Troy Victorian Rehabilitation & Nursing Care Cntr
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, New York.
- Location
- 100 New Turnpike Road, Troy, New York 12182
- CMS Provider Number
- 335377
- Inspections on file
- 28
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Troy Victorian Rehabilitation & Nursing Care Cntr during CMS and state inspections, most recent first.
The facility failed to adequately supervise two residents identified as elopement risks and did not follow its own elopement, missing resident, and AMA policies. One cognitively intact resident with substance use disorders and documented wandering/elopement risk repeatedly expressed a desire to leave, attempted to exit through the front door, and was later allowed to sleep unattended in the lobby; staff did not notify the provider of these behaviors, did not provide or document AMA counseling or paperwork, and only discovered the resident was gone when they could not be found, learning from the health care proxy that the resident had already arrived at a hospital. A second resident with severe cognitive impairment and an ankle alert care-planned for elopement risk exited through an alarmed emergency door and was seen alone outside in a wheelchair before being brought back inside; the DON later acknowledged that electronic monitoring orders had not been entered into the MAR/TAR and that the exit door was not tied to the monitoring system.
The facility failed to report an alleged elopement to the State Survey Agency as required. A resident with alcohol abuse, withdrawal delirium, dysphagia, and opioid dependence, who had been assessed as an elopement risk but cognitively intact, left the building with all belongings and was later found in a local hospital ED. Staff discovered the resident missing, notified the DON, medical provider, and the resident’s health care proxy, and learned of the resident’s location only after the proxy checked a hospital portal. The DON reviewed camera footage showing the resident leaving through the front door and stated that, because the resident was alert and oriented, the incident was not considered an elopement and was not reported to the state, contrary to facility policy and regulatory requirements.
Two residents with documented wandering/elopement risk care plans were not adequately supervised, resulting in both leaving the facility without appropriate oversight. One resident with intact cognition but a history of alcohol abuse with withdrawal delirium and opioid dependence repeatedly expressed a desire to leave, attempted to exit through the front door, and was last seen sleeping in the lobby before being discovered missing; the DON later stated that, because the resident was alert and oriented, they could leave at any time and the event was not considered an elopement, despite an active elopement-risk care plan. Another resident with Alzheimer’s disease and severely impaired cognition, who had a care plan including supervision, orientation, and an ankle alert, was found outside alone in a wheelchair after exiting through an alarmed emergency door that was not WanderGuard-equipped, indicating that the planned elopement-prevention interventions were not effectively implemented.
Three residents were not protected from abuse and neglect when a resident requiring a mechanical lift was improperly transferred by two CNAs, resulting in a femur fracture, and another resident with a history of aggression struck a peer in the eye, causing swelling and distress. Staff did not follow care plans or ensure adequate supervision, leading to actual harm.
Surveyors found that the facility failed to maintain a clean and safe environment, with soiled floors, damaged walls, stained ceiling tiles, and worn furniture across multiple areas. Two residents reported that their toilet and handwashing sink were in disrepair for about a week, and additional issues included stagnant water, broken fixtures, and stained privacy curtains.
Surveyors identified that the facility did not consistently develop or implement comprehensive, person-centered care plans for multiple residents, resulting in missing or incomplete interventions for medical, behavioral, and safety needs. For example, a resident at risk for falls experienced multiple falls when care plan interventions were not in place, and another resident's pressure sore worsened without updates to the care plan. Nursing staff interviews revealed gaps in communication and care plan updates, contributing to these deficiencies.
The facility did not maintain adequate nursing staff, resulting in residents experiencing delays in care such as incontinence management and showers, with staff and residents reporting frequent understaffing and unmet needs. Staffing records showed that actual nurse and CNA coverage often fell below the facility's own minimum requirements, and leadership turnover contributed to ongoing staffing instability.
The facility did not ensure that a licensed pharmacist conducted monthly drug regimen reviews for all residents, with no documentation of reviews for three consecutive months. Additionally, the facility's policy lacked required time frames for the medication review process, as confirmed by the DON.
A resident with multiple chronic conditions received several scheduled medications significantly late, resulting in a medication error rate of 36 percent. An LPN reported being unable to complete the morning medication pass on time due to a heavy workload and lack of assistance, and failed to notify the nurse practitioner as required by policy. The issue was known to management but not addressed with additional support.
Surveyors found that several residents did not receive prescribed medications as ordered, including missed doses of antibiotics and eye ointments, and one resident was given insulin without a physician's order. In multiple cases, there was no documentation or provider notification regarding the missed or incorrect medication administration, and staff could not explain the reasons for these errors.
Surveyors found that medications, including lidocaine injectables, insulin pens, and inhalers, were not labeled with open or expiration dates on medication carts and in a medication room. Additionally, narcotic storage was compromised: one narcotic box had broken locks and was unsecured for weeks, while another was inaccessible, leading to narcotics being stored on medication carts. Staff interviews revealed lack of awareness about medication expiration and improper storage practices, in violation of facility policy and regulations.
Several residents reported being treated without dignity and respect by CNAs, including being left unattended after call lights were turned off, experiencing insensitive and degrading comments during personal care, and being denied assistance with toileting. These actions led to residents feeling humiliated, objectified, and emotionally distressed, with staff interviews confirming awareness of such incidents and ongoing complaints.
The facility did not report the results of investigations into suspected abuse and neglect to the State Survey Agency within the required five working days. In one case, a resident with dementia struck another resident, and in another, a dependent resident was improperly transferred and sustained a femur fracture. Although initial incident reports were submitted, there was no documentation that investigation results were reported as required, and staff interviews revealed missing files and lack of involvement in the reporting process.
The facility did not consistently review or update comprehensive care plans for several residents, including failing to update allergy information, omitting care plan meetings for a resident with respiratory and cardiac conditions, and not revising a care plan after a resident developed a pressure ulcer. Staff interviews indicated a lack of awareness and insufficient support for care plan management.
Several residents with skin and edema issues did not receive timely or appropriate assessment, monitoring, or treatment. One resident with signs of cellulitis was not monitored or seen by a provider for an extended period, while another with severe leg edema reported no interventions and had no care plan addressing the condition. A third resident had untreated dry, scaly feet with no documented podiatry care, and ace wraps were not administered as ordered for another resident.
The facility did not ensure proper documentation of controlled substance receipt and shift counts, including missing signatures for the receipt of a narcotic pain medication for a resident and incomplete shift count records on multiple nursing units. Nursing staff and the DON confirmed that while narcotics were counted, required signatures and documentation were not consistently completed.
Surveyors identified multiple failures in food service safety and sanitation, including inadequate dishwashing machine water pressure, equipment in disrepair, missing or broken tiles, water puddling, and widespread unclean surfaces in the main kitchen and both unit kitchenettes. Numerous areas were found soiled with food particles and dirt, and several fixtures were either non-functional or damaged.
Handrails on both resident units were found with broken or missing plastic, resulting in exposed sharp edges in multiple locations. These deficiencies were observed in the corridors and near the elevator, and confirmed by the maintenance director.
Surveyors found that the facility did not maintain a pest-free environment, with observations of a wasp in a resident room, gnat-like flies in multiple areas including the kitchen and staff rooms, and ants in a resident room and break room. Documentation showed previous pest issues and treatments for some pests, but there was no evidence of treatment for wasps or for small flies and ants in several affected areas. The lack of consistent pest control measures led to ongoing infestations.
Two residents experienced significant changes in their medical conditions—one developed new leg wounds and another developed conjunctivitis requiring new medication—but the facility failed to promptly notify the provider and the residents' representatives as required by policy. Documentation and staff interviews confirmed that notifications were delayed or not made, and the required documentation was missing.
