Tolstoy Foundation Rehabilitation And Nrsg Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Valley Cottage, New York.
- Location
- 100 Lake Road, Valley Cottage, New York 10989
- CMS Provider Number
- 335311
- Inspections on file
- 16
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 47 (2 serious)
Citation history
Health deficiencies cited at Tolstoy Foundation Rehabilitation And Nrsg Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not initiate or update care plans for a resident at high risk for falls who later experienced a fall, and for two residents involved in a physical altercation, despite existing care plans for abuse. Staff interviews confirmed that care plans were not revised to reflect these incidents or to implement new interventions as required.
A resident with cognitive impairment physically struck their roommate, who had multiple medical conditions, during a verbal altercation. Both residents had care plans addressing abuse risk and cognitive issues, but the incident still occurred, indicating a failure to protect residents from abuse as required by facility policy.
A resident with moderate cognitive impairment and mobility limitations was found with floor mats propped upright against their bed, secured by night tables, preventing movement out of bed. This setup, implemented by a CNA who believed it would prevent falls, constituted a physical restraint without a physician order or documented medical need, contrary to facility policy. Staff interviews confirmed the mats should have been placed flat on the floor, and the incident was identified during a federal survey.
The facility did not promptly report suspected abuse incidents or submit required investigation results to the state health department for two residents. In one case, a resident was physically restrained with floor mats and furniture, and in another, a resident reported being struck by a roommate. Both incidents were not reported or concluded within the required timeframes.
A resident with significant medical needs experienced a witnessed fall while attempting an independent transfer, despite prior instructions to seek assistance. The required accident/incident report was incomplete, lacking an investigative summary, staff statements, and documentation of family notification, contrary to facility policy. The RN involved cited short staffing and multiple duties as reasons for not completing the investigation.
A resident with severe cognitive impairment and multiple pressure ulcers did not have their care plan updated to reflect the development and progression of a sacral/buttocks pressure ulcer. The care plan only addressed a heel ulcer, omitting documentation of the additional wound, its measurements, treatments, and physician findings, despite regular wound care assessments and communication. Nursing leadership confirmed that care plan updates were expected but not completed as required.
A resident admitted with significant comorbidities was found to have a Stage 2 pressure ulcer during the admission skin check, but the physician was not notified and no treatment orders were obtained, contrary to facility policy. Nursing staff and the DON confirmed this oversight, resulting in a failure to provide necessary care and services for the pressure ulcer.
A resident with severe cognitive impairment was reportedly abused by a CNA, who was witnessed punching the resident in the head. Despite the lack of physical evidence and the resident's inability to communicate, the facility terminated the CNA to ensure safety. The incident highlighted a deficiency in the facility's abuse prevention measures, as there was no documented risk for abuse care plan for the resident.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with severe cognitive impairment. A visitor reported seeing a CNA physically assault the resident, but the facility did not obtain a written statement from the CNA or assess other residents under their care. Despite assessments by medical staff, the investigation lacked comprehensive documentation, leading to an unsubstantiated conclusion.
The facility did not complete annual performance appraisals for its Certified Nurse Aides, as required. During a survey, it was discovered that appraisals were not documented for five aides, with the most recent appraisals dating back several years. The Director of Human Resources confirmed that the Nursing Department had not completed the necessary appraisals, despite a recent initiative to update them.
The facility failed to maintain an effective infection control program, with deficiencies in linen handling, water management, and contact precautions for a resident with C. Diff. Clean linens were transported uncovered, and staff did not practice proper hand hygiene. The facility lacked a current Water Management Plan, and staff were not educated on Legionella prevention. Additionally, appropriate contact precautions were not implemented for a resident with C. Diff, with staff observed not wearing required PPE and inadequate signage and PPE availability.
The facility did not ensure proper documentation of COVID-19 vaccination status for three staff members, as identified during a recertification survey. The Assistant DON acknowledged efforts to encourage vaccination, but many staff were resistant, and records from HR did not show screening or offering of the vaccine.
A resident developed an unstageable sacral pressure ulcer, but the facility failed to notify the resident's family as required by the care plan. Despite documentation of the ulcer and treatment recommendations, there was no record of family notification, which was confirmed by the Assistant Director of Nursing.
