Utica Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Utica, New York.
- Location
- 2535 Genesee Street, Utica, New York 13501
- CMS Provider Number
- 335471
- Inspections on file
- 29
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Utica Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A facility failed to prevent accident hazards, resulting in three residents being served a cleaning solution stored in an unlabeled pitcher, mistaking it for juice. One resident ingested the solution, leading to physical and psychosocial harm, while two others were served but did not consume it. The incident occurred due to improper labeling and storage of substances, violating facility policy.
The facility did not ensure that contact information for the Ombudsman and the New York State Nursing Home Complaint Hotline was posted in an accessible manner for residents. During a resident group meeting, 13 residents reported being unaware of where to find this information. Staff interviews revealed that signs were removed during construction and not replaced, violating residents' rights.
The facility did not ensure the most recent Federal and State survey results were posted in an accessible location. Observations during a recertification survey found that the inspection binder in the lobby lacked the latest health survey results and complaint survey results. Interviews revealed that the administrator was responsible for the binder's contents, but it was not maintained as required.
The facility failed to inform residents about the grievance process, as 13 residents did not know who the grievance officer was or how to file a grievance. The Social Services Director and Administrator confirmed that the grievance process was not clearly communicated, and there were no signs posted to inform residents. Additionally, the Administrator was unaware of the residents' right to file grievances anonymously.
A facility failed to maintain accurate records for controlled drugs on a nursing unit, leading to discrepancies in medication counts for a resident. The reconciliation process was not properly executed, with narcotic keys transferred insecurely and count logs inaccurately completed. Interviews revealed systemic issues with shift changes and key management, exacerbated by staffing challenges.
The facility failed to maintain an effective infection control program, with deficiencies including lack of proper signage and PPE for residents on precautions, improper PPE use by staff, and unsanitary maintenance of suction equipment. These lapses were observed in two residents, one on contact isolation and another on enhanced barrier precautions, highlighting significant infection control issues.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with diabetes did not have a care plan for insulin management, another on anticoagulants lacked monitoring for bleeding, and a third with multiple conditions had no care plan for high-risk medications. Staff interviews revealed gaps in knowledge and responsibility for care plan updates.
During a survey, it was found that three medication carts in the facility contained expired and improperly labeled medications. On the 3rd floor, an LPN administered medications without verifying expiration dates, including an inhaler, eye drops, and insulin. Additionally, acetaminophen tablets were stored in an unlabeled cup. On the 4th floor, expired and unlabeled medications were also found, with nurses unsure of who was responsible for checking expiration dates. The RN Manager confirmed that nurses should check expiration dates before administration.
The facility failed to maintain food storage and sanitation standards, with surveyors observing unclean surfaces, moldy bread, and inaccurate temperature monitoring in kitchenettes and the main kitchen. The Food Service Director acknowledged these issues, highlighting lapses in adherence to facility policies on cleaning and temperature control.
The facility failed to maintain a safe and clean environment across multiple units. A stove/oven in an activity room was left accessible and operational, posing a safety risk. A resident's tube feeding pole was repeatedly found unclean, and another resident's enabler bar was improperly secured and unusable. Staff acknowledged these issues, but there were lapses in addressing them.
Two residents in a facility experienced deficiencies in nutritional and hydration care. One resident had significant weight fluctuations without reassessment of nutritional needs, while another did not receive the prescribed water flushes via feeding tube, risking dehydration. The facility failed to follow its policies on nutrition assessment and gastrostomy tube feeding, leading to inadequate monitoring and communication among staff.
The facility failed to post daily nurse staffing information, including the resident census and staff hours, in a prominent location for six consecutive days. Despite a policy requiring this information to be posted at the beginning of each shift, observations showed it was not displayed in the main lobby or at the reception desk. The Administrator and HR/Staffing Scheduler acknowledged the oversight, noting that the information was usually in a clear frame on the receptionist desk.
A resident with diabetes and COPD did not receive their preferred meal choices, as their breakfast meal ticket was not accurately followed. The resident received fewer items than listed, and staff interviews revealed inconsistencies in meal preparation and service. Menus and alternative options were not readily available due to remodeling, leading to frequent resident inquiries about meal options.
A resident with dementia was struck by a CNA after requesting ice and ginger ale, an incident witnessed by a Dietary Aide who delayed reporting it for three days. Other staff were aware but also failed to report promptly. The resident had no injuries but the facility's inaction led to Immediate Jeopardy and Substandard Quality of Care, risking harm to all residents.