Surveyors found that two residents did not receive comprehensive and timely assessments, with one resident's edema and cellulitis not addressed in their care plan or medical records, and another resident's baseline care plan left incomplete regarding key medical and care needs. Nursing staff reported that high workload and lack of assistance contributed to incomplete assessments and care planning.
The facility did not ensure accurate PASARR assessments for two residents with serious mental illness diagnoses. One resident with bipolar disorder was incorrectly documented as having dementia, and another with schizophrenia did not have a Level II referral initiated, despite clear evidence of mental health needs. Staff interviews confirmed that required screening and referral processes were not properly followed.
A resident at risk for pressure ulcers developed an open area on the coccyx that was not promptly assessed or treated, and the care plan was not updated to include necessary interventions. Facility staff did not document weekly wound assessments as required, and there was confusion regarding responsibilities for wound care and care plan updates during an electronic medical record transition. The resident's wound worsened, leading to hospitalization for sepsis.
Surveyors found that a resident complained of inedible, unidentifiable meals that did not match the meal ticket, with issues such as overcooked vegetables, stale bread, and lack of fresh fruit or choice. Test trays on two units also revealed unpalatable food, including salty, dry, or mushy items, confirming poor food quality and meal preparation.
Surveyors found that the facility failed to ensure proper disposal of garbage and refuse, as the dumpster side door was left open and garbage was scattered around the dumpster and parking lot.
Surveyors found that a carbon monoxide detector was not installed as required near gas-fired equipment in the main kitchen, but instead was placed on a shelf below the steamtable, contrary to regulatory requirements. This was confirmed through observation and staff interview.
Surveyors found that the facility did not ensure accurate and complete documentation of resident conditions and treatments. For example, a resident with multiple wounds was documented as having no wounds in nursing notes, despite ongoing wound care. Additionally, two residents receiving antibiotics had no nursing progress notes reflecting their condition or response to treatment. Staff interviews confirmed that documentation was incomplete or inaccurate.
Surveyors found that enhanced barrier precautions were not implemented for a resident with an indwelling catheter, despite a physician's order and facility policy, and that nebulizer equipment for another resident was not properly cleaned or stored to prevent contamination. Staff interviews confirmed awareness of the required procedures, but these were not followed during the survey period.
A working call system was not available in the bathrooms of two resident rooms, where call bell devices were either missing or improperly mounted with exposed wires. Multiple instances of call bell disrepair were documented, and there was no evidence that repairs were requested for the affected rooms.
Surveyors found that the facility's exterior was not properly maintained, with moss and algae on the building facade, piles of construction debris, leaves, and litter on the grounds, and garbage dumpsters not placed in the designated area with vegetation encroaching on fencing.
Unpleasant and musty odors were found in the second floor soiled holding and shower rooms due to insufficient ventilation, as the existing ventilation system motors were not strong enough to remove the odors.
A resident on a Nothing by Mouth (NPO) diet due to high aspiration risk was given pizza by another resident in a common area, leading to coughing and medical assessment. The resident, with a history of cerebral palsy and developmental disabilities, was supposed to receive nutrition only through a gastrostomy tube. Despite clear dietary restrictions, inadequate supervision allowed the resident to access food, resulting in a deficiency report.
The facility experienced significant staffing shortages from July 1 to July 16, 2024, failing to meet the required levels of LPNs and CNAs for each shift. This led to inadequate care for residents, as observed during a survey where multiple call lights were unanswered due to the absence of CNAs. The DON acknowledged the staffing issues, exacerbated by an increase in COVID-19 cases and the resignation of the Human Resources Director. A CNA reported being overwhelmed with an assignment of 40 residents, resulting in some residents not receiving appropriate care.
A resident with cognitive and mental health issues eloped twice from the facility due to inadequate supervision and communication among staff. The first incident was not reported promptly, and no immediate measures were taken. The second incident involved the resident being found in the parking lot, after which an electronic monitoring device was applied but not properly monitored. Staff were unaware of the device's removal, highlighting a lack of communication and documentation, resulting in Immediate Jeopardy and Substandard Quality of Care.
A resident with cognitive and mental health issues eloped from the facility due to inadequate supervision and failure to follow elopement prevention policies. Despite a previous elopement attempt, the resident was not provided with an electronic monitoring device or proper oversight. The resident was later found in the parking lot, and although a device was applied, it was not documented, and the resident removed it without staff awareness. Staff interviews revealed communication lapses and procedural failures.
A resident with cognitive and mental health diagnoses was found outside the facility in the parking lot, but the incident was not reported to the New York State Department of Health as required. Staff misunderstood the reporting requirements, and the event was not considered an elopement by the Administrator, despite facility policy mandating immediate reporting.
The facility failed to prevent resident-to-resident abuse, as evidenced by multiple incidents involving two residents with cognitive impairments. Despite care plans and interventions, measures were not consistently implemented or documented, leading to repeated abuse incidents.
A resident with Guillain-Barre syndrome, chronic kidney disease, and type 2 diabetes reported $75 missing from their drawer. The facility provided a locked drawer but failed to provide a key, leaving the resident's belongings unsecured. Interviews revealed that the facility was aware of the issue but did not provide an alternative means to secure the resident's property promptly.
The facility failed to update a resident's care plan to include a floor mat intervention after a fall, despite it being recommended in the Accident and Incident report. Observations and staff interviews confirmed the oversight, with the Director of Nursing acknowledging the lapse in updating the care plan and Kardex.