A resident with multiple diagnoses reported an incident of sexual abuse during a shower to the facility Administrator. The Director of Nursing was informed and began an investigation but failed to report the allegation to the New York State Department of Health within the required two-hour timeframe, mistakenly believing they had 24 hours to do so.
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet needs in ADLs and specific medical conditions. Interviews revealed confusion among staff regarding responsibility for care plan initiation and updates, contributing to the deficiencies identified.
The facility did not ensure that certified nurse aides received the required training in dementia care and abuse prevention. Documentation for two nurse aides was missing, and the MDS Nurse/Staff Educator confirmed the inability to locate the necessary records.
Two residents with severe cognitive impairments were not provided a dignified dining experience. A CNA stood over one resident while assisting with meals, contrary to facility policy, and another resident was inappropriately referred to as a "feeder". Despite being advised to sit, a CNA stood over the second resident during meals, citing a lack of chairs.
A facility failed to ensure a resident's right to formulate advance directives, as there was no physician's order for such directives. The resident, with moderately impaired cognition and serious medical conditions, had a MOLST form signed by the resident but not by a physician, leading to conflicting instructions regarding life-sustaining treatments. Staff interviews revealed a lack of awareness and proper documentation of the resident's advance directives.
The facility failed to provide written notification to two residents and their representatives about hospital transfers, and did not notify the Ombudsman. Both residents had intact cognition and were transferred without documented notice. The Director of Social Work confirmed the absence of required notices in the residents' files.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during hospital transfers. Despite having intact cognition, these residents, with conditions such as diabetes and hypertension, were transferred without receiving the required notification. The Director of Social Work confirmed the absence of documentation, indicating that the responsibility lay with the nurse on duty after hours and an administrative staff person during business hours.
A resident's MDS 3.0 admission assessment was not completed within the required 14 days, as it was submitted late by the facility's MDS/Discharge Planning Coordinator. The resident, with conditions including diabetes and dementia, was admitted, but the assessment was delayed beyond the mandated timeframe.
The facility failed to ensure that PASRR assessments were signed and included digital IDs for three residents before admission. Interviews revealed confusion over responsibility for verifying these documents, with the Director of Admissions or Outreach Coordinator expected to ensure completion.
A newly admitted resident with an unstageable pressure ulcer and other conditions did not have a baseline care plan developed within 48 hours, as required by facility policy and CMS regulations. The omission was due to staffing issues, with the RN on duty unable to complete the plan due to time constraints.
The facility's designated Infection Preventionist, the Assistant DON, did not complete the required specialized training in infection prevention and control before assuming the role. The IP had outstanding training modules, including Antibiotic Stewardship and Occupational Health, and only completed the necessary training after the survey began.
Failure to Develop and Update Comprehensive Care Plans After Clinical Events
Penalty
Summary
A deficiency was identified in the facility's development and implementation of comprehensive, person-centered care plans for residents. Specifically, for three residents reviewed, the facility failed to initiate or update care plans in response to significant clinical findings and incidents. One resident, admitted with multiple diagnoses including diabetes mellitus and end stage renal disease, was assessed as high risk for falls upon admission, but there was no documented evidence that a fall risk care plan was initiated. This resident later experienced a fall when attempting to self-transfer from bed to chair. Another incident involved two residents who were roommates. One resident reported being struck by the other following a verbal disagreement. Although both residents had existing care plans noting potential for abuse, there was no documentation that these care plans were updated to reflect the incident or that new interventions were implemented. The resident who was struck was relocated for safety, but the care plan documentation did not reflect this event or any subsequent changes in interventions. Interviews with facility staff, including registered nurses and directors of nursing, confirmed that care plans should be initiated or updated when assessments trigger specific care areas or after incidents occur. However, in these cases, the required updates and documentation were not completed as per facility policy and regulatory requirements. The lack of timely and appropriate care plan development and revision was observed through record reviews and staff interviews during the survey.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident reported being physically struck by their roommate during a verbal altercation. The incident involved one resident propelling their wheelchair to the other side of the shared room and striking the other resident twice on the left chest and neck area. Documentation showed that both residents had care plans addressing potential for abuse and impaired cognitive function, with interventions such as monitoring behaviors and assessing needs. Despite these plans, the altercation occurred, and the incident was reported as required by facility policy. The resident who was struck had diagnoses including atrial fibrillation, hypotension, and cardiomegaly, and was cognitively intact but required assistance with daily activities. The other resident had acute kidney failure, hypotension, hyperlipidemia, and moderate cognitive impairment, with a history of impaired thought processes. The facility's policies required immediate reporting and individualized monitoring for residents at risk of altercations, but the event still took place, indicating a failure to protect the resident from abuse as required.