A facility failed to report an incident of staff abuse towards a resident to the State Agency and law enforcement in a timely manner. A dietary aide witnessed a CNA strike a resident but did not report it for three days. Multiple staff were aware but did not report the incident. The facility did not notify authorities as required, resulting in Immediate Jeopardy and Substandard Quality of Care.
A facility failed to protect residents from sexual abuse, involving a resident with a history of inappropriate behaviors and another with severe cognitive impairment. Despite the resident's ongoing inappropriate actions, the facility did not implement timely interventions or notify relevant parties. The resident was placed in a unit with vulnerable residents, increasing the risk of abuse. Staff interviews revealed a lack of awareness and action, leading to immediate jeopardy and substantial quality of care issues.
The facility failed to provide timely care and medication management, resulting in significant deficiencies. A resident with bleeding was not assessed or reported to a provider promptly, leading to hospitalization. Another resident's wound care was inadequately documented and monitored, and a third resident's pain management patch was frequently unavailable without proper documentation or alternative treatment. These incidents reflect a breakdown in the facility's care and medication management processes.
The facility failed to investigate allegations of abuse and neglect thoroughly. A cognitively impaired resident was found in another resident's room engaging in a sexual act without timely assessment or notification of authorities. Another incident involved a physical altercation between two residents, with delayed assessments and notifications. Additionally, a resident received vaccinations from an unqualified staff member, with no immediate suspension or proper investigation.
The facility failed to update care plans for residents with inappropriate sexual behaviors, leading to ongoing incidents and potential harm. A resident with a history of sexually inappropriate actions did not have an individualized care plan, and two other residents at risk of abuse were not adequately protected. Despite multiple incidents, care plans were not revised to address these issues.
The facility failed to provide adequate social services and behavioral interventions for three residents. A resident with a history of sexually inappropriate behaviors was moved to a unit with cognitively impaired residents without effective interventions. Another resident with wandering behaviors entered this resident's room without documented interventions to address the risk. Additionally, a cognitively impaired resident was subjected to inappropriate requests without proper social services response. The facility's social services staff lacked necessary qualifications, and the Director of Social Services did not consult with behavioral health professionals or implement recommended interventions.
The facility failed to protect residents from sexual abuse and did not implement timely interventions. A resident with a history of inappropriate behaviors was placed on a dementia unit, leading to an incident with another cognitively impaired resident. Investigations were inadequate, with delayed assessments and notifications. The facility also failed to provide appropriate social services, lacking person-centered interventions and consultation with qualified professionals.
Unlabeled Cleaning Solution Mistakenly Served as Juice
Penalty
Summary
The facility failed to ensure the resident environment was free of accident hazards, resulting in three residents being served a cleaning solution stored in an unlabeled pitcher in the kitchenette refrigerator. Residents consumed or were served the solution, mistaking it for juice, which led to physical and psychosocial harm. The facility's policy required that all foods and substances be properly labeled and stored separately from cleaning compounds, which was not adhered to in this instance. Resident #72, who had diagnoses including end-stage renal disease, hypertension, and diabetes, was cognitively intact and required assistance with eating. On the evening of the incident, the resident inadvertently ingested a gulp of the cleaning solution, resulting in a terrible taste in their mouth and subsequent anxiety about drinking fluids. The resident experienced intermittent nausea and a sore throat following the incident. Resident #75, with moderately impaired cognition, was served the solution but did not consume it, while Resident #98, with severely impaired cognition, took a sip but did not swallow it due to the taste. The investigation revealed that the cleaning solution was mistakenly served as juice due to a lack of labeling and improper storage. The Food Service Aide, who poured the drinks, assumed the liquid was juice and did not notice any scent indicating otherwise. The Dietary Supervisor identified the issue when they noticed the liquid's odd appearance and chemical smell. The facility's failure to adhere to proper labeling and storage protocols led to the incident, posing a risk of serious harm to the residents involved.
Removal Plan
- The Administrator provided an immediacy removal plan when all the chemicals were removed from the kitchenettes and secured in the locked service closet on the first-floor service corridor.
- All food service staff were to be educated on the process of taking cleaning chemicals from the secured chemical closet after meal service to clean the kitchenettes, and no chemicals were to be left in the kitchenettes.
- All staff were educated that any unlabeled drinks were to be disposed of immediately.
- The Certified nurse aides, food service staff, licensed practical nurses, and registered nurses were educated with emphasis on the fact drinks were to be identified with a label and date.
- The facility would educate 100% of staff prior to the start of their next scheduled shift.