Failure to Supervise Elopement-Risk Residents and Implement Elopement/AMA Policies
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents at risk of elopement remained under adequate supervision and that the environment was free from accident hazards, resulting in two separate elopement incidents. Facility policies required that when a resident was discovered missing, staff conduct a thorough search of the building and premises, notify the Administrator, Director of Nursing Services, the resident’s legal representative, attending physician, and law enforcement, and, under the emergency preparedness missing resident procedure, initiate a Code Pink, search the facility and grounds, and notify police if the resident was not found within 10 minutes. The facility also had an Against Medical Advice (AMA) policy requiring that cognitively intact residents who leave against professional advice receive information about risks, be asked to sign AMA documentation, and that staff complete careful, comprehensive documentation of education, counseling, options, reactions, and all facility actions, including contacts with the physician and Adult Protective Services. One resident, admitted with alcohol abuse with withdrawal delirium, dysphagia, and opioid dependence, was assessed as cognitively intact with a Brief Interview for Mental Status score of 14/15 and identified as an elopement risk on the interdisciplinary assessment. The care plan for wandering and elopement risk set a goal for the resident to remain safely under supervision and within the facility unless escorted, with interventions including documenting and notifying providers of behavior intensity, duration, or frequency and redirecting the resident. The resident also had a care plan for substance use disorder history, including monitoring for signs of acute intoxication or potential substance use and promoting supportive communication. Progress notes documented that an electronic monitoring device was applied on admission for wandering tendency, that the resident repeatedly expressed a desire to leave due to pain and facility restrictions, and that the resident attempted to leave through the front door several times, yelling and being aggressive, but was calmed. There was no documented evidence that the medical provider was notified of the resident’s repeated statements about wanting to leave against medical advice or of the attempts to leave the facility. On the night and early morning when the elopement occurred, documentation and interviews showed the resident continued to complain of pain, paced the hallway, and was sweating, swearing, and talking fast. An LPN documented promising to speak to the physician about an extra dose of tramadol, offering a topical analgesic that the resident refused, and then allowing the resident to sleep in a chair in the front lobby because they were calm. Later, when staff attempted to administer medications, the resident was no longer in the chair or room, and a head count showed the resident was the only one unaccounted for. The resident’s health care proxy reported not being called until hours after the resident had already arrived at a local hospital emergency department and stated the facility asked if they knew the resident’s whereabouts. The proxy also reported being told the resident had cut off their electronic monitoring device and left it at the front desk and that the facility said the resident had the right to leave and there was no risk. The DON stated they reviewed camera footage showing the resident with all belongings in the lobby and then leaving through the front door, and asserted that because the resident was alert and oriented, the facility had no responsibility and the incident was not an elopement. There was no documentation of AMA education, counseling, options, or resident/responsible party reactions, and no evidence that AMA paperwork was discussed or signed, despite the resident being treated as an AMA discharge. A second resident, admitted with Alzheimer’s disease, cognitive communication deficit, and generalized muscle weakness, had severely impaired cognition and was care planned as at risk for wandering into unsafe areas or elopement without supervision. The care plan goal was for the resident to be maintained safely under staff supervision and remain away from unsafe areas and within the facility unless escorted, with interventions including identifying behavior patterns, documenting behavior intensity, duration, and frequency, orienting to daily routines, referring for psychiatric consult as ordered, and ensuring proper placement and functioning of an ankle electronic monitoring device. Treatment records showed electronic monitoring device checks every shift beginning on a specified date. On the day of the incident, an alarm sounded from a unit exit door, prompting staff to initiate resident accountability, and dietary staff observed the resident alone outside near the exit door in a wheelchair and returned the resident inside. Investigation statements indicated the resident had last been seen on the unit shortly before being observed outside. During interviews, the DON acknowledged that electronic monitoring device orders for this resident were never placed in the Medication or Treatment Administration Record when ordered, and that monitoring of residents’ electronic monitoring devices was only added to the record after a quality assurance audit following the elopement incident. The DON also stated that the door the resident exited was an emergency exit with an alarm but was not connected to the electronic monitoring device system. These actions and omissions resulted in one resident leaving the facility without staff knowledge and being located hours later at a hospital, and another resident with severely impaired cognition exiting through an alarmed emergency door and being found outside on facility grounds, constituting Immediate Jeopardy and substandard quality of care for the first resident and no actual harm with potential for more than minimal harm for the second resident.
Removal Plan
- Confirmed by review of camera footage and interviews with six staff of various titles that the front door to the facility was manned.
- Revised the elopement policy to add that when a resident is found missing from the facility, staff are to follow the missing person policy.
- Revised the missing person policy to add steps for residents who have not signed or declined to sign Against Medical Advice paperwork, including immediately notifying the Administrator or Director of Nursing, notifying the police, and notifying the New York State Department of Health.
- Educated employees on the revised elopement and missing person policies, with rosters and education sign-off sheets.
- Verified via interviews with staff members of various titles that they had been educated on the revised elopement and missing person policies.
Failure to Report Alleged Elopement to State Authorities
Penalty
Summary
The facility failed to immediately report an alleged violation involving elopement to the State Survey Agency as required by regulation and its own elopement policy. The facility’s policy dated 7/14/2021 directed staff who discovered a resident missing to thoroughly search the building and premises and notify the administrator, DON, the resident’s legal representative, attending physician, and law enforcement agencies. Resident #5 had diagnoses including alcohol abuse with withdrawal delirium, dysphagia, and opioid dependence. An Interdisciplinary Assessment dated 10/13/2025 documented the resident as an elopement risk, although the Minimum Data Set dated 10/18/2025 showed the resident was cognitively intact with a BIMS score of 14/15 and no documented wandering behavior. On 10/18/2025, an LPN documented that they were notified the resident was not in their room or the lobby, and they notified the DON, medical provider, and the resident’s Health Care Proxy, stating the resident had left against medical advice. Health Care Proxy #1 reported that the resident had left in the middle of the night and that they were not called by the facility until 9:00 AM, at which time the LPN asked if they knew the resident’s whereabouts because the resident could not be located. Health Care Proxy #1 stated they had an alert from the local hospital’s portal that the resident had been in the emergency department since around 8:00 AM and then informed the facility of the resident’s location, later observing the resident in the emergency department with all belongings. The DON stated in interview that the resident was alert and oriented and that the facility had no responsibility if the resident wanted to leave, and after reviewing camera footage from the morning of 10/18/2025, reported that the resident was seen in the lobby with all belongings at 6:42 AM and then leaving through the front door after a staff member returned from break. The DON stated this was not considered an elopement because the resident was alert and oriented and therefore it was not reported to the New York State Department of Health, resulting in the failure to report the alleged violation involving elopement as required.
Failure to Implement Elopement Care Plan Interventions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement comprehensive, person-centered care plan interventions for two residents identified as being at risk for wandering and elopement, resulting in both residents leaving the facility without appropriate supervision. The facility’s care plan policy dated 06/20/2025 required interdisciplinary care plans with measurable objectives and timeframes to meet residents’ identified needs. For one resident with diagnoses including alcohol abuse with withdrawal delirium, dysphagia, and opioid dependence, the comprehensive care plan for "Behavior Problem: Wandering and Elopement risk" dated 10/15/2025 set a goal that the resident would be maintained safely under staff supervision and remain within the facility unless escorted by family or staff. Interventions included documenting and notifying providers of the intensity, duration, or frequency of behavior and redirecting the resident. Despite this, progress notes and interviews showed repeated expressions of the resident’s desire to leave and escalating behaviors without corresponding documented implementation of enhanced supervision or redirection sufficient to prevent elopement. Progress notes documented that on 10/16/2025 the resident stated they wanted to leave against medical advice due to not receiving pain medication but were convinced to stay. On 10/17/2025 at 6:33 AM, an LPN noted the resident was walking up and down the hallway demanding medication, and later that morning another LPN documented that the resident attempted to leave through the front door several times, yelling and being aggressive, but was calmed. A late entry note on 10/18/2025 at 11:43 AM stated the resident was yelling about pain medication, walked to the lobby, sat in a chair by the door, and fell asleep. The same note indicated that later the resident could not be found in their room or in the lobby, and the DON, medical provider, and health care proxy were notified that the resident had left against medical advice. Interviews with CNAs confirmed the resident had repeatedly stated a desire to leave because they found the facility too restrictive, and that this was reported to nursing staff. The overnight LPN reported last seeing the resident in the lobby around 6:00 AM and did not have a discussion with the resident about leaving against medical advice or obtain any signed forms. The DON stated that because the resident was alert and oriented, the facility had no responsibility if the resident wanted to leave, did not consider the incident an elopement, and stated the resident did not need to be supervised and was allowed to leave at any time, despite the existing care plan for wandering and elopement risk. For the second resident, who had diagnoses of unspecified Alzheimer’s disease, cognitive communication deficit, and generalized muscle weakness, the MDS dated 11/26/2025 documented that the resident could be understood and could understand others but had severely impaired cognition. The resident’s care plan titled "Wandering/Elopement" effective 11/03/2025 documented that the resident was at risk for wandering into unsafe areas or eloping out of the building without supervision, with a goal that the resident would be maintained safely under staff supervision and remain within the facility unless escorted by family or staff over the next 30 days. Interventions included identifying patterns of behavior, documenting intensity, duration, or frequency of behavior in progress notes, orienting the resident to daily routines, referring for psychiatric consult per MD order, and ensuring proper placement and functioning of an ankle alert device. Despite these planned interventions, an incident report submitted to the state on 11/16/2025 documented that the resident was able to leave the facility. A dietary aide reported seeing the resident alone outside near the north rehabilitation door in their wheelchair and immediately notifying a supervisor. The DON stated that the door used was an alarmed emergency exit, not a WanderGuard-alarmed door, and also stated that it was the shared responsibility of all staff to know and implement care plans, and that when care plans are updated, the person updating them is responsible for ensuring CNA care cards are updated. The events show that the care plan interventions, including supervision and use of the ankle alert, were not effectively implemented, allowing the resident to elope.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
Three residents were not protected from abuse and neglect as required by facility policy and federal regulations. One resident, who had hemiplegia, Parkinson's disease, and severe cognitive impairment, was care planned for two-person mechanical lift transfers. However, two CNAs attempted to transfer the resident using a stand pivot technique with a walker, contrary to the care plan. During the transfer, the resident's legs gave way, and the resident was lowered to the floor, later being diagnosed with a left femur fracture. Both CNAs involved did not verify the care instructions prior to the transfer, and one CNA relied on the other's familiarity with the resident rather than checking the care card. The incident resulted in actual harm to the resident. Another incident involved a resident with dementia, diabetes, and a history of aggressive behavior, who struck another resident in the eye while attempting to take a personal item. The aggressor had a documented history of psychiatric issues, including agitation, hallucinations, and poor cooperation with medication. The care plan for this resident included close monitoring and behavioral interventions, but the incident occurred in a hallway near the nurse's station without witnesses. The assaulted resident experienced mild swelling to the eye and emotional distress following the event. Staff interviews confirmed awareness of the aggressive resident's behavioral issues and the need for close monitoring. Despite these interventions, the aggressive behavior was not prevented, and the resident was able to physically harm another resident. The facility's failure to follow established care plans and ensure adequate supervision led to both physical injury and emotional harm among the residents involved.