Improper Use of Physical Restraint with Upright Floor Mats
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and multiple medical diagnoses, including metabolic encephalopathy and muscle weakness, was found in bed with floor mats propped upright against the bed and held in place by two wooden night tables. This arrangement prevented the resident from moving out of bed, effectively acting as a physical restraint. The resident required moderate assistance for bed mobility and was dependent for transfers and toileting, with no documented physician order for restraints or side rails in use. The facility's Restraint-Free Environment policy states that restraints are only to be used for the safety and well-being of residents and only after all alternatives have been tried unsuccessfully, and never for staff convenience or fall prevention. Despite this, a Certified Nurse Aide was responsible for placing the mats in this manner, believing it would prevent the resident from rolling out of bed and ensure safety. The incident was discovered during a federal survey, and interviews revealed that the mats were intentionally positioned upright and secured, rather than being placed flat on the floor as intended. Further investigation showed that the resident was bedridden, required a two-person assist for transfers, and had difficulty bearing weight. Staff interviews confirmed that the mats should not have been positioned upright, as this constituted a restraint. There was no evidence of physical harm to the resident, but the use of the mats in this way was not in accordance with facility policy or regulatory requirements, and there was no documented medical need or order for such a restraint.
Failure to Timely Report Suspected Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse and the results of related investigations to the New York State Department of Health for two out of three residents reviewed for abuse. In the first instance, a resident with diagnoses including metabolic encephalopathy, depression, and muscle weakness was found in bed with floor mats propped up against the bed and held in place by two wooden night tables, preventing the resident from exiting. The responsible certified nurse aide believed this would prevent the resident from rolling out of bed. Although the facility's investigation did not substantiate a breach in quality of care, the use of mats in this manner constituted a physical restraint. The incident was not reported to the Department of Health until the following day, and the 5-day investigative conclusion was not submitted until over a year later. In the second instance, a cognitively intact resident reported being struck twice on the chest/neck area by their roommate following a verbal disagreement. The incident was unwitnessed, and a full body and skin assessment revealed no injuries. However, the 5-day investigative conclusion for this incident was not submitted to the Department of Health until six days after the event. The facility's policy required immediate reporting of suspected abuse and submission of investigative results within five business days, but these requirements were not met in either case.
Incomplete Investigation Following Resident Fall
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following a fall involving a resident with multiple diagnoses, including diabetes mellitus, end stage renal disease, and benign neoplasm of the duodenum. The resident, who was cognitively intact but required maximal assistance with transfers and had upper extremity impairments, experienced a witnessed fall while attempting to transfer independently from bed to chair, despite prior instructions to seek assistance. The accident/incident report for this event was incomplete, lacking an investigative summary and staff statements, and there was no documentation that the resident's representative was notified of the fall. According to facility policy, an investigation should be initiated for any outward event, such as a fall, and should include staff interviews and statements from those present during the incident. However, the Registered Nurse who witnessed the fall did not complete the required incident report or obtain statements from Certified Nurse Aides, citing short staffing and multiple responsibilities as reasons. The only documentation provided was a progress note, and the Assistant Director of Nursing confirmed that only the top portion of the report was completed, with no explanation for the omission.