- The Dietary Cook/Supervisor completed an audit of all three kitchenettes to ensure there were no unsecured cleaning agents, or unlabeled drinks.
- The Director of Food Services completed floor round and confirmed there were no chemical bottles in the kitchenettes.
- The Food Service Director completed an audit of the first-floor kitchen and removed unsecured cleaning agents and placed them in the locked first floor corridor kitchen closet.
- 86 of 147 employees (59%) were educated and the plan was to continue to educate employees over the phone and prior to their next scheduled shift.
- 85% of staff, 125 had been educated about storing cleaning products in the kitchen and kitchenettes, labeling all resident drinks in pitchers with the date and juice type, and immediately disposing of anything unlabeled in a pitcher.
Failure to Post State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to ensure that a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the Ombudsman and the New York State Nursing Home Complaint Hotline, were posted in a manner accessible to residents and their representatives. During a resident group meeting, 13 anonymous residents reported that they did not know where to find this information. Observations confirmed that there were no postings of the Ombudsman program or the New York State Nursing Home Complaint Hotline in the main lobby or on the 4th floor during the survey period. Interviews with facility staff revealed that the signs containing this critical information were removed during a construction process and were either damaged or missing. The Social Services Director acknowledged that the information was included in the resident handbook provided upon admission, but the physical signs had not been re-posted since the renovation. The Administrator confirmed that new signage was ordered, and paper versions were temporarily put up but were removed during construction or by residents. This oversight resulted in residents not having easy access to important contact information, which is a violation of their rights.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to ensure that the results of the most recent Federal and State surveys were posted in a location that was easily accessible to residents, family members, and legal representatives. During the recertification survey conducted from February 3 to February 11, 2025, it was observed that the state inspection binder located in the front lobby did not include the most recent standard health survey results from March 2023 or any subsequent complaint survey results. Additionally, there was no posted notification of the availability of the previous three years of survey reports, which is a requirement according to the facility's policy on Resident Rights dated October 2017. Observations made on February 4 and February 10, 2025, revealed that the binder only contained the Life Safety survey results from March 7, 2023, and the facility's star rating from the Medicare website. Interviews with the receptionist and the administrator confirmed that the binder was the administrator's responsibility, and it was supposed to include the last survey results and any updates between surveys. However, the administrator had only recently added the last complaint results and the star rating, indicating a lapse in maintaining the binder's contents as required by regulations.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and how to file grievances, as evidenced by the findings during the recertification survey. Thirteen residents present at a resident group meeting expressed that they did not know who the grievance officer was or how to file a grievance. The facility's grievance policy, revised in 2020, stated that residents had the right to voice grievances with the expectation of resolution, and this information was supposed to be provided upon admission and prominently posted throughout the facility. However, the residents reported not receiving this information, indicating a lack of communication and accessibility regarding the grievance process. Interviews with the Social Services Director and the Administrator revealed inconsistencies in the grievance process. The Social Services Director, who was designated as the Grievance Officer, stated that grievances could only be filed through them, and if a resident wanted to file anonymously, they would not include the resident's name on the form. The Administrator confirmed that the grievance process involved the Social Services Director and that the information was included in the welcome packet, but acknowledged that there were no signs posted in the facility to inform residents of the grievance officer or the process. Additionally, the Administrator was unaware that residents had the right to file grievances anonymously, highlighting a gap in the facility's adherence to its own policy and regulatory requirements.
