Van Duyn Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Syracuse, New York.
- Location
- 5075 West Seneca Turnpike, Syracuse, New York 13215
- CMS Provider Number
- 335184
- Inspections on file
- 42
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 46 (6 serious)
Citation history
Health deficiencies cited at Van Duyn Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with CKD, diabetes, and prior UTIs developed acute dysuria, new urinary incontinence, fever, and systemic symptoms, but an initial urinalysis order resulted in an unsuitable specimen that was never re‑collected, and later urinalysis and culture results showing pyuria and recommending recollection were not documented as reviewed by providers. Over several weeks, the resident had persistent fevers, nausea, vomiting, lethargy, poor intake, and abnormal labs, while being repeatedly treated with Rocephin without obtaining an adequate urine culture and sensitivity. A urology consult with cystoscopy for hematuria and urge incontinence recommended nightly vaginal estrogen for recurrent UTIs, but there was no evidence that a physician or NP reviewed or implemented this recommendation. The resident continued to decline and was ultimately hospitalized in critical condition with severe sepsis due to UTI, metabolic acidosis, and acute kidney injury, and hospital urine culture showed resistance to cephalosporins.
A resident with traumatic brain injury, severe cognitive impairment, and known aggressive behaviors had a care plan requiring two caregivers, no male caregivers, and 1:1 night supervision. Despite this, a male CNA assisted with incontinence care after the resident verbally refused to be touched. During the brief change, the resident became combative and spat at the CNA, who then forcefully pushed the resident’s head/face down, as witnessed by another CNA. The resident was later found by an LPN and RN/ADON to have multiple facial abrasions and redness and was agitated, reporting being scratched and disrespected by staff. There was no clear documentation or confirmation that the CNA accused of abuse was immediately removed from the premises after the incident.
A resident with traumatic brain injury, anxiety, severely impaired cognition, and documented behavioral issues had a comprehensive care plan specifying two staff for care, no male caregivers, and 1:1 supervision at night due to falls. Despite this, male CNAs were repeatedly assigned to the resident, including as a 1:1 on a night shift. During care at the end of that shift, the resident became combative and spat at the male CNA, who was then witnessed forcefully pushing the resident’s face into a pillow, causing facial and neck scratches. Multiple staff, including the ADON, LPNs, RN supervisor, NP, and Medical Director, confirmed that the resident was care planned to have no male caregivers and that this information was available on the care plan and care card, but it was not followed.
A resident with traumatic brain injury, severe cognitive impairment, and behavioral symptoms became agitated during incontinence care and attempted to spit at a CNA, who then forcefully pushed the resident’s face, causing multiple facial abrasions and redness. Another CNA witnessed the incident and recognized it as abuse, and an LPN later observed the injuries after hearing the resident scream, but staff did not immediately notify the on‑duty RN supervisor or management as required by facility policy. The Administrator and DON were not informed until about five hours after the incident, at which time law enforcement was contacted, and the required 5‑day investigative report to the State Agency was not submitted until 12 days later, in violation of abuse reporting and care planning requirements.
A resident with Alzheimer’s disease and bipolar disorder exhibited escalating verbal and physical aggression over several months, including throwing hot liquid, hitting other residents, swinging at staff, and attempting to throw a glass object, culminating in striking another resident in the head with a wheelchair leg rest. Despite repeated incidents, nursing staff did not complete incident reports in all cases, did not conduct root cause analyses, and did not timely initiate or update a behavioral care plan with specific interventions to prevent recurrence. Documentation showed ongoing refusal of psychotropic medication, use of racial slurs, and aggression, while staff interviews revealed reliance on informal monitoring and redirection rather than a formalized, individualized behavior plan. The facility’s policies required comprehensive care planning and abuse prevention measures, but these were not effectively implemented for this resident until after multiple resident-to-resident altercations had already occurred.
A resident with a history of respiratory failure and OSA, on 4 L O2 via nasal cannula, developed sudden labored respirations and severely low O2 saturations in the 20–40% range, became minimally responsive, and was placed on 10 L O2 via non-rebreather without a provider order. Nursing staff notified a supervising RN and repeatedly checked saturations but did not immediately contact the physician or NP, did not promptly call 911, and did not notify the resident’s health care proxy of the change in condition or transfer. EMS was eventually called, and the resident was transported to the ED in critical respiratory distress and later pronounced deceased. Staff interviews confirmed that facility policy required immediate provider and family notification for significant changes in condition and that such low O2 saturations should have triggered emergency response, but these steps were not followed, resulting in an Immediate Jeopardy deficiency.
A resident with respiratory failure and obstructive sleep apnea had a care plan and physician order for continuous oxygen at 4 L via nasal cannula, but a respiratory therapist provided only 3 L without verifying the order, and there was no RN assessment or documented monitoring when the resident reported shortness of breath. Family reported that an oxygen concentrator was not working, staff were notified, and the resident was placed on a portable tank, yet no staff addressed the oxygen issue before the family left. Later, an LPN found the resident minimally responsive with severely low O2 saturation, contacted an RN who briefly assessed and instructed use of a face mask but did not stay, and the LPN increased oxygen to 10 L via non-rebreather without a provider order; there was no documented RN assessment or physician notification before EMS was called, and EMS arrived to find the resident unresponsive and unattended on the unit.
A cognitively intact but high-risk resident with SUD, suicidal ideation, COPD on continuous O2, visual impairment, and poor safety awareness eloped after packing belongings, using a wheelchair with O2 to reach the lobby, and walking out the front entrance without being stopped or signed out. The resident had scored high on an AMA risk assessment but was scored zero on an elopement assessment, received no elopement-related care plan interventions or wander alert device, and had no MD order to be out on pass. Staff did not locate the resident during routine checks, initiated overhead pages and a Code White search hours after the last known contact, and marked later medications as "Out of Building" despite no documented discharge. The facility’s elopement policy lacked a defined timeframe for contacting 911, and emergency services were not called until more than five hours after the Code White, while the resident’s whereabouts were unknown. Police were told the resident was free to leave even though there was no documented AMA counseling, MD notification, or discharge order, and the AMA form was signed the next day at an off-site location without documented risk counseling.
The facility failed to maintain an effective compliance and ethics program and a non-retaliatory reporting culture. Written policies, including a Code of Conduct, a Non-retaliation and Non-retribution policy with an anonymous hotline, and an abuse prevention policy, stated that staff could report concerns without fear of retribution. However, multiple staff reported they did not trust the reporting process, feared loss of vacation, overtime, or work if they reported concerns, and believed anonymous reporting was ineffective. Staff also described fears of retaliation and threats of harm from coworkers. During surveyor interactions, the administrator, assistant administrator, and DON challenged the survey process in raised voices, leaned forward with clenched fists, questioned the Immediate Jeopardy decision, and the administrator attempted to prevent surveyors from leaving, reflecting an environment inconsistent with safe, non-retaliatory reporting.
A resident with Alzheimer’s disease and bipolar disorder, with moderately impaired cognition, was involved in two separate altercations where coffee was thrown and another resident was struck on the cheek, causing redness. Although facility policy and state guidance required review and reporting of incidents involving possible abuse or mistreatment to the state agency within five days, staff did not complete or submit required incident reports to the New York State Department of Health. The DON later explained that these events were not reported because there was no significant injury, pain, or mental anguish, and the Administrator described relying on internal communication processes to learn of such incidents.
A resident with Alzheimer’s disease and bipolar disorder, moderate cognitive impairment, and a known history of agitation and racial slurs exhibited escalating behaviors including throwing coffee that struck another resident, hitting another resident during a meal dispute, refusing Depakote, using racial slurs, physical aggression toward staff, being punched by another resident while cleaning tables, attempting to throw a vase at staff, and later striking the same resident with a wheelchair leg. Despite these repeated behavioral incidents and documentation in progress notes and investigative summaries, the comprehensive care plan either lacked interventions or contained only a generic redirection intervention, with no measurable objectives, timeframes, or detailed, person-centered behavior strategies. Interviews with CNAs, LPNs, RNs, and the DON showed that staff were aware of the behaviors and expected that care plans should be updated after such events, but behavior-focused care plan revisions were not completed in a timely or adequate manner.
A resident with complex medical and psychiatric conditions, including acute respiratory failure requiring O2 and a history of suicide attempts, was care planned as an elopement risk but left the building undetected, without ordered O2, medications, or an evening meal. The resident reported informing a staff member of their intent to leave, exiting through the main lobby with packed bags, abandoning their O2 due to difficulty carrying it, and receiving no challenge or sign-out request from staff. Facility policies required reporting and investigation of incidents such as elopement and potential neglect, yet documentation showed no timely, thorough investigation: key witnesses (day-shift staff, front desk, security, the nurse who contacted EMS, the nurse who spoke with police, and the social worker who later met the resident) were not interviewed, camera review was not documented, and statements were largely limited to evening-shift staff who had not seen the resident all shift. There were also inconsistencies and incomplete documentation around whether the departure was treated as an AMA discharge, contributing to the finding that the facility failed to thoroughly investigate the alleged neglect.
A resident with respiratory failure, OSA, and a history of pulmonary embolism had an active physician order and care plan for continuous O2 at 4 L/min via nasal cannula. During a visit, the resident reported breathing difficulty; the health care proxy found the concentrator not delivering air as expected and was unable to get staff assistance, after which the resident’s granddaughter independently connected the nasal cannula to a portable O2 tank of unknown flow. When a Respiratory Therapist later assessed the resident for reported SOB, the resident was on 3 L/min from the portable tank with SpO2 of 92% and was then switched to the concentrator at 3 L/min. The RT did not verify the current O2 order and stated they were unaware the resident was ordered 4 L/min, relying instead on a prior recollection of a 3 L/min setting, resulting in O2 being provided at a lower flow than prescribed.
A resident with respiratory failure, OSA, and hypertension experienced an acute change in condition with labored respirations, decreased responsiveness, and very low O2 saturations. An LPN notified the RN supervisor, oxygen delivery was escalated from nasal cannula to mask and then to a non-rebreather, and EMS ultimately transported the now unresponsive resident to the hospital. Despite facility policies requiring RN assessment and detailed transfer documentation, there was no recorded RN assessment, no documented vital signs (HR, BP, RR, temp), and no documentation of the resident’s response to oxygen therapy, and the RN’s progress note entry remained blank, leaving the medical record incomplete and not in accordance with professional standards.
A resident with opioid dependence, anxiety, depression, and a history of smoking violations had an active physician order and care plan intervention for 1:1 safety supervision following an IDT decision to place the resident on a safety watch. Facility policy required continuous close monitoring and documentation, but CNAs described inconsistent practices and unclear expectations regarding required proximity during 1:1 supervision. After the resident was readmitted from a hospital stay, the existing 1:1 safety watch was not implemented, no discontinuation order was documented, and staff on the new unit did not provide 1:1 supervision. Within days of this readmission without 1:1 in place, the resident was found with a self-inflicted neck laceration and superficial cuts to both wrists, constituting actual harm.
Staff were observed and reported to have used foul language, ethnic slurs, and laughed at residents in hallways and common areas, causing discomfort and distress among residents. Multiple residents and some staff confirmed that inappropriate language and behavior occurred frequently, in violation of facility policies requiring dignity and respect for all residents.
Surveyors found that the facility did not ensure resident rooms and common areas were clean and in good repair, with strong urine odors, soiled toilets, broken or empty dispensers, stained bedding, dirty floors, and maintenance issues such as broken tiles and missing ceiling tiles. A resident reported unclean bathrooms and shower rooms. Facility staff acknowledged the issues during interviews.
Surveyors found that the facility did not consistently provide palatable, flavorful, or properly temperature-controlled meals. Multiple residents reported cold, unappetizing food and missing meal items, while staff confirmed ongoing issues with food temperatures and tray accuracy. Observations showed food and beverages served outside recommended temperature ranges, and the Food Service Director acknowledged equipment problems affecting meal quality.
Strong urine odors were repeatedly detected in several resident rooms and a common area across multiple units, indicating a failure to maintain a sanitary and comfortable environment. The Director of Environmental Services acknowledged the issue and planned to involve the nursing department for further investigation.
A resident with multiple diagnoses was found with an old bandage on the forearm, with no documentation, physician order, or record of treatment in the medical or treatment administration records. Nursing staff were unaware of the origin or need for the bandage, and there was no incident report or progress note explaining its presence, resulting in a failure to provide care according to professional standards.
Two residents did not receive critical medications as ordered due to failures in medication procurement and administration processes. One resident missed several doses of Lithium because the medication was not available and staff did not follow up with the pharmacy after a refill error. Another resident with kidney disease did not receive cinacalcet and Sevelamer for an extended period due to confusion over medication sourcing and delays in obtaining the medications from the pharmacy. Nursing and pharmacy staff interviews confirmed lapses in following procedures for ensuring medication availability.
Two Deaf residents were not provided with their preferred method of communication, American Sign Language, and were instead limited to using whiteboards and written communication. Staff lacked training and access to technology such as tablets with video relay interpreting services, resulting in the residents' inability to communicate needs, participate in activities, or engage in care discussions, leading to actual psychosocial harm.
Multiple residents on contact and droplet precautions for infectious diseases did not have appropriate isolation signage, and staff frequently failed to use required PPE or perform hand hygiene. Contaminated laundry was not properly separated, and housekeeping and laundry staff did not consistently follow infection control protocols, leading to widespread non-compliance with facility policies.
Two continent residents were placed in incontinence briefs and instructed by staff to urinate or defecate in them instead of being assisted to use the toilet or bedpan. Staff failed to update care plans and reassess toileting needs, resulting in residents being left in soiled briefs for extended periods, causing embarrassment and psychosocial harm. Multiple staff and clinical leaders acknowledged that this practice violated resident dignity and failed to provide individualized care.