Failure to Update Care Plan for Pressure Ulcer Progression
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed, updated, and revised for one resident with significant skin integrity issues. Specifically, the resident, who had severe cognitive impairment, hemiparesis, and was dependent for all care, developed a Stage 2 pressure ulcer to the sacrum and bilateral buttocks while in the facility, in addition to a Stage 4 pressure ulcer present on admission. The care plan in place only addressed a Stage 4 pressure ulcer on the left heel and did not include documentation of the sacral/buttocks ulcer, its measurements, treatments ordered, or updates on wound progression and physician findings, despite these being reported to the facility. Interviews with nursing leadership revealed that wound care physician notes were received weekly, and it was the expectation that nursing staff would update the care plan with any changes in wound status or treatment orders. However, the care plan was not updated to reflect the presence or progression of the sacral/buttocks ulcer, nor were physician findings consistently documented. The responsibility for updating care plans was described as belonging to unit managers, but this was not carried out as required by facility policy and regulatory standards.
Failure to Notify Physician and Obtain Treatment Orders for Pressure Ulcer on Admission
Penalty
Summary
A deficiency was identified when a resident admitted with multiple diagnoses, including diabetes mellitus and end stage renal disease, was found to have a Stage 2 pressure ulcer in the intergluteal medial cleft during the admission skin check. The ulcer measured 5 cm x 4 cm, showed no signs of infection, and the resident denied pain. Despite facility policy requiring that the physician be notified of any wounds or pressure ulcers at the time of assessment and that treatment orders be obtained, there was no documented evidence that the physician was informed of the pressure ulcer or that any treatment orders were obtained upon admission. Interviews with nursing staff and the Director of Nursing confirmed that the standard protocol was not followed in this case. The responsible RN stated that they did not receive a treatment order from the physician for the pressure injury, describing this as an oversight. The DON further clarified that while there are standing orders for different wound stages, the physician must be notified to determine the appropriate protocol. The lack of physician notification and absence of treatment orders for the pressure ulcer constituted a failure to provide necessary care and services consistent with professional standards of practice.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident where a Certified Nurse Assistant (CNA) was reported to have physically abused a resident. A visitor witnessed the CNA punching the resident in the head while in the resident's room. The resident, who had severe cognitive impairment due to dementia, was unable to communicate details of the incident. The facility's abuse policy, revised in January 2024, mandates that all residents be free from abuse, including physical abuse such as hitting and slapping. The resident involved in the incident had a documented history of severe cognitive impairment and required maximal assistance with daily activities. Despite this, there was no documented evidence of a risk for abuse care plan in place for the resident. The facility conducted an investigation following the report of abuse, but was unable to substantiate the allegation due to the lack of physical evidence and the resident's inability to articulate the incident. However, the facility decided to terminate the CNA involved, citing the severity of the allegations and the need to ensure resident safety. Interviews with facility staff, including the Administrator and Medical Director, revealed that the CNA left the facility shortly after the incident and did not provide a statement. The Medical Director and Attending Physician examined the resident and found no physical injuries. The Administrator acknowledged the credibility of the witness and expressed belief that the CNA did abuse the resident. Despite the lack of physical evidence, the facility took the precautionary step of terminating the CNA to maintain a high standard of care and safety.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a resident with severe cognitive impairment. A visitor reported witnessing a Certified Nurse Assistant (CNA) physically assaulting the resident by punching them in the head. Despite the severity of the allegation, the facility did not obtain a written statement from the accused CNA, nor did they interview or assess other residents under the CNA's care to rule out further abuse. The resident involved in the incident had a history of Alzheimer's, diabetes, and muscle weakness, and was severely cognitively impaired, as indicated by a Brief Interview for Mental Status score of 0. The facility's investigation included assessments by the Medical Director, nursing supervisor, and Director of Nursing, but there was no documented evidence of a comprehensive medical assessment by a physician or nurse practitioner. The investigation concluded without substantiating the abuse allegation, despite a credible witness account, due to the lack of physical evidence and the resident's inability to communicate details of the incident. Interviews with facility staff revealed inconsistencies and gaps in the documentation of the incident. The Administrator acknowledged the credibility of the witness but noted the absence of a statement from the CNA. Licensed Practical Nurses involved in the post-incident care of the resident did not document their assessments, and the Director of Nursing admitted to not documenting the skin check. The facility's failure to follow its abuse policy and ensure comprehensive documentation and investigation of the incident led to the deficiency.