Controlled Substance Reconciliation Failure
Penalty
Summary
The facility failed to maintain an accurate system of records and accounts for controlled drugs on Unit 3, as observed during a recertification survey. Specifically, the controlled substance reconciliation process was not properly executed between oncoming and outgoing nurses. The narcotic count log form was completed and signed without an actual count being performed, and narcotic keys were not transferred securely between nurses. This led to discrepancies in the medication count for Resident #65, whose Controlled Substance Record was not accurately reconciled after clonazepam was administered. Resident #65 had a physician order for clonazepam, a narcotic anti-anxiety medication, to be administered twice daily. However, a discrepancy was noted when the narcotic compartment contained 52 tablets, while the Controlled Substance Record indicated there should have been 53 tablets. This discrepancy was attributed to a nurse not signing out the medication the previous night. Additionally, the shift-to-shift count log was inaccurately completed, documenting 54 tablets when the actual count was different. Interviews with nursing staff revealed systemic issues with the transfer and counting of narcotic keys. Nurses admitted to not performing required counts during shift changes, and keys were sometimes left unsecured at the nursing station. The lack of a full-time night supervisor contributed to these lapses, as floor nurses were often tasked with dual roles, leading to improper handovers. Despite awareness of these issues, the facility had not effectively addressed the problem, resulting in potential risks to medication security and accountability.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the recertification survey. On Units 2 and 3, there was a lack of proper signage for transmission-based precautions, and personal protective equipment (PPE) was not readily accessible. Specifically, Resident #100's room lacked precautionary signs and PPE, despite the resident being on contact isolation for antibiotic-resistant organisms. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for ensuring appropriate signage and PPE availability. Additionally, Licensed Practical Nurse #37 was observed performing wound treatment for Resident #100 without the necessary PPE, and the waste was disposed of improperly in a regular garbage bag instead of a red biohazard bag. This indicates a failure to adhere to the facility's policies on contact precautions and PPE usage, which are critical for preventing cross-contamination and protecting both staff and residents from infection. Resident #31's suction equipment was not maintained in a sanitary manner, with the suction canister and tubing not dated and the Yankauer catheter left uncovered on the nightstand. The resident was on enhanced barrier precautions due to a tube feeding, yet the necessary PPE was not used during high-contact activities such as medication administration and dressing changes. These observations highlight significant lapses in infection control practices, potentially exposing residents to harmful microorganisms.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #59, who had a diagnosis of type 2 diabetes mellitus and was receiving insulin, did not have a care plan that included diabetes management or insulin administration. Interviews with staff revealed a lack of awareness and understanding of the resident's diabetic condition and the necessary monitoring for hyperglycemia and hypoglycemia. Resident #88, diagnosed with atrial fibrillation and on an anticoagulant, did not have a care plan addressing the use of the anticoagulant or monitoring for related symptoms. Staff interviews indicated a lack of knowledge about the care plan and the importance of monitoring for signs of bleeding or bruising, which are critical for residents on anticoagulants. The resident's care plan was not updated when they transferred from another floor, leading to the oversight. Resident #100, with multiple diagnoses including diabetes, atrial fibrillation, and Parkinson's disease, was on high-risk medications such as insulin, anticoagulants, and antipsychotics. However, their care plan did not reflect these medications or the necessary monitoring and interventions. Staff interviews highlighted a lack of clarity on whether high-risk medications should be included in care plans, and the responsibility for initiating and updating care plans was not clearly defined among the nursing staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards, as observed during a recertification survey. Specifically, three out of four medication carts contained expired medications and improperly labeled drugs. On the 3rd floor North medication cart, several medications, including an inhaler, eye drops, and insulin, were either expired or lacked proper labeling, such as opened dates. Additionally, a medicine cup filled with acetaminophen tablets was unlabeled, and the nurse on duty admitted to administering some of these medications without verifying their expiration dates. On the 4th floor, both North and South medication carts had similar issues with expired and unlabeled medications. An opened bottle of Geri Care mucus relief was found with an expiration date that had already passed before it was opened, and aspirin bottles lacked proper expiration dates. Nurses interviewed during the survey were unsure of who was responsible for checking the expiration dates, and it was noted that expired medications had been administered to residents. The Registered Nurse Manager confirmed that each nurse was supposed to check expiration dates before administering medications, but there was confusion about who was responsible for monitoring the medication carts.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, surveyors observed unclean surfaces in the kitchenettes on Units 3 and 4 and the main kitchen. Specific issues included food debris and grime in various areas of the main kitchen, such as the dry storage room, freezer, and around kitchen equipment. Additionally, there were discrepancies in thermometer readings in the walk-in cooler and economy refrigerator, indicating inaccurate temperature monitoring. Moldy bread was found in the fourth-floor kitchenette, and food spills and debris were noted in the third-floor kitchenette refrigerator. The facility's policies on cleaning and sanitizing equipment, food storage, and temperature control were not adhered to, as evidenced by the observations made during the survey. The Food Service Director acknowledged the inaccuracies in thermometer readings and the presence of moldy bread, which could pose a health risk to residents. The director also noted that the kitchen and equipment should be cleaned after use, and the floors should be maintained daily. However, the survey revealed that these practices were not consistently followed, leading to unsanitary conditions and potential contamination risks.