Two residents did not receive wound care as ordered, including delayed follow-up for a dehisced surgical site and missed wound VAC changes without backup dressings. One resident experienced harm due to lack of timely specialist consultation and wound management, while another went without prescribed wound therapy during staff absence.
Surveyors found that medication and treatment carts were frequently left unlocked and unattended, with prescription drugs, wound care supplies, and sharp instruments accessible to residents. Medication refrigerators lacked consistent daily temperature monitoring, and several insulin pens and other medications were missing open dates, making it impossible to verify their effectiveness. Discontinued medications accumulated in medication rooms without a clear process for timely removal, and staff interviews revealed inconsistent knowledge and practices regarding medication storage and labeling.
The facility did not ensure that suitable and nourishing snacks and alternative meals were available to residents who wanted to eat outside of scheduled meal times. Observations showed that snack items were often missing from unit kitchenettes, and staff reported difficulties accessing snacks due to frequently changed door codes. Residents stated they did not receive bedtime snacks, and staff sometimes hid snacks to meet resident requests, indicating a breakdown in the facility's snack distribution process.
The facility did not ensure food was held at safe temperatures during meal service and failed to provide properly equipped handwashing sinks in food service areas. Staff did not consistently check or document food temperatures, and multiple handwashing sinks lacked hot water, soap, or paper towels, leading to improper hand hygiene practices during food preparation and service.
Surveyors found widespread uncleanliness and disrepair throughout multiple units, including soiled linens and briefs left on floors, stained furniture, persistent urine odors, and accumulation of trash in resident rooms and common areas. Staff interviews revealed inconsistent cleaning practices and unclear division of responsibilities between nursing and housekeeping, resulting in failure to provide residents with a safe, clean, and comfortable environment as required by facility policy.
Multiple deficiencies occurred when a resident with dysphagia was repeatedly observed using straws despite a 'no straws' order, another resident had a used needle improperly discarded in their room's trash can by an LPN, and a third resident sustained burns after independently removing hot food from a microwave without appropriate care planning or supervision. Staff interviews confirmed awareness of policies, but lapses in supervision and adherence to protocols led to these incidents.
Surveyors observed that food and drink were repeatedly served at improper temperatures and were unpalatable, with multiple residents and staff reporting that meals were cold, lacked flavor, and were unappealing. Direct observations showed that hot foods were served below required temperatures and cold items above safe limits, with delays in meal tray distribution contributing to the issue.
Surveyors identified that several residents did not receive all required food items and nutritional supplements as specified on their meal tickets, with staff and residents confirming that missing items and lack of substitutions were frequent issues. Staff interviews revealed that incomplete trays were a known problem, and while some items were unavailable due to supply shortages, alternatives were not consistently provided.
Surveyors found that the facility did not maintain an effective pest control program, as evidenced by repeated observations of fruit flies and mouse droppings in administrative and resident areas across several floors. Staff interviews revealed inconsistent awareness and reporting of pest issues, and two residents reported seeing mice in their rooms. Despite a policy requiring pest sightings to be logged for vendor follow-up, pests remained present in multiple facility locations.
A resident with cognitive intactness and independence in ADLs was found self-administering medications left at the bedside without nurse supervision, despite facility policy requiring an interdisciplinary assessment for self-administration. Staff confirmed no such assessment or order was in place, and medications were observed unattended in the resident's room.
Two residents were not protected from misappropriation of their property and funds. One resident, who was deaf and non-speaking but cognitively intact, gave a staff member a large sum of money to hold and make purchases, but not all funds were returned or accounted for, and the resident was unaware of the facility's resident account option. Another resident, a trauma survivor, had bags of deposit cans removed from their room by staff; the cans were cashed in by a housekeeper, but the resident did not receive the money, despite making their wishes clear. Facility policy prohibiting staff from accepting or managing resident funds was not followed in either case.
A resident with left-sided paralysis sustained superficial burns after accidentally spilling hot water while preparing food. Staff documented the incident and assessed the resident, but the DON did not report the burn to the Department of Health as required by state policy, citing unawareness that such burns were reportable. This failure to report constituted the deficiency.
A resident who was deaf and non-speaking gave a staff member a large sum of money to hold, but only part of it was returned when requested. The facility did not promptly investigate the incident, failed to use a certified interpreter for communication, and did not document or report the event as required. Staff provided inconsistent information about the incident, and the missing funds were not fully accounted for.
A resident with a tracheostomy and history of cancer was inaccurately documented in the MDS as nonverbal and severely cognitively impaired, despite being able to communicate effectively with a speaking valve and demonstrating cognitive intactness. Staff interviews and observations confirmed the resident's abilities, but the care plan and MDS were not updated to reflect these changes, and the cognitive assessment was not reassessed quarterly as required.
A resident with severe cognitive impairment and multiple diagnoses, including edema and arthritis, was not provided with wheelchair leg rests as recommended by therapy. The care plan failed to include this intervention, and the resident was repeatedly observed without leg rests, despite staff acknowledging their necessity for proper positioning and comfort.
Surveyors found that staff frequently used personal electronic devices in resident care areas, spent excessive time in breakrooms, and failed to respond to call bells in a timely manner. Residents reported staff were often rude, unresponsive, and disrespectful, with some expressing fear of retaliation for complaints. Staff interviews confirmed widespread disregard for facility policies regarding cell phone and earbud use, and a lack of supervision contributed to ongoing issues with resident care and professionalism.
Two residents dependent on staff for ADLs did not receive necessary oral hygiene or hair care, as observed by surveyors and confirmed by staff interviews. Both residents were repeatedly seen with matted hair and foul breath, and reported not receiving scheduled showers, grooming, or assistance with oral care, despite these being outlined in their care plans. Staff acknowledged that these tasks were sometimes missed due to time constraints or lack of follow-up.
Two residents requiring alternating air mattresses for pressure ulcer prevention and care did not have individualized mattress settings based on their weights, and staff failed to monitor or adjust these settings as needed. Staff interviews revealed a lack of knowledge and responsibility regarding proper mattress use, and documentation did not include verification of appropriate settings, resulting in a deficiency in pressure ulcer care.
Two residents with significant weight loss did not receive prescribed fortified foods, supplements, or preferred meal items as ordered, and staff failed to ensure meal tray accuracy or provide dignified assistance with eating. Despite care plans and policies requiring specific nutritional interventions and meal checks, both dietary and nursing staff did not consistently deliver the required items, contributing to ongoing weight loss.
A resident with chronic pain and hemiplegia did not receive their prescribed Lidocaine pain patch as ordered, despite repeated requests and documentation indicating administration. Staff confusion about the storage location of the patches and improper documentation practices led to multiple missed doses, resulting in unmanaged pain for the resident.
A resident with quadriplegia and reduced mobility used bilateral bed rails without a current physician order, comprehensive care plan inclusion, or ongoing risk assessment. Documentation of informed consent and discussion of risks and benefits was outdated, and maintenance checks were infrequent. Staff interviews revealed confusion about facility policy and assessment requirements, resulting in inadequate monitoring and documentation for the safe use of bed rails.
A resident with diabetes and end stage kidney disease was readmitted from the hospital with orders for sliding scale insulin and scheduled blood glucose monitoring, but the facility failed to initiate the sliding scale insulin and did not consistently perform fingerstick checks as ordered. The provider was not made aware of the hospital's recommendations or the resident's high blood glucose readings, leading to a lack of appropriate intervention and the resident's subsequent hospital readmission for hyperglycemia.
A diabetic resident was given fast-acting insulin before leaving for an early medical appointment but was not provided breakfast or any food to take along, despite facility policy requiring medications to be administered in relation to meals. Staff interviews revealed inconsistent practices and a lack of a clear process to ensure diabetic residents receive food when leaving for appointments after insulin administration.
Two residents did not receive timely dental care as recommended by dental professionals. One resident, dependent on staff for daily living, was not scheduled for denture impressions after a dentist's recommendation, due to uncertainty about their length of stay. Another resident, who required a tooth extraction, experienced delays in scheduling the procedure due to lack of follow-up and insurance issues. Staff interviews confirmed lapses in scheduling and follow-up for dental services.
A resident with severe cognitive impairment was sexually assaulted by another resident with intact cognition. The incident occurred when the cognitively impaired resident, known to wander, entered the other resident's room unsupervised. Staff failed to prevent the incident despite the resident's care plan indicating a potential for wandering and being a victim of abuse. The incident was discovered by a CNA who found both residents undressed in the room.
The facility failed to maintain acceptable water temperatures in four resident rooms, with temperatures recorded at 70 and 80 degrees Fahrenheit, below the acceptable range of 90 to 120 degrees. This issue arose during the replacement of water circulator pumps, affecting a specific vertical water line. Despite daily checks, the cold water issue was not reported by management, though a resident and a complainant noted the problem. Staff mentioned running water before use to ensure suitable temperatures.
Failure to Follow Up Abnormal Urine Testing and Urology Consult Leading to Urosepsis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards, physician/NP orders, and facility policies related to lab follow-up and outside consults. The resident had chronic kidney disease, diabetes, and a history of UTIs, and was cognitively intact and normally continent. On 12/15, nursing and the NP identified acute dysuria, new/increased incontinence, urgency, and frequency, and an order was obtained for a urinalysis and urine culture. The NP documented a plan to send urine to evaluate for a possible UTI. However, the 12/17 urine specimen was reported on 12/19 as unsuitable, with instructions to resubmit using the correct transport tube. There was no documentation that nursing obtained a new specimen or that the NP or physician were aware the urinalysis was not performed. During this same period, the resident developed fever, lethargy, diaphoresis, abdominal and back pain, and decreased appetite, and the physician documented a recent fever with a “negative work up” without evidence of reviewing or addressing the unperformed urinalysis. Over the following weeks, the resident repeatedly reported not feeling well, with ongoing nausea, vomiting, poor intake, lethargy, and new urinary incontinence. Blood work on 12/26 showed elevated WBCs and other indicators of infection, and multiple viral respiratory panels and chest x‑rays were negative. Despite this, there was no documented evidence that the NP reordered a urinalysis after the initial unsuitable specimen, and when a urinalysis and culture were finally obtained on 12/30, the 01/01 report showed trace blood and protein, 2+ leukocyte esterase, 40–60 WBCs, and squamous epithelial cells suggesting an unclean specimen, with a recommendation for recollection and culture. The culture showed <10,000 CFU/mL of a single gram‑negative organism and recommended recollection using a method to minimize contamination. There is no documentation that this urinalysis and culture report was reviewed by the NP or physician on or after 01/01, despite multiple subsequent NP visits for abdominal pain, nausea, cough, congestion, and abnormal labs, and repeated nursing notes describing fever, lethargy, poor appetite, vomiting, and continued complaints of not feeling well. During this same timeframe, the resident was repeatedly treated empirically with Rocephin (a cephalosporin antibiotic) without obtaining a definitive urine culture and sensitivity to guide therapy. Orders were given for one‑time and multi‑day Rocephin courses in response to fevers and systemic symptoms, even though the 01/01 urinalysis suggested infection and recommended recollection and further culture, and no culture and sensitivity was obtained to determine organism susceptibility. On 01/20, the resident underwent a urology consult and cystoscopy for gross hematuria and urge incontinence; the urologist recommended nightly vaginal estrogen for atrophy and concerns for recurrent UTIs. Nursing documented review of the consult and the recommendation to start vaginal estrogen, but there was no documentation that a physician or NP reviewed the consult details, discussed them, or implemented the vaginal estrogen order. The attending physician’s 01/21 visit note did not reference the 01/01 urinalysis or the urology consult, and subsequent NP notes continued to omit genitourinary assessments and did not address the abnormal urinalysis or consult recommendations. The resident continued to be ill, with persistent systemic symptoms, multiple Rocephin doses, and no documented provider follow‑up on the abnormal urinalysis, lack of adequate urine culture and sensitivity, or urology recommendations, until the resident became unresponsive and was sent to the hospital, where they were diagnosed with severe sepsis due to UTI, metabolic acidosis, and acute kidney injury, and the urine culture showed resistance to cephalosporins. The survey determined this resulted in actual harm that was not Immediate Jeopardy.
Failure to Prevent Physical Abuse and Follow Care Plan Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during the provision of care. The resident had a history of traumatic brain injury, anxiety, severely impaired cognition, and exhibited verbal and physical aggression toward staff. The resident’s comprehensive care plan required two caregivers for care, specified no male caregivers, and ordered 1:1 supervision during the night shift due to falls. Despite these documented interventions, a male certified nurse aide (CNA) participated in providing incontinence care to the resident during the night shift, and the care was initiated even after the resident verbally refused to be touched. During early morning care, two CNAs, including a male CNA, attempted to change the resident’s incontinence brief. The resident, who was lying naked on the bed, stated they did not want to be touched. One CNA suggested reapproaching later, but the male CNA insisted on proceeding due to time constraints. The resident initially allowed repositioning but began swinging when the brief was being pulled up and stated they did not want the CNAs touching them. The resident then spat in the male CNA’s face, after which the male CNA placed a hand on the resident’s face and forcefully pushed it down. This action was witnessed by the assisting CNA, who observed the resident become red in the face and more agitated. Following the incident, the assisting CNA pushed the male CNA away from the resident and told him to leave the room. A nearby LPN heard the resident screaming and, upon entering the room, was told by the resident that a CNA had yelled at and disrespected them and had scratched their face twice. Assessment by the RN/Assistant DON later that day revealed multiple abrasions and areas of redness on the resident’s face, including below the right eye and cheek, the tip of the nose, the left eyebrow and below the left eye, and around the lips and chin. The resident appeared agitated and reported being scratched in the face. The incident was reported up the chain of command, but there was no documented evidence that the male CNA was immediately removed from the premises after clocking out, and facility leadership could not confirm that the CNA had actually left the building at that time.