Deficient Housekeeping and Maintenance Services Impact Resident Environment
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment across two resident units. Observations revealed that floors in numerous resident rooms, corridors, soiled holding rooms, the main dining room, lobby, elevator door tracks, and employee break room were soiled with dirt, grime, or sticky residue. Walls in several resident rooms and corridors had peeling wallpaper, unpainted repairs, and old hardware or holes. Stained ceiling tiles were noted in various resident rooms, bathrooms, and the employee break room. Furniture such as overbed tables, wardrobes, nightstands, and chests of drawers in multiple rooms had worn, chipped, or peeling finishes. Additional findings included stagnant water in a wash basin, out-of-order sinks and toilets, broken mirror hardware, and stained privacy curtains. Interviews with two residents confirmed that a toilet and handwashing sink in their room had been in disrepair for about one week. The underside of tables and sinks in the main dining room were also found to be soiled with food particles or grime. These observations and resident reports demonstrate that the facility did not provide effective housekeeping and maintenance services, resulting in an environment that did not meet regulatory standards for cleanliness, safety, and comfort.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation and facility policy. Surveyors found that for 16 out of 32 residents reviewed, care plans were either incomplete, lacked measurable objectives and timeframes, or were not implemented as written. Specific deficiencies included missing care plans for identified medical needs such as foot care, vascular wounds, infections, abscesses, conjunctivitis, and pressure ulcers. In several cases, care plans did not address person-centered interventions for conditions like diabetes management, behaviors, dementia, mood, and malnutrition risk. For example, one resident with a diagnosis of atrial fibrillation, diabetes, and dysphagia had a care plan for risk of abuse that contained no interventions. Another resident, who was severely cognitively impaired and at risk for falls, experienced multiple falls when interventions such as floor mats and low bed positioning were not in place as directed by the care plan. Additionally, a resident with dementia and diabetes developed a pressure sore that progressed in severity, but the care plan was not updated to reflect changes in skin condition or to address the risk for pressure ulcers. In some cases, care plans did not include documentation of the resident's use of dentures or specific interventions for abuse prevention and safety concerns. Interviews with nursing staff revealed a lack of awareness regarding the absence or non-implementation of care plan interventions, as well as issues with communication and workload. Staff responsible for care planning indicated that interventions were not always communicated to certified nursing assistants, and that updates to care plans were not consistently made following changes in residents' conditions. The facility's policy required care plans to be current, realistic, and individualized, but these standards were not met for the residents reviewed.
Failure to Maintain Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple observations, interviews, and staffing records. Residents reported frequent delays in receiving care, including assistance with incontinence, showers, and bed baths, often waiting extended periods for help. Some residents described being left unattended for long periods, having their call lights turned off without receiving assistance, and feeling degraded when staff refused to help. Staff interviews confirmed that they were unable to consistently provide necessary care due to chronic understaffing, and that these issues were regularly reported to administration. A review of the facility's staffing schedules over several weeks showed that the number of licensed nurses and certified nurse aides on duty frequently fell below the minimum levels established in the facility's own assessment. On numerous occasions, both day and night shifts were staffed with fewer personnel than required, impacting the ability to provide timely and adequate care. The facility's staffing plan called for specific numbers of licensed nurses and aides per shift, but actual staffing often did not meet these targets. Leadership turnover was identified as a contributing factor to the staffing challenges, with the facility ombudsman and staff noting that inconsistent administration had exacerbated the problem. Despite attempts to fill staffing gaps through incentives, the facility was unable to maintain adequate staffing levels, resulting in unmet resident needs and compromised care. Staff competency and training were described as ongoing, but the primary issue remained the insufficient number of staff available to deliver care as required.
Failure to Ensure Timely Monthly Drug Regimen Reviews by Pharmacist
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review for all residents, as required. Record review revealed that there was no documented evidence of a pharmacist's review of medication regimens for the months of January, February, and March 2025. This lapse affected all residents in the facility during that period. Additionally, the facility's policy titled 'Medication Regimen Review' did not specify time frames for the steps involved in the medication review process. During an interview, the current DON confirmed that the pharmacy did not provide medication regimen reviews for the specified months and was unaware that the policy lacked required time frames. The policy, last updated in July 2019, outlined the responsibilities of the consultant pharmacist but did not address the timing for each step in the review process. These deficiencies were identified during the recertification survey and were based on both record review and staff interview.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, as required by policy and regulation. During a recertification survey, it was observed that one resident received their scheduled morning medications significantly late, with administration occurring at approximately 10:45 AM instead of the prescribed 9:00 AM time. The resident, who had diagnoses including congestive heart failure, COPD, and depression, was cognitively intact and able to communicate. The medications administered late included several critical prescriptions such as Albuterol, Cardizem CD, Eliquis, Lasix, Magnesium Oxide, Olanzapine, Trelegy Ellipta, Venlafaxine ER, and Aspirin. The late administration resulted in a medication error rate of 36 percent based on 25 observations. The LPN responsible for the medication pass reported being consistently late due to a heavy workload, managing 28 residents with numerous medications, and not receiving assistance despite informing Human Resources and the nurse manager. The nurse manager confirmed awareness of the issue but did not provide additional support, stating that other nurses were able to complete their medication passes on time. The nurse practitioner was not notified of the late medications as required by facility policy, and instead, the LPN documented the issue in a communication book, which was not the appropriate protocol. The Director of Nursing acknowledged ongoing problems with timely medication administration by this nurse and reiterated the facility's policy for timely administration and proper notification procedures.