Deficiencies in Safety and Cleanliness in Resident Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents across multiple units. On Unit 2, the activity room contained a stove/oven with accessible and operational knobs, which was left plugged in and unattended at times, posing a potential safety hazard. The Director of Activities acknowledged that the room was not locked, and residents had access to it, which could be unsafe if they entered unsupervised. The Director of Environmental Services confirmed that the stove/oven lacked safety features and was accessible to both staff and residents. On Unit 3, Resident #31's tube feeding pole was observed to be unclean on multiple occasions, with a large amount of splattered residue. Interviews with staff revealed that housekeeping was responsible for cleaning equipment, but nursing staff should also clean it if needed. The unclean state of the pole was acknowledged by both housekeeping and nursing staff, indicating a lapse in maintaining sanitary conditions for resident care equipment. On Unit 4, Resident #6's enabler bar was improperly secured and not attached to the bed, rendering it unusable. Observations showed that the bar was missing a bolt and had black electrical tape wrapped around it. Despite being aware of the issue, staff did not submit a work order for repairs. The Director of Environmental Services stated that beds, including enabler bars, were inspected biannually, but there was no record of a request to fix the enabler bar for Resident #6.
Failure to Maintain Nutritional and Hydration Needs
Penalty
Summary
The facility failed to ensure that two residents maintained acceptable parameters of nutritional status. Resident #6 experienced significant weight fluctuations, including a 12.1% weight loss in one month and a subsequent 15% weight increase in another month. Despite these changes, there was no documented evidence that the resident's nutritional needs were reassessed. The resident's weight records were inconsistent, with some weights being struck out, and there was a lack of follow-up on the resident's nutritional status after significant weight changes. The resident's diet and fluid intake were not adequately monitored, and there was no staff encouragement observed during meals. Resident #31, who had a feeding tube due to dysphagia, did not receive the ordered water flushes as prescribed. The resident was supposed to receive 30 milliliters of water every hour, but observations showed that the water flush settings on the feeding pump were incorrect, ranging from every 2 to 4 hours. This discrepancy was not addressed by the nursing staff, who continued to sign off on the medication administration record as if the correct flushes were being provided. The resident's fluid needs were not met, putting them at risk for dehydration. The facility's policies on nutrition assessment and gastrostomy tube feeding were not followed, leading to inadequate monitoring and reassessment of the residents' nutritional and hydration needs. The registered dietitian and diet technician did not effectively communicate or address the significant weight changes and incorrect feeding pump settings. These deficiencies highlight a failure in the facility's processes to ensure residents' nutritional and hydration needs are met, as evidenced by the lack of reassessment and incorrect implementation of physician orders.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, including the current resident census and the actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. This deficiency was observed during a recertification survey conducted from February 3, 2025, to February 11, 2025. The facility did not post the required information in a prominent location accessible to residents and visitors for six consecutive days. Specifically, the staffing information was not displayed at the beginning of the shift on February 3, 4, 5, 6, 7, and 10, 2025, as mandated. Interviews conducted during the survey revealed that the facility's policy, effective April 1, 2022, required staffing to be evaluated and adjusted at the beginning of each shift, with the information to be posted by the night supervisor and updated by shift supervisors as needed. However, observations showed that the staffing information was not posted in the main lobby, on the main entrance doors, or at the reception desk. The Administrator acknowledged that the information should have been posted in the front lobby but noted that items had gone missing from the front desk. The Human Resources/Staffing Scheduler confirmed awareness of the posting requirement and observed that the staffing information was not in its designated location, which was usually a clear frame on the receptionist desk.
Failure to Meet Resident's Dietary Preferences and Needs
Penalty
Summary
The facility failed to provide a nourishing, well-balanced diet that considered the preferences of Resident #24, who had diagnoses of diabetes and chronic obstructive pulmonary disease. The resident's dietary needs and preferences were not met as evidenced by the breakfast meal ticket indicating four fried eggs, yogurt, and cold cereal, but the resident only received one fried egg and none of the other items. The resident expressed that they would have eaten the yogurt and cereal if provided. Additionally, the resident reported not being asked about their drink preferences, not receiving a menu, and not being informed about food alternatives, which led to dissatisfaction with meal options. Interviews with staff revealed inconsistencies in meal preparation and service. Certified Nurse Aide #7 and Dietary Aide #39 acknowledged discrepancies in the meal served to Resident #24, with the latter admitting to possibly confusing the resident's meal with another's. Staff also noted that menus and alternative options were not readily available to residents due to remodeling, and residents frequently inquired about meal options. The dietary ticket, which should reflect the resident's preferences, was not accurately followed, contributing to the deficiency in meeting the resident's nutritional needs.
