30, who had diagnoses including dementia and rheumatoid arthritis, was supposed to wear protective sleeves to prevent skin tears due to fragile skin. On 9/13/24, the resident was not wearing the sleeves and sustained a skin tear while repositioning in their wheelchair. Certified Nurse Aide #5 admitted to not providing the sleeves due to being pulled to another unit, which led to the oversight. Resident #42, with severe cognitive impairments and a history of self-inflicted scratches, was care planned to wear shorts at all times to prevent self-harm. On 12/6/24, the resident was found without shorts and had scratches on their left hip. Certified Nurse Aide #4, unfamiliar with the resident, did not review the care plan and failed to put the shorts on, leading to the injury. Other staff members confirmed the oversight and noted that the care plan was not followed. Resident #161, who was cognitively intact and required assistance for bed mobility, had a care plan specifying that side rails should only be up during care. On 5/9/24, the resident sustained a skin tear after hitting their arm on a side rail that was left up when care was not being provided. Certified Nurse Aide #7 did not recall the incident, but it was confirmed that the care plan was not followed, resulting in the injury. Interviews with staff highlighted the expectation that care plans should be reviewed and followed to prevent such incidents.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 F-656 – Develop/Implement Comprehensive Care Plan I. Per the Directed Plan of Correction, the following actions were accomplished for the residents identified in the sample: - Resident #30: - An assessment by a Registered nurse was completed. No additional injuries were identified due to the deficient practice. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #5 was re-educated on their role to review the care plan prior to providing care. - Resident #42: - At Risk for Skin Integrity Impairment care plan due to self-inflicted scratching and the need to wear shorts as an intervention will be implemented. - An assessment by a Registered nurse was completed. No additional injuries were identified. - A Social Services assessment completed to ensure there were no negative psychosocial impacts. - Certified Nursing Assistant #4 is no longer employed by the facility. - Resident #161: - The resident was discharged from the facility on 7/26/24. - An assessment by a Registered nurse was completed at the time of the incident. No additional injuries were identified. - A review of the resident’s medical record indicated no additional negative impacts from the deficient practice. - Certified Nursing Assistant #12 was re-educated on their role to review the care plan prior to providing care. II. Per the Directed Plan of Correction, the following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected. - All resident progress notes and incident reports for the past 60 days will be reviewed by the Director of Nursing/designee to identify potential incidents related to a failure to follow the care plan. Any incidents will be investigated, reported accordingly, and staff re-educated as appropriate. III. Per the Directed Plan of Correction, the following system changes will be implemented to ensure continuing compliance with regulations: - The policy titled “Comprehensive Care Plans” has been reviewed by the consultant with administration and nursing leadership and no changes were indicated. - As per the Directed Plan of Correction, the Consultant has developed and implemented an In-service Program. - All facility nursing staff (Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides) will be educated by the consultant on the Comprehensive Care Plans policy and ensuring that care plans be reviewed prior to providing care and followed as documented. - All training components will be added to the initial orientation and annual education for facility and agency staff. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: - As per the Directed Plan of Correction, a Quality Assessment & Assurance Committee meeting was held on (MONTH) 24, 2025, to examine this deficiency. - An audit tool will be developed, and all incidents will be reviewed daily by the Director of Nursing/Designee for 1 month then weekly for 2 months to ensure all incidents of failure to follow the care plan are identified, reported timely, and staff educated as appropriate. - Any issues of non-compliance will be addressed at the time of the audit and referred to the Administrator for further education and disciplinary action as indicated. - Audit results will be reported to the Quality Assessment & Assurance Committee monthly for three months. - Frequency of ongoing audits will be determined by the Committee based on audit results. - The consultant will participate in Quality Assessment & Assurance Committee Meeting monthly x 3 months. Responsibility: Director of Nursing or Designee
Failure to Document Supervision for Employees with Pending Criminal History Checks
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements during a standard survey. Specifically, the facility did not maintain continuing documentation for the weekly supervision of two employees who were subject to the Criminal History Record Check and had not yet received a determination letter from the Criminal History Record Check Legal Review Unit. Employee #6, a Certified Nurse Aide, was hired on January 26, 2024, and had a negative determination letter dated February 9, 2024. However, the only supervision documentation available was for January 31 and February 1, 2024, despite the employee working on February 11, 2024. Similarly, Employee #7, a Food Service Helper, was hired on November 7, 2023, and had a pending denial letter dated February 15, 2024. The supervision documentation for this employee was only available for select dates in November and December 2023, even though the employee worked multiple days in February 2024. Interviews with the Infection Control/In-service Coordinator, who was the Authorized Person for Criminal History Record Check, revealed that they were not involved in the Criminal History Record Check process when these employees were hired. The facility's Administrator confirmed that the only supervision documentation available for both employees were the initial Criminal History Record Check Direct Supervision Dates of Provisional Period sheets. This lack of ongoing supervision documentation for employees with pending or negative determination findings constitutes a deficiency in meeting the state's requirements.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employees found to have been missing their criminal history record check weekly supervision documentation have since been cleared for employment and no longer require weekly supervision or documentation of supervision. A review of the last three months of new hires will be completed to determine if any other employees were missing their criminal history record check weekly supervision documentation. Those identified as missing supervision will be noted, and if they continue to lack final criminal history record check clearance for employment, supervision will resume as required by state regulation. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for employee supervision when record check results are pending. A supervision sheet for each employee is created and held within the department providing supervision to the new employee. When final criminal history record check results are received, the supervision document will be marked complete and filed. Staff will be educated to ensure documentation for the weekly supervision of employees that were subject to the New York State Department of Health Criminal History Record Check and had not yet received a determination letter from the Criminal History Record Check Legal Review Unit. All supervisory staff will be educated on these procedures. An audit of criminal history record check supervision documents will be completed weekly for eight weeks to assure that new employees are being supervised weekly per state regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures.