Removal Plan
- Conduct a head-to-toe assessment and psychosocial evaluation for Resident #1 to ensure no further harm occurred.
- Revise the facility abuse policy to include that failure to follow a resident's care plan can place residents at risk for abuse and require employees alleged of abuse to be immediately escorted from the facility by security and placed on administrative leave pending completion of the investigation.
- Terminate Certified Nurse Aide #2's employment.
- Educate 100% of in-house staff on the abuse prevention policy, reporting abuse within appropriate timeframes, and the importance of following the care plan.
- Complete an immediate review to identify individuals with the specific need for no male care and evaluate current staff assignments to match residents based on care plan and needs.
- Review and verify the staff education list against the post-test and staff listing to ensure no discrepancies.
- Verify staff education on site by interviewing certified nurse aides, licensed nursing staff, security, and housekeeping regarding abuse and reporting abuse.
Failure to Follow No-Male-Caregiver Care Plan Resulting in Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan consistent with resident rights for a resident with a documented restriction against male caregivers. The resident had diagnoses including traumatic brain injury and anxiety, with a Minimum Data Set dated 01/22/2026 indicating severely impaired cognition, verbal and behavioral symptoms directed toward others, and a need for moderate assistance or dependence for most ADLs. The comprehensive care plan dated 01/23/2026 documented behaviors related to traumatic brain injury, including verbal and physical aggression toward staff, and included specific interventions: two caregivers for care, no male caregivers, and 1:1 supervision during the night shift due to falls. Undated care instructions also documented two staff for all care and no male caregivers. Despite these documented interventions, multiple CNA assignment sheets showed male CNAs being assigned to the resident. Assignment sheets dated 02/01/2026, 02/09/2026, and 02/12/2026 listed a male CNA assigned to the resident on the 7:00 AM–3:00 PM shifts. The 02/03/2026 CNA assignment sheet documented a male CNA assigned as the resident’s 1:1 during the 11:00 PM–7:00 AM night shift, contrary to the care plan specifying no male caregivers. Interviews with the Assistant DON and other staff confirmed that the resident was more agitated and aggressive toward males, that the spouse agreed with this, and that the care plan had been updated to include no male caregivers, with this information also placed on the care card accessible to CNAs. On the night shift when a male CNA was assigned 1:1, an incident of abuse occurred. According to the 02/04/2026 incident report and witness statements, during morning care at the end of the night shift, the resident became combative while being assisted by the male CNA assigned as 1:1 and another CNA. One CNA interlocked hands with the resident to de-escalate, and the resident spat at the male CNA. The male CNA was then witnessed forcefully pushing the resident’s face down into a pillow, causing scratches over the resident’s face and neck. Multiple staff interviews, including with an LPN, a unit manager, the RN supervisor, the NP, and the Medical Director, confirmed that the resident was care planned to have no male caregivers, that male caregivers triggered the resident, and that the care plan should have been followed. The DON acknowledged that the care card directed care and that CNAs, LPNs, and the RN supervisor were supposed to review it at the beginning of their shift, but the male CNA was nonetheless assigned and involved in the resident’s care, in violation of the care plan.
Removal Plan
- Review Resident #1's care plan to ensure all interventions, including the no-male caregivers requirement, are clearly documented and communicated to all staff.
- Educate all in-house staff on adhering to care plans, identifying residents who require no male care and where it is documented, and reviewing care cards for their assignment prior to starting care with care card acknowledgement sign-off.
- Complete an immediate review to identify individuals with the specific need for no male care.
- Verify unit assignment sheets clearly identify residents requiring no male caregivers by comparing against the facility master list.
- Review and verify the staff education list against the post-test and staff listing to ensure accuracy.
- Verify staff assignments against the no male caregiver list to ensure residents who are care planned to not have male care are not assigned male staff.
- Verify care card acknowledgement sign-off sheets against staff assignment sheets to ensure they are being completed.
- Review care plans and care cards for residents identified as not wanting male care to ensure the information is clearly documented.
- Re-educate staff on reviewing the care card prior to their shift, ensuring the no-male designation is clearly identified on the care plan, and completing the care card acknowledgement sheet process.
Failure to Timely Report Witnessed Staff-to-Resident Abuse and Submit Required Investigation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report a witnessed incident of staff-to-resident abuse to the State Agency, law enforcement, and the Administrator, and to timely submit the required 5‑day investigative report. A resident with traumatic brain injury, anxiety, restlessness, agitation, and severe cognitive impairment had documented verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. On the morning in question, the resident became agitated during incontinence care, attempted to spit at a CNA, and the CNA responded by forcefully pushing the resident’s face with their hands, which was witnessed by another CNA who recognized this as abuse and told the staff member to leave the room. Following the incident, the resident reported that staff had yelled at and disrespected them and had scratched their face twice. An LPN, who entered the room after hearing the resident scream, observed redness and scratches on the resident’s face. The resident was later physically assessed by the Assistant Director of Nursing, who documented multiple abrasions and redness on various areas of the resident’s face, including below both eyes, the right cheek, the tip of the nose, the left eyebrow, above the upper lip, and a scratch extending from the bottom right lip to the chin. Based on interviews, record review, witness statements, and the internal investigation, the facility determined that the resident sustained multiple facial skin alterations related to physical contact made by the CNA. Despite facility policy requiring all allegations of abuse to be reported immediately, but no later than two hours after the allegation, staff did not promptly notify facility leadership or external authorities. The CNA who witnessed the abuse stated they reported the incident to the Assistant Director of Nursing when that person arrived around 8:00 a.m., but the Assistant Director of Nursing reported not being notified until between 11:30 a.m. and 12:00 p.m. The night-shift RN Supervisor was never notified. The Administrator and DON were first made aware around 12:30 p.m., approximately five hours after the 7:00 a.m. incident, and law enforcement was called at about 1:10 p.m. The required 5‑day Nursing Home Investigative Report was not submitted to the State Agency until 12 days after the incident, well beyond the required timeframe, resulting in noncompliance with reporting requirements under F600 and F656.
Failure to Implement and Update Behavioral Care Plan to Prevent Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing effective or timely interventions and care plan revisions for a resident with escalating verbal and physical behaviors. The resident had Alzheimer’s disease and bipolar disorder with psychotic features, and a 10/02/2025 MDS documented moderately impaired cognition and no behavioral symptoms during the assessment period. Despite this, the resident exhibited multiple aggressive incidents over several months, including throwing coffee that struck another resident on 09/10/2025, hitting another resident in the face on 09/30/2025, swinging at staff on 11/10/2025, attempting to throw a glass vase at staff on 12/24/2025, and hitting another resident in the head with a wheelchair leg rest on 12/25/2025. There was no documented behavioral care plan in place for this resident prior to 12/25/2025, contrary to facility policy requiring care plans to be initiated and updated with changes in status, needs, or behaviors. After the 09/10/2025 incident in which the resident threw coffee at staff and hit another resident, the RN Supervisor documented the event and notified medical staff, resulting in lab orders and a Depakote level, which later returned low. However, there was no incident report, no root cause analysis, and no evidence that the care plan was reviewed or updated to address behavioral symptoms. Following the 09/30/2025 incident where the resident hit another resident’s cheek after an attempt to remove food from their plate, an incident report and investigative summary were completed, and the corrective action focused on encouraging the other resident to remain seated during meals. There was still no documented evidence that the aggressive resident’s care plan was reviewed or updated with interventions to prevent recurrence. Nursing notes from 11/05/2025 to 11/10/2025 documented ongoing refusal of medications, use of racial slurs, and physical aggression toward staff, yet no behavioral care plan was initiated during this period. On 12/23/2025, the aggressive resident was punched in the mouth by another resident while attempting to clean up the table, resulting in a loose lower front tooth. Interventions and medication changes, including Depakote and a psychiatric consult, were implemented for the resident who punched, and the aggressive resident’s care plan was updated only with the potential to be abused. On 12/24/2025, documentation showed the aggressive resident attempted to throw a glass vase at staff and used racial slurs; the resident was redirected to their room, and a provider documented a plan to increase Depakote, but there was no corresponding order at that time. On 12/25/2025, the resident hit the same other resident in the forehead with a wheelchair leg rest, stating they wanted the other resident to pay for their dental bill and threatening further harm. Only then was the comprehensive care plan updated with potential to abuse others, and the sole intervention added was to redirect the resident. Interviews with CNAs, LPNs, RNs, and the Medical Director confirmed that staff were aware of the resident’s behaviors, expected care plans to be updated after incidents, and acknowledged that behavior care planning and timely updates had not been done. The facility’s failure to implement and document effective, individualized behavioral interventions and care plan revisions after each incident resulted in a determination of Immediate Jeopardy and Substandard Quality of Care. Interviews further highlighted gaps in care planning responsibility and follow-through. A CNA reported that the resident could be violent, had issues with certain staff characteristics, and had recently thrown a vase, and that staff knew to monitor and keep the resident away from certain residents but could not recall a specific behavior plan. An LPN Assistant Manager confirmed the resident had no behavior care plan prior to 01/09/2026 and stated that RNs were responsible for implementing such plans. Another LPN described the resident as holding resentment after being punched and stated that no changes were made to the care plan after the 12/25/2025 assault, with staff simply continuing to monitor the resident. RNs involved in earlier incidents acknowledged that care plans should have been updated after behavioral events and resident-to-resident altercations but could not explain why this was not done. The Quality Assurance RN stated that any resident-to-resident altercation required a care plan update and that the supervisor should have updated the plan after the 12/25/2025 incident. The Medical Director expected all residents with behaviors to have a care plan and noted that providers were notified of incidents, while a nurse practitioner viewed the events as isolated and deferred care planning decisions to nursing. The Administrator acknowledged that care plan updates were a nursing responsibility and that long-term staff relied on verbal reporting and the general direction to “redirect” the resident, without documented, specific behavioral interventions. The facility’s own policies required comprehensive care plans to describe residents’ mental and psychosocial needs and to be updated with any change in status, needs, goals, or interventions, and required staff to be familiar with prevention of abuse and to prevent further abuse while investigations were in progress. Despite multiple documented aggressive behaviors and resident-to-resident altercations over several months, there was no timely initiation of a behavioral care plan, no documented root cause analyses, and no evidence of effective, individualized interventions to protect other residents from potential abuse by this resident until after the final documented assault. This pattern of inaction and incomplete care planning in the face of repeated behavioral incidents formed the basis of the cited deficiency.
Removal Plan
- Resident #1 was assessed by social work, medical, and nursing, and a psych referral was ordered.
- Pharmacy reviewed the resident's medications.
- Resident #1's care plan was revised to include 1:1 monitoring.
- The plan will be reviewed and revised as needed.
- A complete hazard sweep was completed to ensure no objects could be used as weapons.
- Staff communication included a shift report indicating the resident's supervision level.
- All residents with a resident-resident encounter within the last 90 days had their care plans reviewed and revised as necessary with appropriate interventions in place.
- Facility staff received education.
- Understanding and retention of education for staff was verified by interviews.
Failure to Notify Physician and Family During Resident’s Acute Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative when there was a significant change in the resident’s condition. Facility policy required the nurse supervisor or charge nurse to notify the attending or on-call physician for any significant change in a resident’s physical, emotional, or mental condition, or when a transfer to a hospital was needed, and to inform the resident’s family or designated representative of such changes. Resident #11 had diagnoses including respiratory failure, obstructive sleep apnea, and hypertension, and had an order for 4 liters of oxygen via nasal cannula every shift. The resident was documented as cognitively intact and able to make themselves understood. On the night of the incident, progress notes documented that around 1:00 AM the resident was resting comfortably with no signs of acute distress and remained stable and responsive through the night until approximately 5:00 AM. At that time, the resident was found with labored respirations and minimally responsive to verbal stimuli, with an oxygen saturation of 40% on 4 liters via nasal cannula. The supervisor was notified and changed the nasal cannula to an oxygen mask. Multiple pulse oximeters were used, showing readings of 42%, 43%, and 26%, and the resident’s labored breathing continued. Oxygen therapy was escalated to 10 liters via non-rebreather mask using a portable oxygen tank without a physician order. Despite these significant changes in respiratory status and very low oxygen saturation levels, there was no documented evidence that the medical provider was notified at the time of the change. Emergency Medical Services were not called until approximately 6:00 AM, after the resident’s condition had further deteriorated. Upon EMS arrival, the resident became unresponsive and was transported to the hospital, where emergency department documentation described the resident as responding only to pain, in respiratory distress with agonal breathing, and on high-flow oxygen. The resident was later pronounced deceased due to respiratory arrest. Interviews with staff revealed that the nursing supervisor on duty acknowledged not calling the nurse practitioner, delaying calling 911 while attempting to manage the resident’s oxygen levels, and forgetting to call the family. Other nursing staff described a protocol in which significant changes in condition, especially oxygen saturations in the 40% range or respiratory distress, should prompt immediate notification of a supervisor, provider, and/or 911. The resident’s health care proxy stated they did not receive any calls from the facility about the change in condition or the transfer to the hospital. The Director of Nursing and Medical Director both stated that the provider should have been called and that failure to call the provider or 911 immediately constituted a delay in treatment. The surveyors determined that the facility failed to follow its own Change in Resident Condition policy by not immediately consulting the physician when Resident #11 experienced a significant change in respiratory status, and by not notifying the resident’s family or representative. This failure occurred despite multiple extremely low oxygen saturation readings, labored breathing, and decreased responsiveness, and despite staff recognition in interviews that such findings represented an urgent or emergent situation requiring provider notification and/or calling 911. The lack of timely physician consultation and family notification, combined with delayed activation of EMS, formed the basis of the cited deficiency and was determined to have resulted in Immediate Jeopardy to the resident and placed other residents with potential significant respiratory changes at risk for serious harm, serious impairment, serious injury, or death.