Failure to Report and Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nurse Aide (CNA) and a resident. The CNA was observed by a Dietary Aide to have struck the resident on the face with an open hand after the resident requested ice and ginger ale. This incident was not reported immediately, as the Dietary Aide waited three days before notifying the Director of Nursing. Other staff members were aware of the incident but also failed to report it in a timely manner. The resident involved had a history of dementia, unspecified psychosis, and anxiety disorder, with intact cognition and independence in transfers and ambulation. The resident's care plan noted potential for being abused due to kleptomaniac behaviors that could annoy others. During the incident, the resident was reportedly slapped by the CNA after a verbal exchange, and the resident retaliated by striking the CNA. Despite the altercation, the resident was assessed with no injuries or signs of psychological distress. Multiple staff members, including a Licensed Practical Nurse and a Housekeeper, were aware of the incident but did not report it promptly. The CNA involved continued to work with access to residents until the incident was reported. The facility's failure to ensure timely reporting and protection from abuse resulted in Immediate Jeopardy and Substandard Quality of Care for the resident, placing all residents at risk for serious harm.
Removal Plan
- Certified Nurse Aide #8 was terminated.
- All staff that were aware of the abuse and failed to report it were terminated.
- All staff were educated on abuse and reporting abuse, and education occurred shift to shift until 100% of all staff were educated.
- Resident #1 was assessed by the medical provider and seen by the psychiatric nurse practitioner.
- All residents on the affected unit were evaluated to determine if they were victims of abuse or witness to any abuse.
- All staff received education on abuse, types of abuse, requirements for reporting abuse, the timeframe in which to report abuse, and the ramifications of not reporting abuse timely. Any staff who were not present during the training will be educated on their first day back to work prior to beginning their shift.
- Verification interviews were completed with multiple staff from multiple departments to ensure understanding of the abuse education.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to report an incident of staff abuse towards a resident to the State Agency and law enforcement in a timely manner. Dietary Aide #4 witnessed Certified Nurse Aide #8 strike Resident #1 on the face with an open hand, but did not report the incident to the administration until three days later. Multiple staff members were aware of the abuse allegations but failed to report them to the administration. Upon receiving the report, the facility did not notify the State Agency or law enforcement as required. Resident #1, who had diagnoses including dementia, unspecified psychosis, and anxiety disorder, was assessed to have intact cognition and was independent with transfers and ambulation. The incident occurred when Resident #1 requested ice and ginger ale from Dietary Aide #4, and Certified Nurse Aide #8 intervened, telling the resident to sit down and subsequently striking them. Resident #1 retaliated by striking back and then sat down. The Director of Nursing and Administrator were notified of the incident three days later, and an assessment of Resident #1 showed no injuries or signs of psychological distress. Certified Nurse Aide #8 continued to work after the incident until they were suspended on the day the administration was notified. There was no documented evidence that the aide was immediately removed from resident contact or that law enforcement was notified of the alleged abuse. The facility's failure to report the abuse in a timely manner resulted in Immediate Jeopardy and Substandard Quality of Care for Resident #1, placing all residents at risk for serious harm.
Removal Plan
- Local law enforcement was notified of the alleged abuse toward Resident #1.
- Resident #1 was assessed by the medical provider and assessed by the psychiatric nurse practitioner.
- All residents on the affected unit were evaluated to determine if they were victims of abuse or witness to any abuse. No other residents identified.
- The Administrator and Director of Nursing were educated by the Corporate Administrator on the need to report all allegations of staff abuse towards a resident to local law enforcement. Education included the process for reporting, whom to report, the timeframe in which to report, and the professional and criminal ramifications of not reporting.
- The Administrator and Director of Nursing reported they had received the education.
- Certified Nurse Aide #8 was terminated.
- All staff that were aware of the abuse and failed to report it were terminated.
- All staff working were educated on abuse and reporting abuse, and education occurred shift to shift until 100% of all staff working were educated.
- 88% of all staff received education on abuse, types of abuse, requirements for reporting abuse, the timeframe in which to report abuse, and the ramifications of not reporting abuse timely. Any staff who were not present during the training will be educated on their first day back to work prior to beginning their shift.