Deficiency in Certified Nurse Aide Performance Appraisals
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months, as required. During a recertification survey conducted from May 28, 2024, to June 4, 2024, it was found that performance appraisals were not documented for five certified nurse aides. Interviews with the Director of Human Resources revealed that a project to update performance appraisals had begun about a month prior, but the Nursing Department had not completed appraisals for any nurse aides. Upon request, the Director of Human Resources was unable to provide recent performance appraisals for the selected staff members, with the most recent appraisals dating back several years, and one staff member having no documentation of any appraisal.
Infection Control Deficiencies in Linen Handling, Water Management, and C. Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the recertification survey. Firstly, clean linens were transported throughout the facility without being covered, which is against infection control protocols. Maintenance staff were unaware of the requirement to cover linen carts, despite the Director of Maintenance acknowledging that staff had been previously instructed to do so. Additionally, a Certified Nurse Aide was observed handling dirty linens and then making a resident's bed without changing gloves, indicating a lapse in hand hygiene practices. The facility also lacked a current Water Management Plan, which is essential for preventing Legionella infections. The Director of Maintenance was unable to articulate a plan or next steps in the event of positive test results for Legionella, and the Assistant Director of Nursing admitted that the Director of Maintenance had not been educated on the Legionella Plan upon hiring. This lack of a comprehensive water management strategy poses a risk of Legionella growth and spread within the facility's water systems. Furthermore, the facility failed to implement appropriate contact precautions for a resident with a confirmed Clostridium Difficile infection. Despite a physician's order for contact isolation, the resident was observed outside their room without proper signage or personal protective equipment (PPE) available for staff. Multiple staff members, including a Certified Nurse Aide and the Director of Rehabilitation, were observed not wearing the required PPE while interacting with the resident. The Director of Nursing acknowledged the oversight in signage and PPE availability, and the Assistant Director of Nursing was unsure why the contact isolation sign was not posted, despite attending daily clinical meetings discussing residents on precautions.
Deficiency in COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to ensure that each staff member was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with the vaccine. This deficiency was identified during a recertification survey conducted from May 28 to June 4, 2024, where it was found that there was no documented evidence of immunization records for three out of ten staff members reviewed for COVID-19 vaccines. Specifically, the facility lacked documentation of screening, education offering, or current COVID-19 vaccination status for these staff members. During an interview, the Assistant Director of Nursing acknowledged the issue, stating that efforts had been made to encourage staff to receive the COVID-19 vaccine, but many employees were resistant. They also mentioned that vaccine records were obtained from Human Resources and reviewed upon hire, but they were unaware that the records for these employees did not show they were screened, offered, or given an opportunity to decline the COVID-19 vaccine.
Failure to Notify Family of Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident's representative was immediately notified of the development of an unstageable sacral pressure ulcer. This deficiency was identified during a recertification and abbreviated survey, where it was found that the representative of a resident with a history of urinary tract infection, metabolic encephalopathy, and brain tumor was not informed about the pressure ulcer. The resident, who was admitted with modified independence for decision-making and required assistance with daily living activities, did not have a pressure ulcer documented upon admission. The care plan for the resident, which included an intervention to inform the resident or family of any new skin breakdown, was not followed. On 12/5/2022, a nurse's note documented a sheer injury to the sacrum, and a subsequent physician consultant wound note on 12/7/2022 described the ulcer as unstageable. Despite these developments, there was no documentation that the family was notified of the pressure ulcer. The Assistant Director of Nursing confirmed the lack of documentation regarding family notification.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the New York State Department of Health within the required two-hour timeframe. The incident involved a resident with diagnoses including amyotrophic lateral sclerosis, cerebrovascular accident, dementia, reflux, and hypertension, who had intact cognition and was dependent on staff for activities of daily living. The resident reported to the facility Administrator that during a previous shower, three women forcibly removed their clothes, dragged them down the hallway naked, and one of the women squeezed their genitals multiple times. This allegation was made known to the Administrator on 5/6/24. The Director of Nursing was informed of the allegation on the same day by the Administrator and began an investigation by reviewing the previous three showers and obtaining staff statements. However, the report to the New York State Department of Health was not submitted until the following day, 5/7/24, at 13:39 PM. The Director of Nursing admitted to not being aware of the two-hour reporting requirement, mistakenly believing they had 24 hours to report the incident. This oversight resulted in a failure to comply with the mandated reporting timeframe for allegations of abuse.