Removal Plan
- All residents on oxygen had a pulse oximetry reading completed and any results deviating from the resident's baseline had a registered nurse assessment and physician notification via telephone.
- Education for licensed nursing staff was implemented on the Change in Resident Condition Policy requiring documented physician notification via telephone for all significant changes in resident condition.
- All oncoming licensed nursing staff would be educated on the Change in Condition Policy.
- Licensed nursing staff were educated on the Change in Condition Policy.
Failure to Follow Respiratory Orders and Monitor Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory treatment and care according to physician orders, professional standards of practice, and the resident’s comprehensive care plan for a resident with significant respiratory diagnoses. The resident had respiratory failure, obstructive sleep apnea, and hypertension, and the care plan identified risk for compromised respiratory status with interventions including monitoring respiratory status, breath sounds, vital signs, and providing oxygen per physician order. A physician order dated 11/18/2024 required four liters of oxygen via nasal cannula every day, every shift. On 11/25/2025, the resident complained of intermittent shortness of breath, and a respiratory therapist assessed the resident, documented oxygen saturation of 92% on three liters of oxygen, and switched the resident to an oxygen concentrator at three liters without checking the current physician order for four liters. There was no documented evidence that a registered nurse assessed the resident when they were experiencing shortness of breath on 11/25/2025, nor that the resident’s respiratory status was monitored as outlined in the care plan. The resident’s health care proxy reported that on the same day, family members found the oxygen concentrator not working, notified staff, and another family member placed the resident on a portable oxygen tank; when they left at 5:00 PM, no staff had come to address the oxygen issue. These events indicate that the resident’s respiratory complaints and equipment concerns were not appropriately addressed, and physician orders for oxygen therapy were not followed. On 11/26/2025, between approximately 4:30 AM and 5:00 AM, a CNA notified an LPN that the resident was not breathing right. The LPN found the resident minimally responsive with labored breathing and an oxygen saturation of 40% on four liters via nasal cannula, and contacted an RN, who instructed the LPN to place the resident on a face mask but did not remain in the room. The LPN later rechecked the oxygen saturation, which remained in the 40s with increased labored breathing, and escalated the portable oxygen to ten liters via non-rebreather mask without a provider order. There was no documented RN assessment of the resident’s declining condition and no documentation that a physician was notified. Emergency Medical Services records show 911 was called at 6:04 AM, and upon arrival the resident was unresponsive with agonal respirations and no staff present on the unit, requiring EMS to call the fire department for assistance. These actions and omissions demonstrate failure to monitor and respond to a significant change in condition, failure to follow physician orders, and failure to provide supervision while awaiting EMS, resulting in Immediate Jeopardy and substandard quality of care for the resident.
Removal Plan
- Complete a pulse oximetry reading for all residents on oxygen and ensure any results deviating from the resident's baseline receive a registered nurse assessment and physician notification via telephone.
- Ensure any resident demonstrating respiratory distress is not left unattended while awaiting Emergency Medical Services.
- Review all resident accident and incident reports for the last 30 days.
- Review any significant change in status and abnormal laboratory results requiring action to ensure they were addressed and determine whether treatment needed to be significantly altered or the resident needed to be transferred.
- Re-educate Registered Nurse #8 on assessments and supervision.
- Educate licensed nursing staff on the Change in Condition Policy for significant change in respiratory status.
- Educate licensed nursing staff on communication with the registered nurse and proper assessment of respiratory complaints.
- Educate certified nursing assistants on communicating respiratory changes in condition and other changes in condition to licensed nursing staff.
- Educate licensed nursing staff on following physician orders and performing within scope of practice.
- Educate licensed nursing staff on obtaining vital signs with a change in condition.
Failure to Supervise High-Risk Resident Resulting in Elopement and Delayed Emergency Response
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for one cognitively intact resident with significant mental health and substance use history. The resident had diagnoses including cocaine and opioid dependence, other psychoactive substance abuse with mood disorder, suicidal ideations and past suicidal behavior, depression with psychotic features, PTSD, cluster B personality traits, chronic pain, COPD requiring 3L O2 via nasal cannula at all times, right eye blindness with depth perception issues, and poor safety awareness as reported by therapy and the physician. An elopement risk assessment completed on admission scored the resident as zero because they were documented as not independently mobile, and no elopement-related care plan interventions or wander alert device were implemented, despite the resident scoring above five on the Against Medical Advice (AMA) risk assessment and having suicidal ideations and substance use disorder. The basic care plan initiated for discharge did not include supervision or elopement prevention interventions related to the resident’s medical and behavioral history. On the day of the elopement, the resident’s last documented meal was breakfast, and a nurse administered a scheduled medication at 2:00 PM. The resident later reported packing their bags, using a wheelchair with oxygen to reach the lobby, and then walking out the front entrance carrying their bags, leaving the oxygen behind because it was too heavy. The resident stated that no staff attempted to stop them, ask where they were going, or request that they sign out. A stranger in a car picked the resident up off the property, and the resident went to a friend’s house rather than their last known address. Facility documentation and staff interviews showed that the LPN assigned to the resident’s floor did not see the resident in the room at 2:45 PM, was told by the roommate that the resident visited friends on other floors, and continued to check back, finally initiating overhead pages and a Code White search around 5:45 PM when the resident still had not returned. Medication administration records for later that day were marked “Out of Building,” although there were no physician orders for the resident to be out on pass or to leave the building. The facility’s Code White/Elopement policy required internal searches and announcements but did not specify a timeframe for calling 911 or define which outside agencies should be contacted. After the Code White failed to locate the resident, the facility delayed calling emergency services; 911 was not contacted until 11:16 PM, more than five hours after the Code White was initiated, during which time the facility did not know the resident’s whereabouts. Law enforcement records and interviews documented that staff told police the resident was free to leave, despite no documented discharge, no evidence of required AMA counseling, and no physician notification or discharge order. The AMA form was dated with the day of departure but was actually signed by the resident the following day at a friend’s home, with no documentation that the resident was counseled on risks or that the physician was notified. The facility’s own staff, including the NP and social work, reported they were not notified of the resident’s departure or elopement and that there was no clear documentation of when or with whom the resident left. Surveyors determined this failure to supervise and to promptly recognize and respond to the resident’s unaccounted absence constituted Immediate Jeopardy and substandard quality of care for the resident and others at risk of elopement or leaving AMA.
Removal Plan
- All residents in the facility had their elopement risk assessment completed in accordance with the Minimum Data Set and had interventions in place in accordance with the assessed risk.
- All residents assessed as an elopement risk that triggered the requirement for use of a Wanderguard bracelets had their bracelet in place.
- Residents with Wanderguard bracelets were placed on the Adventure Club list, which contains their picture indicating their elopement risk.
- The Adventure Club list was within the electronic medical records and available to staff.
- If the resident required 1:1 supervision, that supervision was provided.
- Exit doors were inspected, locked, and alarmed.
- Exit door functionality was confirmed.
Failure to Maintain Effective Compliance Program and Non-Retaliatory Reporting Culture
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective compliance and ethics program that promotes quality of care and prevents and detects violations. Facility policies such as the Code of Conduct and the Non-retaliation and Non-retribution policy state that all affected individuals must act ethically, report concerns in good faith, and are protected from retaliation when reporting suspected violations, fraud, waste, abuse, or unethical behavior. The Non-retaliation policy describes prohibited retaliatory actions and lists various reporting channels, including an anonymous hotline, and the abuse prevention policy states that all employees shall receive information on how and to whom they report concerns without fear of retribution. Despite these written policies, staff interviews revealed that employees did not believe they could report compliance concerns without retaliation and did not trust the facility’s reporting mechanisms. One staff member stated that reporting violations to the DON was a “long shot” and that a unit manager conveyed that their title was more important than the staff reporting to them. Another staff member reported fear of losing vacation, overtime, or future work if they reported issues, and described being contacted by the DON after a prior State Surveyor interview to ask what was discussed. Additional staff reported that anonymous reporting was “a joke,” that someone would always find out who reported, and that they did not feel confident reporting beyond their immediate manager. Another staff member reported fear of retaliation from coworkers, including threats of tire slashing and physical harm, and hearing a threat in the breakroom about having a grown son beat someone up. Surveyor observations of facility administration during the survey further demonstrated an environment inconsistent with an effective compliance and ethics program. The DON told surveyors that their presence stressed staff and that they would “hate for the facility staff to get punchy” with them. During a meeting with the administrator, assistant administrator, and DON, all three spoke in elevated voices, leaned forward, clenched their fists on the table, and repeatedly challenged the survey process, the basis for the Immediate Jeopardy determination, and the questions asked of staff. They demanded to know who decided on the Immediate Jeopardy and what data were provided to supervisors. Later, when surveyors attempted to leave the building, the administrator followed them, stated they could not leave after issuing an Immediate Jeopardy, and questioned how they could depart, despite the surveyors explaining the next steps. These actions and staff reports showed that the facility did not create and promote a credible, safe program contact and anonymous reporting method free from fear of retribution, as required by its own policies and regulatory standards.
Failure to Report Resident-to-Resident Altercations to State Agency
Penalty
Summary
The facility failed to report resident-to-resident altercations to the New York State Department of Health (NYSDOH) as required by state regulations and its own policies. Facility policy on Reporting and Monitoring Accidents and Incidents, revised in 09/2024 and again in 05/2025, required the DON, ADON, Director of Investigations or designee to review all incidents for alleged abuse, mistreatment, neglect, injury of unknown origin, or elopement, and to report such incidents immediately to Administration. State guidance in DAL NH 22-20 and CMS memo QSO-22-19-NH required nursing homes to submit an initial incident report and a final Investigation Summary Report to NYSDOH within five days of an incident involving reportable events such as abuse, neglect, mistreatment, exploitation, misappropriation, injury of unknown origin, elopement, and certain deaths. Despite these requirements, the facility did not submit required reports for two separate resident-to-resident altercations involving one resident. Resident #1, who had Alzheimer’s disease and bipolar disorder with psychotic features and was documented as having moderately impaired cognition and no behavioral symptoms during the 10/02/2025 MDS assessment period, was involved in two incidents. On 09/10/2025, a RN Supervisor’s progress note documented that Resident #1 threw coffee on staff, striking another resident seated at the table, then refused to discuss the behavior and used excessive profanity toward staff and residents; there was no incident report or evidence this event was reported to NYSDOH. On 09/30/2025, an incident report and attached investigative summary documented that Resident #1 hit another resident on the cheek, causing light redness, after the other resident attempted to remove food from Resident #1’s plate; there was no documented evidence this altercation was reported to NYSDOH. In interviews, the DON stated the 09/10/2025 coffee incident was considered incidental and not reported because the coffee was cold and the other resident was not injured, and the 09/30/2025 altercation was not reported because there was no injury, pain, or mental anguish noted. The Administrator stated they became aware of incidents through internal processes and were involved when there was an incident report for resident-to-resident abuse, but there was no indication that these two incidents were reported externally as required.
Failure to Develop and Update Comprehensive Behavior Care Plan for Resident With Recurrent Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s behavioral symptoms and psychosocial needs. The resident had diagnoses of Alzheimer’s disease and bipolar disorder with psychotic features, and the MDS documented moderately impaired cognition. An initial comprehensive care plan noted the resident was pleasant and cooperative but could become agitated and had a history of using racial slurs toward peers and staff; however, no specific interventions were documented. Despite multiple subsequent behavioral incidents, there was no documented evidence that the care plan was updated to address the resident’s behaviors, potential to abuse others, or potential to be a victim of abuse until late in the sequence of events. On one occasion, staff reported the resident threw coffee at staff, which also hit another resident, and the resident used excessive profanity toward staff and residents. On another date, an incident report and investigative summary documented that the resident struck another resident on the cheek after that resident attempted to remove food from the resident’s plate, causing light redness. Nursing progress notes over several days later in the year documented that the resident was refusing medications, including Depakote, using racial slurs, and being physically aggressive toward staff. There was no documented evidence that the care plan was revised to include behavior-specific, person-centered interventions or measurable goals in response to these events. Further incidents included the resident being punched in the mouth by another resident while attempting to clean up a dining table, resulting in a loose lower front tooth, and later attempting to throw a glass vase at staff while using racial slurs before being redirected to their room. Another incident documented that the resident hit the same other resident in the head with a wheelchair leg as that resident ambulated down the hallway, and multiple wheelchair legs were found in the resident’s room. The comprehensive care plan was eventually updated to note a history of altercations and abusing others, but the only intervention listed was redirection, with no additional resident-centered interventions or measurable objectives. Interviews with CNAs, LPNs, RNs, and the DON confirmed that staff recognized the resident’s behavioral issues and history of altercations, but there was no timely or adequate behavior care plan in place, and expected care plan updates after each incident were not completed.