- Verification interviews were completed with multiple staff from multiple departments to ensure understanding of the abuse education.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, specifically involving two residents. One resident, with intact cognitive function and a history of sexually inappropriate behaviors, continued to exhibit such behaviors without documented interventions to address them or protect other residents. This resident made verbal sexual requests to others and was found in a compromising situation with another resident who had severe cognitive impairment. The facility did not assess the cognitively impaired resident timely, nor did they notify the resident's representative, medical provider, or the police in a timely manner. Additionally, interventions to protect this resident and other vulnerable residents were not implemented promptly. The facility's policy on abuse prevention was not effectively followed, as there was a lack of analysis and intervention for residents with behaviors that could lead to conflict or neglect. Despite the resident's history of sexually inappropriate behavior, including touching others and making explicit comments, the facility's response was inadequate. Staff were advised to ignore the resident's comments and keep them away from female residents, but no substantial measures were taken to prevent further incidents. The resident was moved to a unit primarily for residents with dementia, which increased the risk of abuse due to the vulnerability of the other residents. Interviews with staff revealed a lack of awareness and action regarding the resident's behaviors and the risks posed to others. The Director of Social Services and other staff were aware of the resident's inappropriate behaviors but failed to implement effective interventions. The resident continued to make inappropriate comments and engage in sexual acts with other residents, yet remained on the same unit without adequate supervision or intervention. The facility's inaction and failure to protect residents from abuse resulted in immediate jeopardy and substantial quality of care issues.
Removal Plan
- A comprehensive review of all current residents' records (progress notes, incidents) was completed by the Corporate RN. The review included direct care staff interviews by the Corporate RN to identify any potential unidentified behavioral concerns.
- A review of all behavioral consults was completed to ensure any recommendations were addressed.
- A Regional Administrator/Licensed Master Social Worker and telehealth psychology services were identified for availability for consultation as needed.
- 100% of all staff currently working have been educated on abuse, sexual abuse prevention, responding to abuse, signs of abuse, steps to take to protect residents, and reporting abuse.
- 86% of the total staff population have received education, with education planned to continue until 100% is reached.
- 100% of all supervisors were educated on response to abuse allegations, including documentation and protection of residents.
- The remaining staff will be educated prior to the start of their next shift or upon return from their leave.
- Staff education sign in sheets were reviewed and compared to the current staff list and no discrepancies were identified.
- Staff education was verified during an onsite visit. Multiple staff including nursing, therapy, dietary, housekeeping, and activities were interviewed.
- Staff were able to report content of education and confirmed the day they received the education and the facility staff who presented the education (Corporate Registered Nurse, Educator/Assistant Director of Nursing, and the Director of Social Services.)
Deficiencies in Timely Care and Medication Management
Penalty
Summary
The facility failed to provide timely and appropriate treatment and care to several residents, leading to significant deficiencies. One resident experienced episodes of vaginal and rectal bleeding, but was not assessed by a qualified professional for over 11 hours, and the medical provider was not notified until more than 8 hours after the onset of bleeding. Despite being on anticoagulant medications, there was no evidence that the medication was reviewed by the provider to determine if it should be held. The resident was eventually sent to the hospital with gastrointestinal bleeding and acute blood loss anemia, requiring a blood transfusion. Another resident had an intact left heel blister for which a treatment was ordered, but there was no documentation of monitoring or assessment of the wound after the treatment was ordered. The resident's care plan was not updated to include necessary interventions, and there was no follow-up to ensure the wound was healing or deteriorating. This lack of documentation and follow-up indicates a failure to adhere to the facility's policy on pressure injury prevention and management. Additionally, a resident's ordered Lidocaine Pain Patch was not obtained or administered in a timely manner on multiple occasions. There were no corresponding nursing notes explaining why the patches were unavailable, and the issue was not communicated effectively to the provider to seek an alternative treatment. This repeated failure to provide the prescribed pain management treatment highlights a breakdown in the facility's medication management process.
Removal Plan
- 83% of nursing staff and therapy staff had been educated on recognizing a change in condition, actions for staff to take when a change in condition was identified, notification of the registered nurse, notification of the medical provider, monitoring and follow-up, and follow-up responsibilities.
- The remaining staff would be educated prior to the start of their next shift.
- Staff education sign in sheets were reviewed and compared to the current nursing/therapy staff list and no discrepancies were identified.
- 100% of nursing staff and therapy staff currently working received education.
- Staff education was verified during an onsite visit, multiple nursing staff on multiple units along with therapy staff were interviewed.
- Staff were able to report content of education.
- 30 days of 24-hour reports were reviewed to identify other affected residents related to change in condition.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure thorough investigations of abuse and neglect allegations for several residents. In one instance, a cognitively impaired resident was found in another resident's room engaging in a sexual act. The facility did not assess the involved residents promptly, nor did they notify the police, family, or medical provider in a timely manner. Additionally, protective interventions were not implemented immediately, and a staff member left the residents after discovering them in the act. Another incident involved a physical altercation between two residents, where neither was assessed by a qualified professional in a timely manner. A staff member reported the incident to a supervisor, who declined to assess the residents at that time. There was no documentation of assessments or notifications to the residents' representatives until the following day. In a separate case, a resident received vaccinations from an unqualified staff member, and the staff member was not suspended pending the investigation. The facility's investigation did not address the type of vaccination administered, discrepancies in the medication administration records, or the lack of medical provider notification related to the medication error. Additionally, there was no disclosure to the resident about the medication error or the unqualified staff member who administered the vaccination.