Failure to Remove Employee After Negative CHRC Determination
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements by not immediately removing an employee from direct care or supervision of residents upon receiving a negative determination letter. Employee #7, a Food Service Helper, was hired on 11/7/23, and a negative determination letter was issued on 2/15/24. Despite this, the employee continued to work in the facility on multiple occasions after the letter was received, specifically on 2/15/24, 2/17/24, 2/18/24, 2/20/24, and 2/21/24. The facility's policy required immediate removal of any employee with a disapproval letter from direct care or supervision of residents. However, the facility's Criminal History Record Check Authorized Person at the time was only checking for updates in the morning, which led to missing the Pending Denial letter for Employee #7. This oversight resulted in the employee continuing to perform duties that involved physical access to residents' living quarters and face-to-face care, contrary to the facility's policy and state regulations.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employee not immediately removed for direct contact or supervision of residents upon receiving New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter (Pending Denial) was removed from direct contact once the determination letter was viewed and has since been cleared to return to employment at the facility. A review of the last three months of new hires will be completed to determine if any other employees were not immediately removed for direct contact or supervision of residents upon receipt of New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter documentation. No other employees were found. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for frequently checking the criminal history check result reports to assure that any negative determination letters are acted upon immediately, without delay. Additionally, systems will be in place for alternate authorized users of the New York State Department of Health Criminal History Record Check (NYSDOH CHRC) to check for results in the absence of the primary user. Staff will be educated to ensure employees are immediately removed from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. Authorized persons and supervisory staff will be educated on this procedure. An audit of criminal history record check online results will be completed weekly for eight weeks to assure that any negative determination letters are viewed and acted upon the day of receipt. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures.
Failure to Remove Employee After Negative CHRC Determination
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements by not immediately removing an employee from direct care or supervision of residents upon receiving a negative determination letter. Specifically, Employee #6, a Certified Nurse Aide, was hired on January 26, 2024, and a negative determination letter dated February 9, 2024, was found in their file. Despite this, the employee continued to work on February 11, 2024, indicating a lapse in the facility's protocol for handling such determinations. The deficiency occurred because the facility's Criminal History Record Check Authorized Person was only checking for updates in the morning and missed the negative determination letter for Employee #6. This oversight allowed the employee to continue working with residents, contrary to the facility's policy, which mandates immediate removal from direct care upon receiving a disapproval letter. The Administrator acknowledged this procedural gap during an interview, highlighting the failure to adhere to the established policy and procedure for Criminal History Record Checks.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employee not immediately removed for direct contact or supervision of residents upon receiving New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter (Hold in Abeyance) was removed from direct contact once the determination letter was viewed and has since been cleared to return to employment at the facility. A review of the last three months of new hires will be completed to determine if any other employees were not immediately removed for direct contact or supervision of residents upon receipt of New York State Department of Health Criminal History Record Check (NYSDOH CHRC) negative determination letter documentation. No other employees were found. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for frequently checking the criminal history check result reports to assure that any negative determination letters are acted upon immediately, without delay. Additionally, systems will be in place for alternate authorized users of the New York State Department of Health Criminal History Record Check (NYSDOH CHRC) to check for results in the absence of the primary user. Staff will be educated to ensure employees are immediately removed from direct care or supervision of residents upon receiving a New York State Department of Health Criminal History Record Check (CHRC) negative determination letter for the employee. Authorized persons and supervisory staff will be educated on these procedures. An audit of criminal history record check online results will be completed weekly for eight weeks to assure that any negative determination letters are viewed and acted upon the day of receipt. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures.