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for four residents, leading to deficiencies in meeting their needs. Resident #42, who required varying levels of assistance with activities of daily living (ADLs), did not have an active care plan outlining these needs. Interviews with staff revealed confusion and lack of clarity regarding responsibility for initiating and updating care plans, with multiple staff members pointing to others as responsible for the oversight. Resident #229, admitted with a seizure disorder and other conditions, also lacked a care plan addressing ADLs and seizure management. Staff interviews indicated that care plans should be initiated upon admission, but there was a disconnect between policy and practice, as evidenced by the absence of a care plan for this resident. The Director of Nursing acknowledged the expectation for care plans to address all resident needs, including specific diagnoses and medication management. Resident #70, who experienced an alleged abuse incident, did not have a care plan addressing ADLs or abuse prevention. Despite the incident being reported, there was no follow-up in terms of care planning to prevent future occurrences or address the resident's needs. Similarly, Resident #327, who required assistance with ADLs, did not have a documented care plan, and family members reported inadequate care. Staff interviews highlighted a lack of awareness and responsibility for ensuring care plans were in place, contributing to the deficiencies identified.
Deficiency in Nurse Aide Training Documentation
Penalty
Summary
The facility failed to ensure that certified nurse aides received the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention. During a recertification survey, it was found that the facility could not provide evidence of mandatory training for two of the five nurse aides reviewed. Specifically, the training documentation for Staff #8 and Staff #11 was missing. The MDS Nurse/Staff Educator, responsible for maintaining these records, confirmed the inability to locate the 'Mandatory In-Service Sign-Off Sheets' for these staff members.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents during a recertification survey. Resident #328, who has severe cognitive impairment and requires extensive assistance with eating due to conditions such as dementia and Parkinson's disease, was observed being assisted with their meal by a certified nurse aide who stood over them instead of sitting. This action was contrary to the facility's feeding program policy, which aims to promote residents' self-esteem and well-being. The staff member acknowledged knowing the correct protocol but did not follow it during the observation. Similarly, Resident #46, who also has severe cognitive impairment and requires moderate assistance with eating, was addressed inappropriately as a "feeder" by a certified nurse aide. Additionally, this resident was fed by another aide who stood over them during meals, despite being advised to sit by a licensed practical nurse. The aide cited a lack of available chairs as the reason for standing. These actions were inconsistent with the facility's policy and compromised the residents' right to a dignified dining experience.
Failure to Ensure Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate advance directives, as evidenced by the lack of a physician's order for such directives. Resident #334, who was admitted with diagnoses including anemia, malignant neoplasm of the prostate, and occlusion and stenosis of precerebral arteries, had moderately impaired cognition. During a record review, it was found that there were no advance directives in the electronic medical records or a hard copy of Medical Orders for Life Sustaining Treatment (MOLST) for the resident. Interviews with staff revealed that in the event of a medical emergency, the facility would contact the family and physician and send the resident out for evaluation. A review of the resident's MOLST form showed it was signed by the resident but not by a physician, and it included conflicting instructions regarding CPR and other life-sustaining treatments. A physician's order indicated the resident was Full Code, but there was no evidence the physician was aware of the resident's other advance directives. The Director of Social Services acknowledged the need for a physician's signature on the MOLST form.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as well as failing to notify the Ombudsman, for two residents. Resident #18, who had diagnoses including diabetes mellitus, chronic kidney disease stage 3, and protein calorie malnutrition, was transferred to the hospital on 3/19/24. Despite having intact cognition, there was no documentation that Resident #18 or their representative received a written notice of the transfer, nor was there evidence that the Ombudsman was notified. The Director of Social Work confirmed that no notice of transfer was found in the resident's file, and it was noted that the responsibility for completing the form varied depending on the time of transfer. Similarly, Resident #24, with diagnoses including diabetes mellitus, hemiplegia and hemiparesis affecting the right side, and hypertension, was transferred to the hospital on 4/1/24. The resident also had intact cognition, yet there was no documentation of written notification to the resident or their representative, nor was there a record of notification to the Ombudsman. The Director of Social Work acknowledged the absence of the notice in the resident's file. The facility's policy, revised in February 2018, mandates issuing a valid notice of discharge/transfer to residents, their representatives, and the Ombudsman, which was not adhered to in these cases.