Failure to Thoroughly Investigate Resident Elopement and Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of neglect related to a resident elopement. The resident had multiple significant diagnoses, including diabetes, pneumonia, protein-calorie malnutrition, cocaine and opioid dependence, other psychoactive substance abuse with mood disorder, suicidal ideations and history of suicidal behavior, noncompliance with medical treatment, anxiety disorder, and acute respiratory failure. On admission, the resident was assessed as alert and oriented, on 2L oxygen with diminished lung sounds, requiring supervision with meals and limited assistance with toileting, and having a history of falls. The comprehensive care plan documented that the resident had compromised respiratory status with oxygen therapy in place, was an elopement/wandering risk with a goal to remain safely in the facility, and had a history of suicide attempts. On the date of the incident, the resident left the facility undetected and was last seen by staff at 2:00 PM, with their absence not discovered until 5:45 PM. The resident left the building without their required oxygen, did not receive ordered medications, and did not receive their evening meal. A 911 audio file later documented that the resident had walked or “snuck” out of the building on foot, and the caller, an RN starting the night shift, did not know when the resident left. In a later interview, the resident stated they told a staff member on the seventh floor they were leaving and the staff member responded dismissively. The resident reported packing their bags, using a wheelchair with oxygen to reach the lobby, then walking out the front door with their bags, leaving the oxygen behind because they could not carry it, and experiencing difficulty breathing when picked up by a stranger off the property. The resident stated no one attempted to stop them, ask where they were going, or request that they sign out. The facility’s own policies required that all accidents/incidents, including potential abuse, neglect, and elopements, be reported and investigated, with the DON, ADON, Director of Investigations, or designee responsible. However, there was no documented evidence of a thorough investigation of this elopement. The facility initially reported there were no investigations for this resident, and when an investigation dated 03/04/2025 was later produced, it contained limited and incomplete information. Statements were obtained primarily from evening-shift staff who reported not seeing the resident for the entire shift and described overhead pages, a Code White, and searches after the resident was found missing. A recreation therapy director reported finding a wheelchair with an oxygen tank and name tag in an elevator and leaving it with security, but there was no documentation that information was obtained from reception, security, or day-shift staff about the elopement. The DON acknowledged that there were no statements from front desk staff, the nurse who called emergency services, the nurse who spoke with police, or the social worker who later met with the resident, and that the review of camera footage was not documented. The DON could not confidently state that all unknowns related to the incident were investigated. This lack of comprehensive documentation and follow-through on all relevant leads and witnesses constituted the failure to ensure that the allegation of neglect was thoroughly investigated. Additionally, there were inconsistencies and gaps in the facility’s documentation regarding whether the resident left against medical advice (AMA). The DON stated the resident departed against medical advice and that emergency services were contacted for a wellness check for residents who left AMA, but there was no documented evidence that the resident left AMA on the date of elopement. A Nursing Discharge Against Medical Advice form was dated with the elopement date but signed and witnessed the following day, with the reason for leaving documented as not wanting to stay at the facility. The resident later reported being contacted by the facility and meeting a staff member at a friend’s house to sign papers that were not explained and that they did not know were AMA papers. These inconsistencies, combined with the absence of a complete investigative record, demonstrate that the facility did not conduct and document a thorough investigation into the circumstances of the resident’s elopement and the associated allegation of neglect.
Failure to Administer Ordered Oxygen Flow Rate and Verify Respiratory Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice and the resident’s person-centered care plan. A cognitively intact resident with diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, pulmonary embolism without acute cor pulmonale, and hypertension had a physician’s order, in place since 11/18/2024, for oxygen therapy at four liters per minute via nasal cannula every day, every shift. The resident’s care plan for risk of compromised respiratory status directed staff to monitor respiratory status, breath sounds, activity tolerance, vital signs, and to provide oxygen per physician order and consult Respiratory Therapy as needed. The facility’s oxygen administration policy required verification of the physician’s order and setting the oxygen flow as prescribed. On the date in question, the resident’s health care proxy reported that during a visit, the resident complained of trouble breathing. The proxy removed the nasal cannula and perceived that no air was coming out. They checked the oxygen concentrator, which they believed was set at three or four liters, and observed it was not working; when they attempted to increase the flow, the floating ball did not move. The proxy sought assistance from a nurse, who reportedly stated they could not help and that an order was placed for a Respiratory Therapy consult. According to the proxy, no staff entered the room before they left temporarily, and during that time the resident’s granddaughter noticed a portable oxygen tank in the room, asked staff for help and was told they could not assist, and then independently connected the nasal cannula to the portable tank without knowing the oxygen flow setting. Later that day, a Respiratory Therapist assessed the resident after being called by an LPN for reported shortness of breath. The Respiratory Therapist found the resident in their room during dinner, eating pizza and in no apparent distress, with even, unlabored respirations and clear bilateral lung sounds. At that time, the resident was on a portable oxygen tank set at three liters per minute, with an oxygen saturation of 92%. The Respiratory Therapist switched the resident from the portable tank to the oxygen concentrator, maintaining the flow at three liters per minute, and documented the assessment and oxygen saturation. The Respiratory Therapist later stated they were not aware the resident was ordered four liters of oxygen and did not verify the current physician order, relying instead on a recollection that the resident had previously been on three liters during their stay. Subsequent review by the DON confirmed that the physician’s order in effect required four liters of oxygen.
Failure to Document RN Assessment and Vital Signs During Acute Respiratory Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and professionally acceptable medical records for a resident who experienced an acute change in respiratory and mental status. The resident had diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, and hypertension, and was care planned for risk of compromised respiratory status with interventions such as monitoring respiratory status, vital signs, and providing oxygen per physician order. Facility policies on Change in Resident Condition and Resident Hospital Transfer required the RN to complete and document an assessment, use an SBAR tool, and write a nursing progress note including all steps taken, the time of transfer, transport details, and report to the emergency department. On the night in question, an LPN documented that around 1:00 AM the resident was resting comfortably and remained stable and responsive through the night until approximately 5:00 AM, when the resident was found with labored respirations and minimally responsive to verbal stimuli. The LPN documented that the resident’s oxygen saturation was 40% on 4L nasal cannula, that the RN supervisor was immediately notified and came to the bedside, changed the nasal cannula to an oxygen mask, and that oxygen saturation levels were rechecked with three separate oximeters, yielding readings of 42%, 43%, and 26% with increased labored breathing. The LPN further documented that the RN supervisor was again updated with a recommendation to send the resident to the emergency department, oxygen therapy was escalated to 10L via non-rebreather mask, and that upon EMS arrival the resident became unresponsive and was transported to the hospital. Despite these events, there was no documentation in the medical record of the resident’s vital signs (heart rate, blood pressure, respiratory rate, and temperature) on that date, no documented assessment by the RN supervisor when the resident had respiratory and mental status changes, and no documented evidence of the resident’s response to the oxygen treatment provided. The nursing progress note entry for the RN supervisor at 5:57 AM was blank, and another RN later documented only that they received report from the LPN, that the resident’s oxygen saturation was in the low 40s, that the resident was unresponsive and vital signs were unable to be taken, that the RN supervisor had assessed the resident per the LPN, and that the resident was sent to the hospital and the NP was notified. In interviews, the LPN stated they had taken and written vital signs on a “cheat sheet,” and the RN supervisor stated they forgot to write a note; the DON stated they would expect RNs to write assessment notes and that the RN supervisor attempted but did not save a note in the computer system. These omissions resulted in an incomplete and non-compliant medical record for this resident’s acute change in condition and transfer.
Failure to Implement Ordered 1:1 Safety Supervision Resulting in Self-Inflicted Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of a physician-ordered 1:1 safety watch for a resident with behavioral issues and prior smoking violations. The resident had diagnoses including opioid dependence, anxiety disorder, depression, and diabetes, and a psychological evaluation documented moderate depression symptoms, though at that time the resident was assessed as not being a danger to self or others. Following multiple smoking violations, the Interdisciplinary Team met on 12/28/2024 and agreed the resident was to be placed on 1:1 supervision for safety, and a telephone order for a 1:1 safety watch was obtained from a nurse practitioner. A subsequent physician order dated 12/30/2024 documented 1:1 for safety with an ongoing end date, and the comprehensive care plan, reviewed on 01/15/2025, included 1:1 supervision for safety as an intervention for behaviors and multiple smoking violations. Despite the active 1:1 order and care plan intervention, documentation showed that the 1:1 safety watch was not consistently reflected on CNA assignment sheets prior to the resident’s hospitalization, and there was confusion among staff about the required distance and expectations for 1:1 supervision. Multiple CNAs reported having previously performed 1:1 safety watches for this resident due to smoking, generally staying within reach or at least within eyesight, often sitting outside the bathroom door or at the nurse’s station. Staff interviews revealed variability and lack of clarity in how “required distance” was interpreted, with some CNAs stating there was no clear definition and that the level of proximity depended on the resident and situation. The facility’s 1:1 Supervision policy required staff to stay within the required distance at all times, remain with the resident unless relieved, and complete necessary documentation, but practice as described by CNAs did not consistently align with these expectations. When the resident was readmitted from the hospital on 01/15/2025, the facility failed to implement the existing 1:1 safety supervision order. The admission nurse was responsible for assessing the resident, entering orders into the computer, and contacting the medical provider to review orders, and the DON later stated that 1:1 safety watches required a physician order and would appear on the care plan and Kardex so staff would know via the care card. However, upon readmission, the resident was not placed on a 1:1 safety watch, there was no documented physician order discontinuing the prior 1:1, and the DON acknowledged uncertainty about why 1:1 was still listed on the care plan. The resident was cared for on a different floor after readmission, and a CNA who cared for the resident at that time confirmed the resident was not on a 1:1 safety watch. On 01/17/2025, two days after readmission without 1:1 supervision in place, the resident was found with a self-inflicted laceration to the neck and superficial vertical cuts to both wrists, resulting in actual harm that was not Immediate Jeopardy.
Failure to Ensure Resident Dignity Due to Staff Use of Foul Language and Ethnic Slurs
Penalty
Summary
Surveyors found that the facility failed to ensure residents were treated with respect and dignity, as required by facility policy and state regulations. Seven residents reported that staff used foul language, ethnic slurs, and laughed at or made jokes about residents in hallways and common areas, making them feel uncomfortable. Observations confirmed that a certified nurse aide used an ethnic slur in a hallway with staff and residents present, and another aide laughed at a confused and distressed resident in the dining area in front of other residents. Multiple residents stated that staff frequently used foul language, ethnic slurs, and made inappropriate jokes, including about drug use, in the presence of residents. Interviews with staff revealed that some were aware of the inappropriate language and behavior, acknowledging that swearing and ethnic slurs were used in the facility and that such actions were not appropriate. Staff also recognized that laughing at or talking about residents in public areas was undignified and could make residents feel humiliated or belittled. Facility policies required all individuals to be treated with dignity and respect, prohibiting harassment, offensive language, and slurs, but these standards were not upheld in practice, as evidenced by the observations and resident reports.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment across all five resident units. Multiple resident rooms and common areas were found with strong urine odors, soiled toilets with black or brown stains, broken or empty soap and paper towel dispensers, stained bedding, and dirty bedside tables. Shower rooms contained toilet paper stuck to the floor, used personal items left behind, and empty dispensers. Soiled linens were found on the floors of several rooms and the shower area. Trash, dirt, sticky substances, used surgical gloves, and food debris were present on the floors of numerous rooms. Additional maintenance issues included broken floor tiles, missing ceiling tiles, malfunctioning thermostats, soiled windows, old tape on walls, chipped or cracked nurse station enclosures, scrape marks on walls, curtains off hooks, and doors with various marks and stains. Handrails and brass door guards were also found to be soiled, and floors in corridors and rooms were dirty, with scuff marks and unswept areas. During interviews, a resident reported that bathrooms were not cleaned and that shower rooms often had feces present. Facility staff acknowledged the cleanliness and maintenance issues, noting that cleaning, repairs, and restocking of supplies would be addressed. The observations and interviews confirm that the facility did not provide effective housekeeping and maintenance services, resulting in an environment that did not meet regulatory standards for cleanliness and repair.
Failure to Serve Palatable and Safe-Temperature Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, flavorful, and served at appetizing and safe temperatures during two observed meals. Multiple residents reported that their food was cold, overcooked, or did not taste good, and several did not receive all items listed on their tray tickets. Observations during meal service confirmed that food and beverages were often served outside of recommended temperature ranges, with hot foods below 140°F and cold foods above 40°F. Specific examples included milk and juices served above safe cold temperatures, hot foods such as pancakes and eggs served below recommended hot temperatures, and missing or incorrect meal items on trays. Staff interviews corroborated resident complaints, with CNAs and LPNs stating that food was frequently served cold and that complaints were forwarded to dietary staff and food service managers. The Food Service Director acknowledged that hallway carts used to transport food did not maintain proper temperatures due to damaged doors, and that this was a known and ongoing issue. The facility's own policies and USDA guidelines for food safety were not consistently followed, resulting in repeated instances of unpalatable and improperly served meals.
Failure to Maintain Sanitary and Comfortable Environment Due to Persistent Urine Odors
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment on three out of five resident units. During multiple observations conducted over several days, strong urine odors were detected in specific resident rooms and in the north elevator lobby area on the third floor. These odors were noted in rooms #555, 566 (on two occasions), and 671, as well as in a common area, indicating a persistent issue with cleanliness and sanitation in these locations. During an interview, the Director of Environmental Services acknowledged awareness of the odors and indicated intent to involve the nursing department for further investigation.