Failure to Prevent Significant Medication Errors
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as evidenced by multiple instances where medications were not administered as ordered or were given inappropriately. For example, one resident with diabetes, COPD, and atrial fibrillation had a physician's order for Tobradex ophthalmic ointment to be administered four times daily for conjunctivitis, but several doses were missed over multiple days without proper documentation or notification to the medical provider. The medication administration record listed reasons such as 'clinical monitoring' or 'within normal range,' but there was no supporting documentation in the progress notes, and nursing staff could not explain the rationale for these omissions. Another resident with severe cognitive impairment and a diagnosis of cellulitis was prescribed Rocephin injections for five days, but only four doses were administered due to a reported lack of lidocaine, which was not verified by staff. There was no documentation that the physician was informed of the missed antibiotic dose, nor was there any adjustment to the medication schedule to compensate for the missed dose. Staff interviews confirmed that the provider should have been notified and that such communication should have been documented in the resident's progress notes. Additionally, a resident with right hemiplegia, Parkinson's disease, and muscle weakness received 40 units of Lantus insulin without a physician's order, as documented in both the medication error report and hospital records. The resident's medication administration record did not include an order for insulin, and the incident was only discovered after the resident exhibited symptoms of hypoglycemia. Staff interviews confirmed that nurses are trained to follow the six rights of medication administration, but this protocol was not followed in this instance.
Improper Medication Labeling and Insecure Storage of Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards in one of two medication rooms and two of three medication carts reviewed. Specifically, two open bottles of lidocaine injectable solution, seven insulin kwik pens, and multiple inhalers were found without open or expiration dates. Additionally, one inhaler lacked a resident name, and several insulin pens were not labeled with expiration dates as required by facility policy. Staff interviews revealed a lack of awareness regarding medication expiration after opening, and the facility's own policy mandates that multi-dose containers be labeled with the date opened and expiration date. Further observations revealed that the second-floor medication room's narcotic box had both inside and outside locks broken, leaving it unsecured for several weeks. On the first floor, narcotic boxes were inaccessible due to missing keys, resulting in narcotics being stored on medication carts instead of in locked compartments. Staff interviews confirmed that the narcotic box was not used due to a previous disagreement about the medication room's location, and that maintenance was aware of the broken locks but had not yet completed repairs. These findings demonstrate noncompliance with regulations requiring proper labeling and secure storage of medications, including controlled substances.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
Multiple residents experienced a lack of dignity and respect in their care, as evidenced by their direct statements and staff interviews. Three residents on the same nursing unit reported feeling degraded when requesting assistance, with one resident describing how certified nurse aides (CNAs) would enter the room, state they were not assigned to the resident, turn off the call light, and leave without providing help. This resulted in the resident waiting for extended periods, sometimes up to three hours, and being left in soiled conditions. The resident also reported witnessing CNAs argue about assignments in front of residents and being told directly that certain aides were not responsible for their care. Another resident, who was cognitively intact and independent in personal hygiene, recounted an incident where, after an episode of incontinence, three CNAs discussed the situation in an undignified and insensitive manner within earshot, making the resident feel objectified and dehumanized. The resident expressed that the staff acted as if they had not received proper training in providing sensitive care. A third resident, totally dependent on staff for toileting due to mobility restrictions, described being denied a bedpan by a CNA after a previous unsuccessful attempt, despite repeated requests. The CNA responded with sarcasm and ultimately refused to assist, resulting in the resident soiling the bed. The resident reported feeling humiliated and emotionally distressed by the staff's lack of compassion and failure to meet basic care needs. Staff interviews confirmed awareness of these issues and ongoing complaints about certain shifts, as well as acknowledgment that the care provided did not meet the facility's standards for dignity and respect.
Failure to Timely Report Investigation Results of Abuse and Neglect
Penalty
Summary
The facility failed to report the results of all investigations of suspected abuse, neglect, or theft to the administrator or designated representative and to the State Survey Agency within five working days, as required by regulation. This deficiency was identified in three out of seven residents reviewed for abuse and neglect. In one instance, a resident with a history of dementia and major depressive disorder struck another resident in the face while attempting to take a personal item. The facility's investigative summary was completed and signed by the Assistant Director of Nursing Services, but there was no documented evidence that the results of the investigation were reported to the State Survey Agency within the required timeframe. Another incident involved a resident with right hemiplegia, Parkinson's disease, and severe cognitive impairment, who was dependent on a two-person mechanical lift for transfers. Two CNAs transferred the resident using a stand pivot instead of the required mechanical lift, resulting in the resident being lowered to the floor and later diagnosed with a femur fracture. Although the initial incident report was submitted to the State Survey Agency, there was no documentation that the results of the investigation were reported within five working days, nor evidence that appropriate corrective action was communicated if the violation was verified. Interviews with facility staff, including the DON and administrator, revealed gaps in knowledge and documentation regarding the investigation and reporting process. The DON and Assistant DON were either new to their positions or not involved in the investigations, and the investigative files were missing or not properly filed by previous administrators. This lack of documentation and timely reporting constituted a failure to comply with state regulations for reporting the results of abuse and neglect investigations.
Failure to Update and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in response to residents' changing needs and conditions for four residents. For one resident with a history of femur fracture, end-stage renal disease, and diabetes, the allergy care plan was not updated to reflect current medication allergies, resulting in the administration of a medication listed as an allergy. Another resident with chronic respiratory failure, COPD, and congestive heart failure did not have a care plan meeting held to review and revise the care plan after admission, despite being cognitively intact and expressing interest in attending such a meeting. Additionally, a resident with dementia, diabetes, and hypertension developed a pressure ulcer, but the care plan was not updated to reflect the new skin condition or subsequent changes in the wound's status. The skin integrity care plan only referenced a rash and did not address the progression of the pressure sore, despite multiple wound care assessments documenting changes. Staff interviews revealed a lack of awareness and insufficient staffing support for care plan updates, contributing to the deficiencies.
Failure to Provide Timely and Appropriate Skin and Edema Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for four residents, as evidenced by multiple instances of inadequate assessment, monitoring, and documentation. One resident exhibited signs of cellulitis on the left leg, including redness, pitting edema, and open blisters, but there was no evidence of ongoing monitoring or provider assessment for nearly two weeks after the initial findings. Nursing notes and wound care documentation did not reflect the change in condition, and there was no order for periodic skin checks during this period. The resident was not evaluated by a provider until much later, at which point cellulitis was diagnosed and treated. Another resident was observed with severely edematous legs and reported that the facility was not providing any treatment for the condition. There were no interventions for edema or cellulitis documented in the resident's care plan, medication administration record, or treatment administration record. Nursing staff confirmed that there should have been an assessment and plan in place for these issues, but none was found. A third resident had dry, scaly, and peeling feet observed on multiple occasions, but there were no treatments ordered or documented for foot care, and the care plan did not address this issue. Although a podiatry consultation was ordered as needed, there was no documentation of any podiatry visits. Additionally, the facility failed to administer ace wraps as ordered for another resident. These deficiencies demonstrate a lack of adherence to facility policies and professional standards regarding assessment, care planning, and treatment for residents with skin and edema-related conditions.
Failure to Document Receipt and Shift Counts of Controlled Substances
Penalty
Summary
The facility failed to establish and maintain a system for accurately documenting the receipt and disposition of all controlled drugs, as required by policy and regulation. Specifically, there was no documentation of the receipt of Oxycodone, a Schedule II narcotic pain medication, for a resident with hemiplegia, hemiparesis, pain, and anxiety disorder. The individual controlled substance administration record for this resident did not include the signature of the person receiving the drug, the date received, or the amount received, as required by the facility's policy. Additionally, the facility did not consistently document the required signatures of both the off-going and oncoming nurses on the narcotic and controlled substance shift count sheets for both the first and second-floor nursing units. Multiple instances were identified where signatures were missing for either or both nurses during various shifts across different dates. This lack of documentation occurred despite the facility's policy requiring both nurses to count and sign for controlled substances at each shift change. Interviews with nursing staff and the Director of Nursing confirmed that while narcotics were counted, the required documentation was not always completed. Staff acknowledged awareness of the process and responsibility for counting and signing for controlled substances, but admitted to not consistently signing the records. The Director of Nursing also confirmed the expectation that narcotics should be counted and documented by two nurses at the time of receipt and at each shift change.
Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and both unit kitchenettes. Specifically, the automatic dishwashing machine's final rinse water pressure was recorded at zero pounds per square inch, despite the manufacturer's requirement of 15 to 25 psi. Additional equipment issues included a leaking steamtable sink faucet, a non-functional cold-water faucet, a loose faucet fixture, and an empty paper towel dispenser at the handwashing sink. The exterior metal finish was torn off in multiple sections on both the walk-in freezer and refrigerator, and several ceramic wall and floor tiles were missing or broken. Water was found puddled on the floor of the dishwashing machine room, and the bottom interior of the Second Floor Unit kitchenette sink cabinet was heavily warped, cracked, and had exposed unsealed particleboard. Multiple areas throughout the kitchen and kitchenettes were found soiled with food particles and dirt, including the spice rack tray, handwashing sink, fire extinguishers, ceiling and ceiling lights, kitchen windows, and various floors in the kitchen, kitchen office, emergency food stock room, dietary suite corridor, janitor closet, and both unit kitchenettes. These observations were made during a scheduled recertification survey and were confirmed through interviews with the Food Service Director.
Handrails Not Maintained, Exposing Sharp Edges
Penalty
Summary
Handrails on both resident units were not properly maintained, as observed during a recertification survey. On the second floor unit, a six-inch section of the south corridor handrail had broken plastic with sharp edges, and the elevator corner guard also had broken plastic with sharp edges. On the first floor unit, six areas of the handrail were missing edge turn pieces, resulting in exposed sharp edges. These deficiencies were identified through direct observation and confirmed during an interview with the Director of Maintenance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors identified that the facility failed to maintain a pest-free environment and did not have an effective pest control program in place across both resident units. Observations revealed the presence of various pests, including a wasp in a resident room, gnat-like flies in the conference room, resident room, employee break room, and the main kitchen dishwashing area, as well as ants in a resident room and the employee break room. Documentation from the pest management vendor and the facility's pest-sighting logbook confirmed previous findings of fruit flies in specific resident rooms and periodic treatments for ants and small flies in certain areas, but there was no evidence of treatment for wasps or for small flies and ants in several affected locations since the previous year. The deficiency was further substantiated by the lack of documented pest control interventions for wasps, small flies, and ants in the specific rooms and areas where pests were observed. Interviews with facility staff confirmed that the pest control vendor had only been contacted for treatment after the most recent observations, and there was no record of prior action taken to address the infestations in those areas. The failure to provide consistent and comprehensive pest control measures resulted in ongoing pest presence in resident and staff areas.
Failure to Notify Physician and Representative of Significant Change in Condition
Penalty
Summary
The facility failed to promptly notify the attending physician and the resident's representative of significant changes in the residents' physical status, as required by facility policy. In one case, a resident with a history of multiple medical conditions, including a femur fracture, multiple myeloma, and heart failure, developed new wounds on the left leg. The nurse observed redness, pitting edema, and multiple blisters, one of which was open. Although the findings were documented in the Nurse Practitioner communication book, the provider was not notified until several days later. There was no documentation of provider notification in the progress notes between the initial observation and the eventual evaluation, and the care plan for the new wounds was not created until much later. Interviews with staff confirmed that the nurse should have called the on-call provider immediately rather than relying on the communication book for such a significant change in condition. In another instance, a resident with diabetes, COPD, and atrial fibrillation developed conjunctivitis, and a new order for TobraDex eye ointment was initiated. While the change in condition and the new treatment were documented in the medical record, there was no documentation that the resident's representative was informed of either the change or the initiation of treatment. Staff interviews confirmed that the representative was not notified, and the Director of Nursing stated that notification and documentation should have occurred according to facility policy. The deficiencies were identified through record review and staff interviews, which revealed lapses in communication and documentation regarding significant changes in residents' conditions. The facility's own policy required prompt notification of both the attending physician and the resident's representative within 24 hours of a significant change, but this was not followed in the cases reviewed. The lack of timely notification and documentation was confirmed by multiple staff members, including nursing and administrative personnel.
Failure to Complete Comprehensive Resident Assessments and Care Plans
Penalty
Summary
The facility failed to conduct comprehensive, accurate, and timely assessments for two residents, as required by regulation. For one resident with chronic obstructive pulmonary disease, chronic ischemic heart disease, and cellulitis, the Minimum Data Set and care plan did not address the presence of edema or cellulitis, despite these conditions being observed and mentioned in the baseline care plan. Medication and treatment administration records also lacked documentation for these issues, and the resident reported that staff rarely addressed their edematous legs, which were visibly swollen and sometimes weeping. For another resident with dementia, diabetes, and hypertension, the baseline care plan contained multiple prompts regarding skin integrity, medical diagnoses, antibiotic use, presence of an ostomy, and other care needs, but none of these prompts were completed. There was no documentation confirming the presence of an ostomy, and the comprehensive care plans for skin integrity, psychosocial well-being, and nutrition did not address all relevant conditions or risks, such as the risk for pressure sores or ostomy care. Interviews with nursing staff revealed that assessments and care plans were incomplete due to staffing shortages and workload issues. One nurse stated that they were responsible for multiple roles, including medication administration and direct care, which limited their ability to complete thorough assessments and care plans as required.
Failure to Complete Accurate PASARR Assessments for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that accurate and complete Preadmission Screening and Resident Review (PASARR) assessments were conducted for two residents. For one resident admitted with a diagnosis of bipolar disorder, the PASARR assessment incorrectly documented dementia and did not reflect the actual diagnosis of a serious mental illness. The resident's medical record confirmed the absence of dementia and the presence of bipolar disorder, but this was not accurately captured in the screening process. Staff interviews revealed that the admissions and nursing teams were responsible for verifying diagnoses and making appropriate Level II PASARR referrals, but this process was not properly followed. For another resident admitted with schizophrenia, the PASARR assessment did not document the presence of a serious mental illness or trigger a Level II referral, despite the resident's history and ongoing involvement with community mental health services. Progress notes indicated the resident's connection to mental health housing and treatment teams, yet the required screening and referral were not completed. Staff interviews confirmed that a diagnosis of schizophrenia should have prompted a Level II evaluation, but this step was missed.
Failure to Provide Timely Pressure Ulcer Care and Update Care Plan
Penalty
Summary
A resident with multiple comorbidities, including type 2 diabetes, dementia, and chronic kidney disease, was identified as being at risk for pressure ulcers. Despite this, when an open area was first noted on the resident's coccyx, there was no documented evidence of a wound assessment or progress note on the day of discovery. Treatment for the pressure ulcer was not initiated until several days later, and the care plan was not updated to reflect the new wound, its treatment, or additional interventions. The only intervention documented in the care plan was the use of a pressure-reducing cushion in the wheelchair, with no mention of turning, positioning, or wound care measures. The facility's policies required daily skin inspections, prompt evaluation and documentation of skin changes, and weekly wound assessments by the wound care team. However, there was no evidence of weekly wound assessments for the resident between the initial wound care team assessment and the resident's subsequent decline. Interviews with staff revealed confusion regarding responsibilities for skin checks, wound documentation, and care plan updates, particularly during a transition between electronic medical record systems. Staff also reported that care plan changes were not automatically reflected in care cards used by certified nurse aides, leading to gaps in communication and implementation of interventions. The resident's condition deteriorated, with the wound progressing to an unstageable ulcer with necrotic tissue and signs of infection. The resident became minimally responsive and was ultimately transferred to the hospital, where they were diagnosed with sepsis. Throughout the period in question, there was a lack of timely documentation, delayed initiation of treatment, and failure to update the care plan and implement recommended interventions, all of which contributed to the deficiency cited in the report.