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers, as required by regulations. This deficiency was identified during a recertification survey conducted from May 28, 2024, to June 4, 2024, affecting two out of three residents reviewed for hospitalization. Specifically, the facility could not provide evidence of written notification for Residents #18 and #24, who were transferred to the hospital with the anticipation of return. Resident #18, who had diagnoses including diabetes mellitus, chronic kidney disease stage 3, and protein-calorie malnutrition, was transferred to the hospital on March 19, 2024. Despite having intact cognition, there was no documentation that the resident or their representative received a written notice of the bed hold policy. Similarly, Resident #24, with diagnoses including diabetes mellitus, hemiplegia, and hypertension, was transferred to the hospital on April 1, 2024, and also did not receive the required notification. Interviews with the Director of Social Work confirmed the absence of these notifications, attributing the responsibility to the nurse on duty after hours and an administrative staff person during business hours.
Delayed MDS Assessment for Resident
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) 3.0 comprehensive assessment for a resident in a timely manner, as required by federal and state regulations. Specifically, the MDS admission assessment for a resident with diagnoses including diabetes, hypertension, and dementia was not completed within the mandated 14 calendar days from the date of admission. The resident was admitted on January 7, 2024, and the assessment was scheduled for January 9, 2024, but was not completed until January 24, 2024, exceeding the required timeframe. The facility's policy, revised in January 2024, mandates that the Resident Assessment Instrument (RAI) be used to ensure optimal care planning and quality of care, with the assessment coordinator responsible for timely completion. During an interview, the MDS/Discharge Planning Coordinator acknowledged the delay, stating that the admission assessment was submitted late. This deficiency was identified during a recertification survey conducted from May 28, 2024, through June 4, 2024.
Deficiency in PASRR Documentation
Penalty
Summary
The facility failed to ensure that each resident's Pre-Admission Screening and Resident Review (PASRR) assessment was signed and included the required digital ID prior to admission. This deficiency was identified during a recertification survey, where it was found that three out of twenty-five residents reviewed did not have the necessary documentation. Specifically, the electronic medical records for these residents lacked evidence of a signed and digitally identified PASRR assessment, which is required to assess for mental illness, dementia, and intellectual disabilities. Interviews conducted during the survey revealed a lack of clarity regarding responsibility for ensuring the completion and documentation of PASRR assessments. The Director of Social Work was unaware of who was responsible for verifying the signatures and digital IDs. The facility Administrator indicated that the Director of Admissions or the Outreach Coordinator should ensure the completion of these assessments before admission. However, the Outreach Coordinator, who was temporarily filling in for the Director of Admissions, confirmed that they were responsible for this task during the interim period.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours of admission, as required by their policy and CMS regulations. The resident, who was admitted with diagnoses including an unstageable pressure ulcer, local skin infection, and darkened skin, did not have a baseline care plan documented in their electronic record. This omission was identified during a recertification survey. Interviews with facility staff revealed that the baseline care plan was not completed due to staffing issues. The Assistant Director of Nursing acknowledged the absence of the care plan and stated that it should have been completed by a Registered Nurse within the first 48 hours. A Registered Nurse Supervisor admitted to not completing the care plan, citing a lack of time as they were the only RN on the floor at the time.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), who was the Assistant Director of Nursing, completed specialized training in infection prevention and control before assuming the role. During the recertification survey, it was found that the IP had not completed the necessary training modules, including those on Antibiotic Stewardship and Occupational Health, until after the survey had commenced. The IP had been in the role since March 2024 but only completed the required Centers for Disease Control training course and presented the certificate on 5/29/24, after the survey began on 5/28/24.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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