Failure to Document and Obtain Orders for Resident Wound Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Parkinson's disease, dysphagia, and dementia was observed with an old bandage on their left forearm, dated several days prior, without any corresponding documentation or physician order. The resident was cognitively intact and able to communicate, but was unaware of the reason for the bandage. Multiple observations confirmed the bandage remained in place for several days, and there was no evidence in the medical record, Medication Administration Record, or Treatment Administration Record of any treatment orders or documentation regarding the bandage or a skin issue on the left forearm. Additionally, there were no progress notes or Incident and Accident forms explaining the presence of the bandage or any related skin condition. Interviews with nursing staff revealed a lack of awareness regarding the origin of the bandage and whether an order existed for its application or change. One LPN recalled changing the bandage but did not remember the underlying issue and assumed it had been reported. Both RNs and the Director of Nursing confirmed that any dressing should have an accompanying order and be documented, and that skin issues should be reported and tracked. The absence of documentation, orders, and reporting for the bandage and any associated skin issue constituted a failure to provide treatment and care in accordance with professional standards and regulatory requirements.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to ensure the timely provision and administration of routine and emergency medications for two residents, resulting in missed doses of critical medications. For one resident with schizophrenia and a physician order for Lithium Carbonate, the medication was not administered on multiple occasions because it was not available in the automated medication dispensing machine. The pharmacy had rejected refill requests due to a computer error, and facility staff did not follow up with the pharmacy to resolve the issue. As a result, the resident's Lithium blood level was found to be low, and the resident was subsequently transported to the hospital at the family's request after concerns about symptoms were raised. Another resident with end stage renal disease, diabetes, and malnutrition did not receive prescribed medications, including cinacalcet and Sevelamer, for an extended period after admission. The medications were not available in the facility, and there was confusion regarding whether they would be provided by the dialysis center or needed to be obtained from the facility's pharmacy. Multiple nurses documented that the medications were not available and reported the issue to supervisors, but the medications were not obtained in a timely manner. The pharmacy did not fill the medications until several days after the resident's admission, and the resident missed numerous doses as documented in the Medication Administration Record. Interviews with nursing staff and pharmacy personnel confirmed that the facility's process for ordering, tracking, and ensuring the availability of medications was not followed as required by policy. Staff did not consistently notify the pharmacy or medical provider when medications were unavailable, and there was a lack of timely follow-up to resolve issues with medication procurement. These failures resulted in residents not receiving essential medications as ordered by their physicians.
Failure to Provide Preferred Communication Methods for Deaf Residents
Penalty
Summary
The facility failed to ensure the rights of two residents who were Deaf to choose activities and health care services consistent with their interests, assessments, and care plans, and to participate in social and community activities. Both residents were not provided with their preferred method of communication, which was American Sign Language (ASL), and instead were limited to using whiteboards and written communication. Staff interviews revealed a lack of knowledge and training on how to use available technology, such as tablets with video relay interpreting services, and there was no consistent provision of in-person or video ASL interpretation for daily communication, medical care, or participation in activities. One resident, who was cognitively intact but non-speaking and Deaf, reported feeling isolated and unable to communicate needs, socialize, or participate in meaningful activities. The resident's care plan and speech therapy recommendations specified the use of live ASL interpreting services via tablet, but this was not implemented. Staff relied on whiteboards, which the resident was not comfortable using due to limited English proficiency, and staff were unaware of or unable to use the tablet for interpretation. The resident experienced psychosocial harm, including feelings of isolation, inability to communicate about medication changes, and lack of participation in activities due to the absence of interpreters. The second resident, who was also Deaf with highly impaired vision and moderate cognitive impairment, was similarly not provided with their preferred communication method. Although care plans and therapy notes recommended live ASL interpretation and the use of tablets, these were not made available to the resident on a regular basis. Staff and family interviews confirmed that the resident could not effectively communicate needs or participate in care discussions, and staff often resorted to writing, which was ineffective due to the resident's vision and handwriting difficulties. The lack of appropriate communication support resulted in the residents' inability to express preferences, participate in activities, and communicate with staff and peers.
Removal Plan
- Facility provided Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident.
- Education was provided to the staff and residents on the use of the tablets.
- Tablets were to be kept in the resident's rooms.
- Facility provided in-service education to staff with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in infection control practices for six of eight residents reviewed. Several residents who were on contact or droplet precautions for communicable diseases such as Clostridium difficile, COVID-19, and metapneumovirus did not have the appropriate isolation precaution signage posted on their doors. In some cases, precaution signs were missing, posted late, or incorrectly identified the resident on precautions. Staff frequently entered and exited rooms of residents on isolation precautions without donning the required personal protective equipment (PPE) or performing proper hand hygiene. For example, staff were observed entering rooms without PPE, removing PPE outside of rooms, and failing to wash hands after glove removal. In one instance, a physical therapist wore PPE but left the resident's room to take phone calls without changing PPE, and a nurse entered a room with only a surgical mask when an N95 was required but unavailable in the PPE caddy. Laundry and housekeeping practices also failed to meet infection control standards. Contaminated laundry from residents on contact precautions was not consistently separated from general population laundry, and laundry staff were not always informed when items required special handling. Housekeeping staff did not consistently use PPE when handling refuse from isolation rooms and did not follow enhanced cleaning protocols, such as using bleach for rooms of residents with Clostridium difficile. Some staff reported cleaning all rooms the same way, regardless of isolation status, and using plain water for mopping instead of disinfectant. Additionally, staff responsible for laundry and housekeeping were not always aware of which residents were on precautions and did not consistently wear appropriate PPE due to discomfort or lack of communication. The facility's own policies required the use of color-coded precaution signs, proper PPE usage, and specific cleaning and laundry protocols for residents on isolation precautions. However, observations and staff interviews revealed widespread non-compliance with these policies. Staff were often unaware of the correct precautions, did not follow signage, and failed to implement required infection control measures, increasing the likelihood of transmission of communicable diseases among residents and staff.
Removal Plan
- The facility ensured all residents on precautions were reviewed and had the appropriate isolation precaution signage in place.
- All in-house staff were educated on infection control with competency-based training.
- All oncoming staff would be educated prior to the start of their shift.
- The facility provided in-service education to staff, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Failure to Honor Resident Dignity and Provide Individualized Toileting Assistance
Penalty
Summary
Surveyors found that two residents who were continent of bladder and/or bowel were routinely placed in incontinence briefs and instructed by staff to urinate or defecate in the briefs rather than being assisted to use the toilet or bedpan. One resident, who had moderate cognitive impairment and required assistance for transfers, was not reassessed for toileting after their transfer status improved. Despite being able to verbalize the need to use the bathroom and having the physical ability to transfer with assistance, this resident was denied toileting assistance and told to use the incontinence brief, including during their menstrual cycle. Staff interviews confirmed that the resident was not provided with regular toileting opportunities and that care plans were not updated to reflect the resident's improved abilities. Another resident, with intact cognition and a history of anxiety disorder and morbid obesity, was also continent but was made to wear incontinence briefs for staff convenience. This resident preferred to use a bedpan but was told that if they returned to bed for toileting, they would have to remain there for the rest of the day, limiting their participation in activities. The resident was left in soiled briefs and on urine-soaked lift pads for extended periods, leading to embarrassment and distress. Staff acknowledged that the resident was continent and that the use of incontinence briefs was not appropriate, but cited lack of underwear and staff availability as reasons for this practice. Observations and interviews revealed that both residents experienced psychosocial harm as a result of being denied appropriate toileting assistance and being left in soiled briefs. Staff and clinical leadership, including the Director of Rehabilitation, LPNs, and the Medical Director, confirmed that the residents should not have been told to use incontinence briefs and that this practice was a violation of their dignity and quality of life. The facility failed to update care plans, reassess residents' needs, and provide individualized care, resulting in a lack of respect for resident rights and dignity.
Failure to Provide Timely and Appropriate Wound Care per Physician Orders
Penalty
Summary
Two residents did not receive treatment and care in accordance with professional standards and physician orders. One resident, who had a right above-the-knee amputation, experienced wound dehiscence with signs of infection. The nurse practitioner ordered antibiotics and requested a vascular consult as soon as possible, but there was no documented evidence that the consult was scheduled promptly. The resident's wound worsened, with increased dehiscence and drainage, and the resident was eventually sent to the hospital for post-operative infection and wound dehiscence. Multiple staff interviews confirmed that the request for an expedited vascular consult was not acted upon in a timely manner, and the scheduled appointment was not considered soon enough given the resident's condition. Another resident with a history of osteomyelitis, diabetes, and left toe amputations did not receive wound vacuum-assisted closure (VAC) therapy or the backup wet-to-dry dressing as ordered during a period when the primary wound care nurse was absent. Documentation showed that the VAC dressing was not changed for nearly two weeks, and there was no evidence that the backup dressing was applied as per physician orders. The resident reported that during this time, they had to cover their wound themselves and seek assistance from staff, as no one was available to provide the required wound care. Staff interviews revealed a lack of continuity in wound care coverage and documentation during the wound nurse's absence. In both cases, the facility failed to follow physician orders and ensure timely and appropriate wound care interventions. There was a lack of documentation and communication regarding changes in the residents' conditions and the implementation of backup care plans when primary treatments could not be provided. These failures resulted in harm to one resident and placed both residents at risk due to lapses in wound management and follow-up care.
Deficient Storage and Labeling of Medications and Biologicals
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals across all resident floors. Unattended and unlocked medication and treatment carts were observed on several occasions on the 3rd, 4th, 5th, 6th, and 7th floors, with prescription creams, ointments, insulin syringes, wound care supplies, and even scalpels left accessible. In many instances, no staff were present in the vicinity of these carts, and residents were observed nearby or moving through the area. Staff interviews confirmed that carts were sometimes left unlocked, including during night shifts when residents were presumed to be sleeping, and staff acknowledged that this practice was not in accordance with facility policy. Medication refrigerators on the 3rd, 4th, and 7th floors were found without daily temperature monitoring as required by facility policy. Temperature logs were missing entries for several days, and in one case, the refrigerator temperature was found to be outside the recommended range. Staff interviews revealed a lack of knowledge regarding the appropriate temperature range and the importance of daily monitoring to ensure medication efficacy. Additionally, several insulin pens and other medications were found without open dates on the 3rd, 5th, and 6th floors, making it impossible to determine if the medications were still within their effective use period. Staff stated that without open dates, they could not verify the safety or effectiveness of the medications. The facility also failed to manage discontinued medications appropriately. Excessive quantities of discontinued or expired medications were found stored in medication rooms on the 4th and 7th floors, with staff unable to describe a consistent process for their timely removal or return to the pharmacy. Interviews with nursing staff and the Director of Nursing indicated uncertainty about the frequency of pharmacy pickups and the process for handling discontinued medications. The accumulation of these medications in unsecured areas was acknowledged as inappropriate by the Director of Nursing, who noted the risk of medication diversion.
Failure to Provide Snacks and Alternative Meals Outside Scheduled Times
Penalty
Summary
The facility failed to provide suitable and nourishing alternative meals and snacks to residents who wished to eat at non-traditional times or outside of scheduled meal service, as required by their care plans. Despite having documented procedures and par lists for stocking snacks and beverages on the nursing units, observations revealed that snack items were not consistently available in the unit kitchenettes or refrigerators. Multiple observations across several units found refrigerators either empty or containing only minimal items such as beverages, cheese, or a small number of sandwiches and snacks. Residents reported during a council meeting that they did not receive bedtime snacks and that snacks were not available on the units. Interviews with certified nurse aides indicated that staff access to snacks was hindered by frequent changes to the kitchenette door codes, which were not always communicated to all staff. Some staff reported resorting to hiding snacks or storing them in employee refrigerators to ensure residents could receive snacks when requested. The lack of access to the kitchenettes and inconsistent stocking practices resulted in residents being unable to obtain snacks outside of scheduled meal times, contrary to facility policy and resident care plans. The Food Service Director confirmed that the facility had changed its snack distribution process, intending for snacks to be stocked on the units and accessible to staff. However, the director acknowledged that staff sometimes claimed not to know the codes to the kitchenettes, and that resident snack items should not be stored with employee food. Despite these procedures, the survey found that the intended system was not effectively implemented, leading to the deficiency in providing residents with access to snacks and alternative meals as needed.
Failure to Maintain Food Safety and Hand Hygiene Standards
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in both the main kitchen and one of the kitchenette nourishment areas. During multiple meal services, hot food items such as cooked pasta, stewed tomatoes, and pureed chicken were found to be held at temperatures below the required standard for safe hot holding. Staff responsible for serving meals did not consistently measure or document food temperatures, and when temperatures were checked, some items were not removed from service or reheated as required. The improper holding temperatures were attributed to issues such as unplugged or malfunctioning hot boxes and a lack of proper temperature checks by staff. Additionally, the facility did not maintain proper hand hygiene standards in the food production and service areas. Eight out of nine handwashing sinks were not properly equipped with hot water, soap, or paper towels. Several observations documented that staff either did not wash their hands, used alternative means to dry their hands, or applied gloves without washing hands first. In some cases, staff continued to serve food after touching potentially contaminated surfaces, such as garbage can lids, without changing gloves or washing hands. Interviews with dietary aides, supervisors, and management confirmed that there was a lack of awareness and oversight regarding the availability and functionality of handwashing supplies. Staff acknowledged the importance of proper hand hygiene and food temperature maintenance but did not consistently follow procedures or report deficiencies in equipment and supplies. The facility's policies required proper handwashing and food temperature checks, but these were not consistently implemented during the survey period.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents across four of six resident units. Observations revealed multiple instances of uncleanliness and disrepair, including scraped and crumbling walls, holes with exposed wires, dirty and soiled linens left on floors, stained and unclean furniture, and accumulation of trash and debris in resident rooms and common areas. There were also strong and persistent unpleasant odors, particularly of urine, in various hallways, dining areas, and resident rooms. Specific examples included soiled briefs and towels left on floors, dirty tables and chairs in dining areas, and stained or missing furnishings in resident rooms. Interviews with residents and staff confirmed these findings. One resident reported that their room was consistently messy, housekeeping staff did not routinely wipe down surfaces, and they often had to clean their own room. Staff interviews revealed confusion and overlap in responsibilities between nursing and housekeeping staff regarding cleaning, trash removal, and reporting of environmental issues. Staff described that soiled items should not be left on floors and that environmental concerns were to be reported through a work order system, but observations indicated these processes were not consistently followed. The facility's own policy required staff to ensure a safe, clean, and comfortable environment for residents, but the observed conditions and staff interviews demonstrated a failure to adhere to these standards. The issues were widespread, affecting multiple units and both resident rooms and common areas, and included both cleanliness and maintenance deficiencies. These failures directly impacted the living conditions and dignity of the residents.