Failure to Timely Submit CHRC Termination Form
Penalty
Summary
The facility failed to comply with the New York State Department of Health Criminal History Record Check requirements. Specifically, the facility did not submit the 105 Termination Form to the Criminal History Record Check (CHRC) program within thirty days after an employee, who was reassigned from direct care or supervision of residents, no longer had access to residents and their belongings. This deficiency was identified during a standard survey, affecting one of two employees reviewed for CHRC negative determination findings. The employee in question, a Certified Nurse Aide, was hired on January 26, 2024, and last worked at the facility on February 11, 2024. However, the CHRC Termination Form 105 for this employee was not submitted until October 4, 2024, well beyond the required thirty-day period. During an interview, the facility's Administrator acknowledged issues with the CHRC paperwork managed by the previous Infection Control/In-Service Coordinator, who was the authorized person for CHRC. The facility conducted audits of the paperwork but did not maintain documentation of these audits. The facility's policy, dated September 2021, mandates a CHRC for all new non-licensed employees providing care or supervision to residents and requires notification to the CHRC program within thirty days of an employee's withdrawal or termination. The failure to adhere to this policy resulted in the cited deficiency.
Plan Of Correction
Plan of Correction: Approved March 3, 2025 The employee whose 105 Termination Form was not submitted to the New York State Department of Health Criminal History Record Check program within thirty days of terminations has had that termination form submitted. The facility no longer has them as an active employee in our New York State Department of Health Criminal History Record Check roster. A review of the last three months of terminations will be completed to determine if any other employees were missing their 105 Termination Form. Those identified as missing the form will be noted, and will have it submitted as required by state regulation. The policy related to criminal history record checks has been reviewed (and revised) to include language that clearly specifies the requirements for terminating employees, via a 105 Termination Form, out of the system when they are no longer employed by the facility. Staff will be educated to ensure the 105 Termination Form will be submitted to the New York State Department of Health Criminal History Record Check (CHRC) program within thirty days of an employee being reassigned from the direct care or supervision of residents, and no longer having access to residents and their belongings. Authorized persons and supervisory staff will be educated on these procedures. An audit of criminal history record check documents will be completed weekly for six weeks to assure that terminated employees have been removed from the New York State Department of Health Criminal History Record Check system per state regulation. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Infection Control/Inservice Coordinator (Authorized Person for Criminal History Check) will be responsible for ongoing compliance with these corrective measures.
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.
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.
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.
Surveyors found that the facility’s most recent assessment of its 140-bed operation, including rehab, stepdown medically complex, and LTC dementia/chronic illness units, did not adequately specify how necessary resources are maintained for resident care. The assessment lacked a breakdown of bed capacity per unit and, under its staffing plan, only generally stated that staffing is based on census and acuity and reviewed each shift, with additional RNs scheduled for multiple admissions. It failed to identify contingency planning for non-emergency events that could affect direct care nurse staffing or other care resources, and it did not describe any plan to maximize recruitment and retention of direct care staff, resulting in a deficiency under 10NYCRR S415.26.
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 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 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.
Inadequate Facility-Wide Assessment of Resources and Staffing Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document an adequate facility-wide assessment that determines what resources are necessary to care for residents competently during day-to-day operations and emergencies. During an Abbreviated Survey, record review of the most recent facility assessment, dated on an unspecified date and reviewed by the QAPI Committee on 09/04/2025, showed that the assessment did not sufficiently identify how the facility maintains necessary resources for resident care. The assessment described the facility as a 140-bed SNF with four nursing units (one rehabilitation unit, one stepdown medically complex unit, and two LTC units for residents with dementia and other chronic illnesses), but it did not provide a breakdown of bed capacity per unit. Under the staffing plan section, the assessment stated that staffing is based on resident census and acuity, is reviewed prior to each shift, and that the facility intends to assign the same staff to units and schedule additional RNs for multiple admissions. However, the assessment did not adequately identify contingency planning for events that do not trigger the formal emergency plan but could still affect resident care, such as issues with availability of direct care nurse staffing or other needed resources. Additionally, the assessment did not identify how the facility develops or maintains a plan to maximize recruitment and retention of direct care staff, as required by 10NYCRR S415.26.
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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