Unpalatable and Unattractive Food Served to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents. Specifically, a cognitively intact resident reported that meals were often inedible, unidentifiable, and did not match the items listed on the meal ticket. The resident described being served a 'mystery meat' patty with gravy, overcooked vegetables, and stale bread for an alternate meal. The resident also noted inconsistencies in side dishes, such as receiving macaroni salad instead of coleslaw, and a lack of fresh fruit or meal choices. Observation confirmed that the resident's meal tray did not match the meal ticket and the food was left uneaten. Additionally, test trays on two separate units were evaluated by surveyors and found to be unpalatable. On one unit, the roast pork was covered in salty gravy, the sweet potato was mushy and waterlogged, and the cauliflower was overcooked and easily mashed. On the other unit, the roast pork was overcooked and dry, the sweet potato lacked flavor, and the cauliflower was again overcooked and mushy. In both cases, none of the food items were considered palatable, indicating a systemic issue with food quality and meal preparation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed that the facility did not properly dispose of garbage and refuse. Specifically, the side door of the garbage dumpster was left open, and garbage was found littered around the dumpster and the side of the parking lot. These observations were made during the recertification survey and were confirmed through interviews with facility staff. No information about residents or their medical conditions was included in the report.
Carbon Monoxide Detector Not Properly Installed in Kitchen
Penalty
Summary
During a recertification survey, it was observed that carbon monoxide detection was not provided in accordance with adopted regulations. Specifically, a carbon monoxide detector was found placed on a shelf below the steamtable in the main kitchen, rather than being installed as required in the area by the gas fuel fired stove. This observation was made during a walkthrough of the kitchen, and the improper placement of the detector did not meet the requirements set forth by state and local codes, as well as the 2015 International Fire Code, Section 915. The deficiency was confirmed through both direct observation and interview with the Director of Maintenance, who acknowledged the issue with the installation location of the carbon monoxide detector.
Failure to Accurately Document Resident Conditions and Treatments
Penalty
Summary
Surveyors identified that the facility failed to maintain accurate and complete medical records for multiple residents, resulting in documentation that did not accurately reflect residents' conditions, treatments, and responses. For one resident with a history of femur fracture, multiple myeloma, and heart failure, a wound care note documented multiple wounds on the lower extremities, feet, and buttocks, with corresponding treatments. However, Daily Medicare Notes completed by a registered nurse on the same and following day incorrectly stated that the resident had no wounds, despite ongoing wound care being provided. Interviews with nursing staff confirmed the presence of wounds and questioned the accuracy of the nurse's documentation. Additionally, two other residents who were prescribed antibiotics for conditions such as conjunctivitis and respiratory infections had no nursing progress notes documenting their condition before, during, or after antibiotic treatment. Medical provider notes indicated the need for antibiotics based on clinical findings, but nursing documentation failed to provide a record of the residents' status or response to treatment. Staff interviews confirmed that such documentation should have been present to reflect the residents' progress and the rationale for antibiotic use.
Failure to Implement Infection Control Precautions and Proper Equipment Storage
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program based on observations, record reviews, and staff interviews. For one resident with polyneuropathy, COPD, type 2 diabetes, and an indwelling urinary catheter, enhanced barrier precautions were not implemented as required by facility policy and a physician's order. Multiple observations revealed the absence of signage and personal protective equipment near the resident's room, and nursing staff could not explain why precautions were not in place despite being aware of the resident's condition and the existing order. For another resident with chronic respiratory failure, COPD, and congestive heart failure, nebulizer equipment was not stored in a manner that would prevent contamination. Observations showed the nebulizer mask was left uncovered on the machine at the bedside, contrary to facility policy, which requires rinsing, drying, and storing the equipment in a plastic bag. Staff interviews confirmed knowledge of the correct procedure, but the practice was not followed, and there was no physician order specifying the cleaning and storage process for the nebulizer equipment.
Non-Functioning Call Bell Systems in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that a functioning call system was available in each resident's bathroom and bathing area on two units. Observations revealed that in two resident rooms, the call bell devices were either missing from the mounting hardware with exposed wires or were hanging by wires and not properly mounted to the wall. Review of workorders from several months documented multiple instances of call bell disrepair, and there was no documented evidence that workorders were submitted to repair the call bells in the affected rooms. These deficiencies were confirmed through staff interviews and direct observation.
Failure to Maintain Clean and Safe Facility Grounds
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During the recertification survey, sections of the lower portion of the building facade were found to be covered with moss and algae. Additionally, piles of old construction materials, accumulations of leaves, and litter were present on the grounds along the building. The garbage dumpsters were not placed within the designated fenced area, and vegetation was encroaching on the fencing. These conditions were directly observed during the survey and confirmed through staff interviews.
Inadequate Ventilation in Soiled Holding and Shower Rooms
Penalty
Summary
Unpleasant odors were observed in the Second Floor Unit Soiled Holding Room and a heavy musty odor was detected in the Second Floor Unit shower room during a survey. The Director of Maintenance reported that the motors servicing the ventilation systems in these areas were not powerful enough to remove the odors and required replacement. These findings indicate that the facility did not ensure adequate ventilation in one of its resident units, specifically affecting the soiled holding and shower rooms on the second floor.