Failure to Prevent Accidents and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for several residents, resulting in multiple deficiencies. One resident with a physician order and care plan specifying 'no straws' due to dysphagia was repeatedly observed with straws in their possession and using them to drink, despite clear documentation and staff awareness of the restriction. Staff interviews confirmed knowledge of the restriction, but straws continued to appear in the resident's room, and staff did not consistently remove them or prevent their use. Another resident was exposed to an accident hazard when a used needle and vacutainer from a blood draw were disposed of in the regular trash can in their room, rather than in a designated sharps container as required by facility policy. The nurse responsible admitted to discarding the needle improperly due to being rushed, acknowledging the risk of needle stick injuries and potential transmission of bloodborne pathogens. Housekeeping and infection control staff also recognized the improper disposal as a significant safety concern. A third resident sustained superficial burns after independently removing hot food from a microwave, an activity not addressed in their care plan despite their history of attempting to use staff microwaves. Staff statements revealed that residents were not permitted to use the staff breakroom microwave, but this resident had a pattern of accessing it, especially when new staff were present. The incident occurred when the resident was allowed to remove their food from the microwave without supervision, resulting in burns to their thigh and abdomen. The care plan did not address the resident's repeated attempts to use the microwave independently.
Failure to Serve Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors found that the facility failed to provide food and drink that was palatable, flavorful, and at an appetizing temperature during three observed lunch meals. Multiple residents reported that the food was cold, lacked flavor, and was unappealing. During meal observations, food and beverage temperatures were measured and found to be below the facility's required standards for both hot and cold items. For example, hot foods such as mashed potatoes, glazed carrots, roast turkey, oven fried chicken, and green beans were served at temperatures significantly below the required 135 degrees Fahrenheit, while cold items like milk, diced pears, and juice were above the maximum allowed 45 degrees Fahrenheit. Residents and staff consistently reported dissatisfaction with the food's temperature and taste, and some residents stated they often resorted to ordering takeout due to the poor quality of meals. The deficiency was further evidenced by direct observations of meal service delays, such as food carts being left open and meal trays not being distributed promptly, which contributed to the food cooling before being served. Staff interviews confirmed that the process for plating and passing trays involved both food service and nursing staff, and delays in tray distribution were acknowledged as a factor affecting food temperature and palatability. The facility's own temperature logs and policies were not adhered to during the observed meals, resulting in residents receiving food and beverages outside of safe and appetizing temperature ranges.
Failure to Provide Complete and Appropriate Meal Service
Penalty
Summary
Surveyors found that the facility failed to provide meals that accommodated resident allergies, intolerances, and preferences for three out of five residents reviewed. Multiple residents did not receive all items listed on their meal tickets, including essential nutritional supplements and specific food items. The facility's policy required certified nurse aides to serve food per meal tickets and ensure accuracy, with nursing staff responsible for delivering and monitoring room trays. However, observations revealed repeated omissions of required food items during meal service. One resident with severe cognitive impairment, weight loss, and a mechanically altered diet was observed missing yogurt, coffee, fortified juice, health shake, and other items across several meals. Another resident with dysphagia and dehydration, who required supervision with eating, reported frequent missing items, and was observed receiving a tray lacking several components, including fruit, cottage cheese, and ice cream. Staff explained that some items were unavailable and offered substitutes, but not all missing items were replaced. A third resident with Alzheimer's and recent weight loss was repeatedly served incomplete trays, missing nutritional supplements and other foods, and reported that staff did not offer replacements for missing items. Interviews with staff, including certified nurse aides, a dining experience manager, and the food service director, confirmed that missing meal items were a recurring issue. Staff acknowledged that residents often complained about incomplete trays and that substitutions were not always provided. The food service director cited a national shortage of certain fortified juices but stated that alternative supplements should have been provided. Despite these expectations, the facility did not consistently ensure that residents received all items listed on their meal tickets.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors observed that the facility failed to maintain an effective pest control program, resulting in the presence of fruit flies and evidence of mice in multiple areas, including the administrative area and three of seven units reviewed (3rd, 4th, and 6th floors). Multiple direct observations were made of fruit flies in dirty utility rooms, resident rooms, nursing stations, conference area bathrooms, hallways, and resident kitchens over several days. Mouse droppings were also found on the floor in a resident's room, and two residents reported seeing mice in their rooms, with one stating that mice came out at night through the vents. Interviews with staff revealed inconsistent awareness and reporting of pest sightings. Some staff stated they had not seen pests, while others acknowledged occasional sightings of fruit flies, particularly near food. The facility's policy required staff to log pest sightings in a vendor book for weekly follow-up by an outside pest control vendor, but not all staff were aware of or had used this process. The Director of Dietary and the Interim Director of Housekeeping confirmed awareness of fruit flies in various units, and audits of kitchenettes and dining areas were performed, though the frequency was unclear. Despite these measures, the presence of pests persisted in multiple areas of the facility.
Failure to Assess and Document Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and documented a resident's ability to self-administer medications as required by facility policy. A resident with diagnoses including deafness, pain, and atherosclerotic heart disease was found to have medications in their room and reported self-administering them. The resident was cognitively intact and independent with activities of daily living, but there was no documented evidence in the care plan or medical record that an assessment for self-administration of medications had been completed. Observations revealed that the resident took medications from a medication cup left at their bedside without nurse supervision, and pills remained unattended on the bedside table for extended periods. Interviews with staff confirmed that there were no current orders for self-administration and that medications should not be left at the bedside. The resident expressed awareness of their medication regimen and a preference for self-administration, but the required interdisciplinary assessment and documentation were not completed.
Failure to Protect Residents from Misappropriation of Property and Funds
Penalty
Summary
The facility failed to protect two residents from the wrongful use of their belongings or money. In the first case, a resident with deafness and non-speaking status, but cognitively intact, entrusted a staff member, Activity Aide, with a significant sum of money over time. The resident, who had difficulty communicating with staff, gave the aide up to $1,000 to hold for safekeeping and to make purchases on their behalf. The aide returned only a portion of the money and provided minimal receipts, with a discrepancy of $181 unaccounted for. The resident was not aware of the facility's ability to hold money in a resident account and became visibly upset when discussing the situation. Staff interviews confirmed that facility policy prohibits staff from accepting money or gifts from residents, and several staff members acknowledged awareness of the policy and the incident. In the second case, another resident, who was a trauma survivor with intact cognition, collected bags of deposit cans in their room with the intention of redeeming them for cash to purchase personal items. The facility removed the cans during a room cleaning, and the resident reported that a housekeeper took the cans to cash in but never returned the money. The resident stated they had made it clear to staff that the cans were to be redeemed for their benefit. Staff interviews revealed confusion about the value of the cans and the process for their removal, with the Director of Social Work initially believing the cans had no value, then later acknowledging they did. The housekeeper admitted to taking the cans instead of disposing of them as instructed by administration. In both cases, the facility did not ensure the residents' rights to their property and funds were protected. There was a lack of clear communication and understanding among staff regarding the handling of residents' money and belongings, and the facility's policies prohibiting staff from accepting or managing resident funds were not followed. The incidents were not reported to outside agencies, and there was no evidence that the residents' consent was properly obtained or that their property was safeguarded as required.
Failure to Report Resident Burn Incident as Required
Penalty
Summary
The facility failed to ensure that all alleged violations were thoroughly investigated and properly reported to the New York State Department of Health as required. A resident with a history of left-sided paralysis following a stroke, who was cognitively intact and generally independent with activities of daily living, sustained superficial burns with blisters to the lower abdomen and upper inner thigh after accidentally spilling hot water while preparing food. The incident was witnessed and documented by multiple staff members, and the resident consistently reported the injury as accidental, occurring while straining hot water from food prepared in the microwave. Facility policy required reporting and investigating any accident or incident involving a resident, and state guidelines specifically mandated reporting burns to the body surface. Despite this, the incident was not reported to the Department of Health. The incident/accident report and staff statements confirmed the sequence of events, including the resident's use of the microwave, the assistance provided by staff, and the resident's subsequent self-inflicted burn. The resident was assessed by nursing staff and a nurse practitioner, with documentation indicating the burns were superficial, resolving, and not causing pain or infection. Interviews with staff revealed that the Director of Nursing was informed of the incident but did not report it to the state authorities, citing a lack of awareness that such burns were reportable. The facility determined internally that the incident was self-inflicted and not reportable, contrary to state requirements. This failure to report the incident as mandated constituted the deficiency identified during the survey.
Failure to Investigate and Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, or mistreatment were thoroughly investigated for one resident who was deaf, non-speaking, and cognitively intact. The resident, who communicated primarily through American Sign Language, gave a staff member a significant sum of money to hold. When the resident later requested the money back, only a portion was returned, and the staff member could not account for the full amount. The incident was brought to the attention of facility administration by the Ombudsman, but there was no timely or documented investigation initiated, and the event was not reported to the appropriate state authorities as required by facility policy and regulation. Multiple interviews revealed that the facility's response was delayed and incomplete. The initial notification of the incident occurred weeks before any formal investigation was started, and the resident's communication needs were not adequately accommodated during the inquiry. Instead of using a certified interpreter, staff attempted to communicate with the resident using a whiteboard, which may not have allowed for a full understanding of the resident's perspective or consent. Key staff members, including social workers and nursing management, were either unaware of the incident or did not follow through with required reporting and documentation procedures. Facility records, including the grievance log and accident/incident reports, did not reflect the incident involving the resident's money. The administrator and other staff provided inconsistent accounts of when they became aware of the situation and what actions were taken. The staff member involved eventually returned some of the money, but receipts for the missing amount were not provided, and the administrator did not consider the unaccounted funds as misappropriated. The lack of timely investigation, failure to use appropriate communication methods, and absence of required reporting constituted a deficiency in responding to alleged violations involving resident property.
Inaccurate MDS Assessment of Resident's Cognitive and Communication Status
Penalty
Summary
The facility failed to ensure the accuracy of a resident's Minimum Data Set (MDS) assessment, resulting in documentation that did not reflect the resident's true cognitive and communication abilities. The resident, who had a history of mouth and throat cancer with a tracheostomy and absence of larynx, was documented in the most recent MDS as nonverbal and severely cognitively impaired. However, multiple observations and interviews revealed that the resident was able to communicate effectively using a speaking valve and was cognitively intact, as confirmed by staff, the resident's significant other, and the resident themselves. The care plan and MDS documentation did not include the resident's use of a speaking valve, and the cognitive assessment was not updated quarterly as required. Staff interviews indicated that the social worker typically carried over the initial cognitive assessment without reassessment, and the MDS coordinator was unaware that the resident's cognition had not been reassessed since admission. The business office notary relied on the inaccurate MDS cognitive score to deny notary services, believing the resident was significantly cognitively compromised. Further, the MDS coordinator and other staff relied on previous documentation and care plans, which perpetuated the inaccuracies in the resident's assessment. The speech language pathologist and other staff confirmed the resident's cognitive abilities and communication skills, but these were not reflected in the official assessments. The lack of accurate and updated assessments led to a misrepresentation of the resident's status in facility records.
Failure to Implement Therapy-Recommended Wheelchair Leg Rests in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including edema, gout, and rheumatoid arthritis. The resident, who had severely impaired cognition and required a wheelchair for mobility, was recommended by physical therapy to use a standard wheelchair with bilateral leg rests. However, the care plan did not include this recommendation, and the resident was repeatedly observed sitting in a wheelchair without leg rests, with their feet dangling and not touching the floor. Interviews with facility staff, including a CNA, LPN, RN Unit Manager, and the Director of Rehabilitation Services, confirmed that leg rests should have been used as per therapy's recommendation and facility policy, especially since the resident's feet did not reach the floor and they spent most of their time in the wheelchair. Staff acknowledged that the absence of leg rests could contribute to discomfort and exacerbate the resident's existing conditions. Despite these findings and documented recommendations, the necessary intervention was not included in the care plan or implemented in practice.
Failure to Maintain Professional Standards and Timely Response to Resident Needs
Penalty
Summary
Surveyors identified that the facility failed to ensure services were provided in accordance with professional standards of quality across all resident units reviewed. Direct care staff were repeatedly observed using personal electronic devices, such as cell phones and earbuds, in resident care areas and during times when they were expected to be providing care. Staff were also seen spending extended periods in the breakroom beyond their scheduled break and meal times, contrary to facility policy. These actions were in direct violation of the facility's staff handbook and policies, which prohibit cell phone use in resident areas and restrict break times. Multiple residents reported that staff did not answer call bells in a timely manner, with some residents experiencing wait times of up to 2.5 hours. Residents described staff as rude, unresponsive, and disrespectful, with some staff refusing to identify themselves or hiding their badges. Residents also expressed fear of retaliation if they complained about staff behavior. Observations confirmed that call bells were often silenced at the nurses' station without addressing the resident's needs, and staff sometimes instructed others to turn off call lights without checking on the resident. In several instances, staff were observed eating in resident dining areas and using their phones in front of residents, further contributing to a lack of professionalism and respect. Staff interviews corroborated these findings, with several staff members acknowledging that cell phone and earbud use was common despite being against facility policy. Some staff admitted to not enforcing these rules due to fear of being targeted by their peers. Supervisory staff and the DON confirmed that staff were not permitted to use electronic devices in resident areas and should not be in break rooms during resident care times. The lack of supervision, especially on weekends and during meal times, contributed to inadequate response to resident needs and a general atmosphere of disrespect and neglect.