Failure to Update Care Plans for Residents with Inappropriate Behaviors
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to meet the needs of three residents, leading to deficiencies in addressing sexually inappropriate behaviors and protecting vulnerable residents. Resident #5, who had a history of sexually inappropriate behaviors, did not have an individualized care plan to address these behaviors. Despite multiple incidents of inappropriate comments and actions towards other residents, the care plan was not updated to include specific interventions to prevent further occurrences or protect other residents. Resident #4, who had severe cognitive impairment and a history of wandering, was at risk of being sexually abused. The care plan did not include updates or interventions to address the risk posed by Resident #5's inappropriate sexual requests. An incident occurred where Resident #4 was found in Resident #5's room engaging in a sexual act, yet there were no documented care plan updates to prevent such incidents. Resident #13, with severe cognitive impairment, was involved in an incident where they kissed Resident #5 after being asked for a kiss. Despite this interaction and the potential risk of abuse, there were no updates to Resident #13's care plan to address the risk posed by Resident #5. The facility's failure to update and individualize care plans for these residents resulted in ongoing inappropriate behaviors and potential harm.
Inadequate Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide adequate medically related social services to ensure the highest practicable physical, mental, and psychosocial well-being for three residents. Resident #5, who had intact cognitive function and a history of sexually inappropriate behaviors, was moved to a unit with cognitively impaired residents without implementing person-centered mental/behavioral health interventions. The responses to Resident #5's inappropriate behaviors were ineffective and punitive, and the recommendations from a licensed psychologist were not incorporated into the resident's care plan. Additionally, the facility's social work staff lacked the necessary academic degrees or licensure, and the contracted Licensed Master Social Worker was not consulted regarding Resident #5's high-risk behaviors. Resident #4, who exhibited wandering behaviors and resided on the same unit as Resident #5, had instances of entering Resident #5's room. There were no documented interventions from social services to address Resident #4's risk of entering Resident #5's room, despite the potential for abuse. Furthermore, Resident #13, who had cognitive impairment, was subjected to an inappropriate request from Resident #5, which was not addressed appropriately by social services. There were no documented interventions to mitigate the risk posed to Resident #13 by Resident #5. The facility's Director of Social Services failed to consult with the Psychiatric Nurse Practitioner or the psychologist regarding Resident #5's ongoing behavioral concerns. The Director of Social Services also did not implement the psychologist's recommendations, which included close supervision and engaging Resident #5 in activities to prevent inappropriate behaviors. The facility's social services department did not effectively address the behavioral issues of Resident #5, nor did they implement protective measures for other residents at risk of abuse.
Failure to Protect Residents from Abuse and Inadequate Investigations
Penalty
Summary
The facility failed to ensure residents were free from sexual abuse and did not implement timely interventions to protect residents from further abuse. Resident #5, with a history of sexually inappropriate behaviors, was placed on a floor primarily for residents with dementia, leading to an incident where Resident #4, a cognitively impaired resident, was found engaging in a sexual act with Resident #5. Despite multiple reports of Resident #5's behaviors, the Director of Social Services did not implement effective interventions or recall the psychologist's recommendations. The Administrator acknowledged that Resident #5 should have been moved sooner to prevent abuse. The facility's investigations into incidents were inadequate, failing to identify concerns or implement timely protective interventions. Resident #4 was not assessed by a qualified professional immediately after the incident, and notifications to family, medical providers, and police were delayed. Additionally, Resident #5 was involved in a physical altercation with another resident, and the staff failed to assess the residents involved promptly. An unqualified staff member administered vaccinations, and there was no immediate suspension pending investigation. The facility did not provide medically-related social services to maintain residents' well-being. Resident #5, with intact cognitive function and a history of inappropriate behaviors, was moved to a unit with cognitively impaired residents without person-centered interventions. The Director of Social Services did not seek consultation from the facility's Licensed Master Social Worker or implement the psychologist's recommendations. The facility's social work staff lacked appropriate academic degrees or licensure, and the contracted Licensed Master Social Worker was not consulted for high-risk behaviors.
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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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