Resident on NPO Diet Fed Pizza by Another Resident
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident who was on a Nothing by Mouth (NPO) diet due to a high risk for aspiration pneumonia. The resident, who had a history of cerebral palsy, Parkinson's disease, and developmental disabilities, was nonverbal and communicated using a communication board. Despite having a gastrostomy tube for feeding and being assessed as high risk for aspiration, the resident was given a slice of pizza by another resident while in a common area. This incident occurred without staff awareness, leading to the resident coughing and requiring medical assessment and monitoring. The resident's care plan and physician orders clearly indicated that the resident was to receive nutrition exclusively through tube feeding, with no oral intake. However, the resident was allowed to be in a common area where other residents had access to food, which led to the incident. Staff interviews revealed that the resident enjoyed being in the common area, but there was a lack of adequate supervision to prevent the resident from accessing food. The incident was documented, and a chest X-ray was ordered to check for aspiration, which returned negative. The deficiency highlights a failure in monitoring and supervision, which resulted in the resident accessing food contrary to their dietary restrictions.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 What corrective actions were taken for the affected resident: 1. Resident #1 suffered no ill effect from receiving pizza from another resident. Resident #1 was assessed by the Nurse Practitioner and chest radiograph was negative for aspiration pneumonia. Care plan was reviewed and revised. How will you identify others at risk to be affected by the alleged deficient practice: 1. A review on 2/12/2025 of current diet orders reveals no other residents have order for Nothing By Mouth. 2. Diet orders will be reviewed on all new admissions to identify residents with Nothing By Mouth status placing them at risk to be affected. Those at risk will be care planned appropriately. What measures will be put in place or what systemic changes you will make to ensure that the alleged deficient practice does not recur: 1. All staff were educated on “Special Considerations for the Resident who is Nothing By Mouth.” 2. The facility will continue to educate all staff on “Special Considerations for the Resident who is Nothing By Mouth” on hire and annually. How the corrective action(s) will be monitored to ensure the deficient practice will not recur: 1. Nursing staff will conduct weekly audits of activities and/or dining to ensure residents with NPO orders are not present while food is being served. Audits will be conducted on various shifts weekly for four (4) weeks then monthly for two (2) months. Audit results will be forwarded to the Quality Assurance Process Improvement Committee for review and further recommendation. Responsibility: Director of Nursing or Designee
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by staffing shortages from July 1, 2024, through July 16, 2024. The facility's assessment required a minimum number of Licensed Practical Nurses (LPNs) and Certified Nurse Aides (CNAs) for each shift, but these levels were not consistently met. For instance, on several days, the day shift was short of the required LPNs and CNAs, and the evening and night shifts also experienced similar shortages. This staffing inadequacy was observed during a survey, where multiple call lights were activated without CNAs available to respond. Interviews with facility staff revealed that the staffing issues were exacerbated by an increase in COVID-19 cases, which affected the availability of staff. The Director of Nursing (DON) acknowledged the staffing challenges and mentioned that they had to work overtime to cover shifts. The facility was also dealing with the recent resignation of the Human Resources Director, which further complicated efforts to fill staffing gaps. The DON indicated that negotiations with a staffing agency were underway, but no resolution had been reached at the time of the survey. The impact of the staffing shortages was evident in the workload of the remaining staff. A CNA reported feeling consistently shorthanded, with an assignment of 40 residents across two floors, which limited the level of care they could provide. Despite their efforts to ensure residents received necessary care, such as feeding and cleaning, the CNA observed that some residents did not receive appropriate care due to the staffing levels. This situation was communicated to the unit manager, highlighting the ongoing challenges faced by the facility in maintaining adequate staffing levels.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide an environment free of accident hazards and adequate supervision to prevent elopement for one resident. On two separate occasions, the resident was able to leave the facility without proper supervision. On the first occasion, the resident was observed leaving the facility with packed bags and was redirected back inside by a social worker who did not report the incident to the appropriate personnel immediately. This lack of communication and failure to follow the facility's elopement policy resulted in no immediate measures being taken to prevent further elopement attempts. On the second occasion, the resident was found in the parking lot by a staff member arriving for work. Although the resident was brought back inside and an electronic monitoring device was applied, there was no system in place to monitor the device or ensure its continued use. The resident later reported removing the device, and staff were unaware of its removal due to the absence of a care plan or physician's order for the device. The facility's failure to implement and monitor appropriate interventions for the resident's elopement risk contributed to the deficiency. Interviews with staff revealed a lack of communication and awareness regarding the resident's elopement risk and the necessary interventions. Key personnel, including the Director of Nursing and the Administrator, were not informed of the incidents in a timely manner, and there was no documentation of the elopement attempts in the resident's care plan or medical records. This oversight resulted in a situation of Immediate Jeopardy and Substandard Quality of Care for the resident.
Neglect Leads to Resident Elopement
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in an elopement incident. The resident, who had cognitive communication deficits, anxiety disorder, and bipolar disorder, attempted to elope on a previous occasion but was not provided with adequate supervision or an electronic monitoring device as per the facility's policy. On the initial attempt, the resident was seen leaving the facility with packed bags but was redirected back inside without further incident. However, the incident was not properly reported or documented, and no preventive measures were implemented. Subsequently, the resident successfully eloped and was found in the parking lot by a staff member. Although an electronic monitoring device was applied afterward, it was not documented in the Medication and Treatment Administration Records, and the resident later removed it without staff knowledge. Interviews with staff revealed a lack of communication and failure to follow procedures, as the incident was not reported to the appropriate personnel, and necessary interventions were not implemented in a timely manner.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident involving a resident who was found outside the building in the parking lot, approximately 40 feet from the front entrance. The incident was not reported to the New York State Department of Health as required by the facility's policy and state regulations. The resident, who had diagnoses including cognitive communication deficit, anxiety disorder, and bipolar disorder, was seen by a staff member exiting the building and was subsequently brought back inside. Despite the facility's policy mandating immediate reporting of such incidents, the event was not reported, and the resident was instead fitted with an electronic monitoring device. Interviews with facility staff revealed a misunderstanding of the incident's severity and the reporting requirements. The Administrator did not consider the event an elopement because the resident was seen exiting the building, while the Assistant Director of Nursing believed the Administrator would report the incident. The Director of Nursing, who was on leave at the time, stated they would have reported it as an elopement had they been present. Surveillance footage confirmed the resident's location and the staff's actions, but the incident remained unreported, violating state regulations and the facility's own procedures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility did not ensure residents were free from physical abuse, as evidenced by multiple incidents involving two residents. Resident #8, who has severe cognitive impairment and a history of wandering and aggression, struck Resident #9 on three separate occasions. Despite having care plans in place, including 30-minute safety checks and interventions to de-escalate agitation, these measures were not consistently implemented or documented. Interviews with nursing staff revealed a lack of awareness and documentation regarding the required 30-minute checks, and the Director of Nursing admitted that these checks had been discontinued without updating the care plan accordingly. Resident #9, who has moderate cognitive impairment, was struck by Resident #8 on two occasions. The only intervention documented in Resident #9's care plan was a stop sign on the door, which the resident found restrictive and ineffective. Observations confirmed that the stop sign was not consistently used, and staff admitted they could not constantly monitor the resident to prevent such incidents. The lack of effective interventions and consistent monitoring led to repeated instances of resident-to-resident abuse, highlighting deficiencies in the facility's abuse prevention and care planning processes.
Failure to Secure Resident's Property
Penalty
Summary
The facility did not ensure that Resident #7's property was secured in a locked drawer, leading to the misappropriation of $75. Resident #7, who has Guillain-Barre syndrome, chronic kidney disease, and type 2 diabetes, reported the missing money to the nurse. The resident was provided with a locked drawer after the incident but did not receive a key to secure it. The Director of Nursing confirmed that an order for a replacement key had been completed but was not fulfilled, and an audit for locked drawers was conducted, but the resident still did not have a way to secure their valuables until the survey. Interviews with the resident, a registered nurse, the Director of Nursing, and the Administrator revealed that the facility was aware of the missing money and the need for a secure drawer. However, the facility failed to provide a key or an alternative means to secure the resident's belongings promptly. The Administrator mentioned that a new lock had been requested from corporate, but a portable safe was not provided in the interim, leading to the deficiency in protecting the resident's property.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility did not ensure that care plans were reviewed and revised in a timely manner for a resident at risk for falls. Specifically, the comprehensive care plan for a resident who had a fall was not updated to include the intervention of a floor mat, which was added to the Accident and Incident report. The resident, who was cognitively intact and admitted with diagnoses including aftercare following joint replacement surgery, muscle weakness, and dysphagia, had an un-witnessed fall. Despite the interdisciplinary team review recommending a door-side fall mat, this intervention was not reflected in the care plan or the Certified Nurse Aide Kardex. Observations confirmed the presence of a folded-up floor mat in the resident's room, but it was not documented in the care plan or Kardex. Interviews with staff, including a Certified Nurse Aide, a Registered Nurse, and the Director of Nursing, revealed that the floor mat intervention should have been included in the care plan and Kardex but was not. The Director of Nursing acknowledged that the care plan should have been reviewed and updated appropriately before the care conference and during the interdisciplinary team meeting.
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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