Failure to Provide Required Oral Hygiene and Hair Care
Penalty
Summary
Two residents who were dependent on staff for activities of daily living did not receive necessary assistance with oral hygiene and hair care, as required by their care plans and facility policy. One resident, with diagnoses including morbid obesity, major depressive disorder, and diabetes, was observed multiple times with uncombed, matted, greasy hair and foul breath. The resident reported not receiving help with brushing their teeth or shampooing their hair, despite being able to perform oral care independently if set up by staff. The resident also expressed fear of retaliation if they asked for their toothbrush and reported losing teeth since admission. Staff interviews confirmed that oral care and hair care were not consistently provided, and documentation did not always reflect the actual care given. Another resident, also dependent on staff for most activities of daily living and with diagnoses including morbid obesity, depression, and heart failure, was observed on several occasions with long, uncombed, tangled hair and foul breath. The resident stated that scheduled showers and grooming were not provided as planned, and requests for a haircut had not been fulfilled despite multiple notifications to the barber. Staff interviews revealed that oral care and hair care were sometimes omitted due to time constraints or other assignments, and that documentation of care did not always match the care actually provided. Facility staff, including CNAs and LPNs, acknowledged that grooming and oral care were important for resident dignity and health, but admitted that these tasks were sometimes neglected. The facility's policy required daily hygiene and weekly showers or baths, but observations and interviews indicated that these standards were not consistently met for the two residents reviewed. The lack of proper hygiene and grooming was attributed to staff not following care plans, inadequate follow-up on resident requests, and inconsistent documentation of care provided.
Failure to Individualize and Monitor Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
Surveyors found that the facility failed to ensure proper pressure ulcer prevention and care for two residents who required alternating air mattresses. Both residents had physician orders for the use of these specialty mattresses, but the orders did not specify individualized settings based on the residents' current weights. Observations revealed that the mattresses were set at inappropriate weight settings, with one mattress set at 420 pounds for a resident weighing 76.5 pounds, and another set at an unspecified but clearly incorrect setting for a resident weighing approximately 117 pounds. Documentation on the Treatment Administration Record indicated that staff were checking for mattress inflation and function, but there was no documentation of the recommended mattress settings or verification that the settings matched the residents' weights. Interviews with staff, including CNAs, LPNs, and unit managers, revealed a lack of knowledge and responsibility regarding the proper use and monitoring of air mattresses. Staff reported that they only responded to alarms or called maintenance if there was an issue, and did not routinely check or adjust mattress settings. The wound care nurse and central supply staff indicated that mattresses were initially set up based on resident weight, but ongoing monitoring and adjustment were not consistently performed by nursing staff. The Assistant Director of Nursing acknowledged that prior to the survey, they were unaware that the mattresses had weight settings that needed to be checked. Both residents involved were at risk for pressure ulcers, with one having a history of left-sided paralysis and the other having active Stage 2 and Stage 4 pressure ulcers. The lack of individualized mattress settings and failure to monitor and adjust these settings as needed constituted a deviation from professional standards of practice, potentially impacting the prevention and healing of pressure ulcers for these residents.
Failure to Provide Prescribed Nutrition and Meal Accuracy for Residents with Weight Loss
Penalty
Summary
Two residents experienced significant unplanned weight loss due to the facility's failure to provide prescribed nutritional interventions and ensure meal accuracy. One resident, with diagnoses including dementia and failure to thrive, had a documented history of severe weight loss and was assessed as severely malnourished. Despite care plans and physician orders specifying double portioned entrees, fortified juices, Magic Cups, and other supplements, these items were frequently missing from meal trays. Observations confirmed that the resident did not consistently receive the required fortified foods or double portions, and staff were unaware of or did not act on the missing items. Additionally, the resident was not always assisted with eating in a dignified manner, as staff were observed standing over the resident and hurrying the feeding process, contrary to facility policy. Another resident, with Alzheimer's disease and a history of mini strokes, also experienced significant weight loss. This resident's care plan included specific food preferences and supplements, such as yogurts, peanut butter and jelly sandwiches, and chocolate milk, to help maintain weight. However, multiple observations revealed that these preferred and prescribed food items were missing from meal trays. The resident reported that, despite frequent discussions with dietary staff about food preferences, the requested items were not provided. Staff interviews confirmed that supplements and preferred foods were not consistently delivered, and there was no evidence of physician intervention for the ongoing weight loss. Facility policies required staff to check meal tickets for accuracy and substitute unavailable supplements as per a documented substitution list. Despite these policies, both dietary and nursing staff failed to ensure that residents received all ordered and preferred nutritional items. Staff interviews revealed a lack of awareness and follow-through regarding missing supplements and meal components, contributing to the residents' continued weight loss. The facility did not document timely weights as ordered for one resident, and there was a lack of communication and coordination among staff to address the deficiencies in nutritional care.
Failure to Administer Prescribed Pain Patch as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic pain, morbid obesity, and hemiplegia did not receive their prescribed Lidocaine pain patch as ordered. The resident had an active order for a Lidocaine patch to be applied daily to the left knee for pain management, as documented in the care plan and medication administration record. Despite this, the medication administration record showed multiple days where the patch was not administered, and staff interviews confirmed that the patch was often not given, even though it was signed as administered. Observations and interviews revealed that the resident frequently reported significant pain, with pain levels ranging from 4 to 7 out of 10, and expressed that the Lidocaine patch was the only effective intervention. The resident was observed on several occasions without the patch and reported that they had repeatedly requested it from nursing staff, who sometimes offered alternative treatments that were ineffective. Staff interviews indicated confusion about the storage location of the patches, with some nurses believing the patches were in the medication cart when they were actually kept in the treatment cart, leading to missed doses. Nursing staff admitted to signing off on the administration of the Lidocaine patch before actually applying it, resulting in the resident not receiving the medication as ordered. The facility's policies required that medications be administered and documented correctly, but these procedures were not followed. The failure to administer the prescribed pain management as ordered led to the resident experiencing ongoing pain and decreased mobility.
Failure to Assess, Document, and Monitor Bed Rail Use
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring of bed rails for a resident with quadriplegia and reduced mobility. The resident had bilateral bed rails in use without a current physician order, and the comprehensive care plan did not address the use of bed rails. Documentation showed that the last side rail consent form was completed over a year prior, with no evidence of ongoing informed consent, discussion of risks and benefits, or regular reassessment of the need for bed rails. Additionally, the care plan interventions did not include the use of bed rails, and there was no documented evidence that alternatives to bed rails were adequately attempted or evaluated. Quarterly side rail safety risk assessments were inconsistently completed, with significant gaps between documented assessments. Maintenance inspections for bed entrapment zones were performed only annually, and there was no evidence of regular maintenance or safety checks for the bed rails in use. Staff interviews revealed confusion regarding facility policy, with some staff believing bed rails were not permitted, while others stated the resident was allowed to keep them due to being "grandfathered in." Staff also indicated uncertainty about the frequency and requirements for ongoing assessments, consent, and physician orders related to bed rail use. Observations confirmed the resident was using bilateral bed rails and expressed a desire to keep them, primarily for support during wound care and bed linen changes. However, therapy and nursing documentation indicated the resident required total assistance for bed mobility and had limited functional use of their upper extremities, raising concerns about the appropriateness of bed rail use. The lack of a current physician order, comprehensive care plan inclusion, ongoing risk assessment, and regular maintenance constituted a failure to ensure the safe and appropriate use of bed rails for the resident.
Failure to Implement and Review Hospital Discharge Orders for Insulin Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's total program of care, including medications and treatments, was properly reviewed and implemented by the medical provider upon readmission from the hospital. The resident, who had diagnoses of diabetes and end stage kidney disease, was discharged from the hospital with specific instructions for sliding scale insulin administration based on blood glucose readings, as well as scheduled fingerstick blood glucose monitoring. However, upon readmission, the sliding scale insulin orders were not initiated, and fingerstick monitoring was not consistently performed as ordered. Documentation showed that the admitting nurse and nurse practitioner reviewed and altered the hospital discharge orders, discontinuing the sliding scale insulin and opting to monitor blood glucose with long-acting insulin only. There was no evidence that the provider was aware of or addressed the hospital's recommendations for sliding scale insulin. Additionally, the resident's blood glucose readings were frequently elevated, and there were multiple instances where fingerstick checks were missed according to the Medication Administration Record. Despite these high readings and missed checks, there was no documentation that the provider was informed or that the care plan was adjusted accordingly. Interviews with facility staff revealed a lack of clarity and communication regarding the hospital discharge orders and the need for sliding scale insulin. The nurse practitioner stated they were not notified of blood sugar issues and believed the sliding scale should have been implemented per the hospital endocrinologist's orders. The admitting nurse acknowledged discontinuing the insulin due to the resident's nausea and vomiting, but the process for reviewing and finalizing orders was not clearly documented. Ultimately, the resident was readmitted to the hospital with hyperglycemia after being found lethargic with extremely high blood glucose levels.
Significant Medication Error: Insulin Administered Without Food for Diabetic Resident
Penalty
Summary
A resident with diabetes, who required set up assistance for eating and received daily insulin injections, was administered 3 units of lispro insulin at 7:00 AM based on a sliding scale after a glucose check showed a level of 196 mg/dL. Facility policy required that medications ordered before or after meals be given in correct relation to meals. However, the resident was scheduled for an outside appointment that morning and did not receive breakfast prior to leaving. The resident's breakfast tray was observed untouched later that morning, and there was no documentation of breakfast intake. Interviews with staff revealed inconsistent practices regarding meal provision for residents with early appointments, with some staff unaware of the need to provide food for diabetic residents who received insulin. The resident reported not eating before the appointment and required their daughter to obtain food from a vending machine during the appointment. Staff interviews confirmed that no food was sent with the resident, and there was no established process to ensure meals were provided in such situations, leading to the resident being at risk after receiving insulin without food.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining routine and emergency dental care for two of three residents reviewed. One resident, who had diagnoses including dysphagia, obesity, and dehydration, was cognitively intact and dependent on staff for activities of daily living. This resident expressed a need for full upper dentures, and the in-house dentist recommended dentures and required impressions. However, the follow-up appointment for impressions was never scheduled by the responsible LPN, who delayed the process due to uncertainty about the resident's length of stay. The resident remained in the facility and did not receive the necessary dental care, despite the dentist's expectation that the process should have begun at the next available appointment. Another resident, with diagnoses including gastroesophageal reflux disease, anxiety, and dental caries, was also cognitively intact and independent with activities of daily living. This resident was identified as needing a dental consult and subsequently required extraction of a fractured tooth. Orders were placed for a dental consult and extraction, but the extraction was not scheduled or completed. The LPN responsible for scheduling did not follow up after placing the order, and the ward clerk cited issues with the resident's insurance as a reason for the delay in arranging the outside dental appointment. The resident reported ongoing pain and had not received the necessary dental care. Interviews with staff confirmed that there were lapses in scheduling and follow-up for dental services, including delays due to administrative decisions and insurance issues. Both residents did not receive timely dental interventions as recommended by dental professionals, and the processes for arranging and following up on dental care were not consistently implemented.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, resulting in harm to a resident who was not competent to give consent. Resident #5, who had severe cognitive impairment and was nonverbal, was sexually assaulted by Resident #4. The incident occurred when Resident #5, known to wander, entered Resident #4's room. Resident #4, who had intact cognition, was found lying over Resident #5, both undressed, with Resident #5's feeding tube dislodged. The facility's policy on the prevention of abuse and neglect was not effectively implemented, as staff failed to prevent the incident despite Resident #5's care plan indicating a potential for wandering and being a victim of abuse. The staff were supposed to monitor Resident #5's whereabouts and intervene when necessary, but the resident was able to enter another resident's room unsupervised. The incident was discovered by a Certified Nurse Aide who found both residents undressed in Resident #4's room. Interviews with staff revealed that there were no prior indications of inappropriate behavior from Resident #4, and the staff had not witnessed Resident #5 entering Resident #4's room before the incident. The facility's response included notifying the police and sending Resident #5 to the hospital for evaluation. However, the lack of continuous monitoring and failure to anticipate Resident #5's needs contributed to the occurrence of the incident.
Deficiency in Maintaining Acceptable Water Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in four isolated rooms, as the water temperatures in these rooms were not within the acceptable range of 90 to 120 degrees Fahrenheit. During an abbreviated survey, it was observed that the water temperatures in the sinks of resident rooms were significantly below the acceptable range, measuring at 70 and 80 degrees Fahrenheit. This issue was linked to the replacement of water circulator pumps, which affected the water temperature consistency in a specific vertical water line covering rooms from the third to the sixth floor. Interviews with facility staff, including the Director of Plant Operations and the Administrator, revealed that while daily water temperature checks were conducted, the issue of cold water was not reported by management or residents. However, a complainant and a resident reported experiencing cold water for several days. Certified Nurse Aides mentioned that they would run the water before use to ensure it was at a suitable temperature, although one aide was unsure of the acceptable temperature range. The Director of Plant Operations noted that the fluctuation in water temperature could have been caused by the replacement of the older circulator pumps, which increased water flow through the pipes.
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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