Van Rensselaer Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, New York.
- Location
- 85 Bloomingrove Drive, Troy, New York 12180
- CMS Provider Number
- 335265
- Inspections on file
- 15
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Van Rensselaer Manor during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, and anxiety, who was documented as cognitively intact for daily decisions, was involved in an incident where a CNA entered the room without knocking, physically pulled the resident into a wheelchair despite apparent resistance, and nearly caused a fall while reseating the resident. Video showed the CNA pushing the wheelchair while the resident tried to block the wheel, then pulling the chair backwards into the hallway, during which the resident stood and fell to the floor onto their side. The CNA then walked away, leaving the resident on the floor alone for several minutes before briefly returning with a mechanical lift and standing away from the resident, who remained unattended on the floor for at least four minutes until an LPN and the ADON arrived and began assessment. Facility leadership stated that staff are expected to treat residents with dignity, avoid physical redirection, and remain with a resident on the floor while summoning help, and that the CNA’s actions were not acceptable.
Two residents with dementia and other comorbidities were not protected from abuse and neglect when a CNA roughly handled one cognitively intact resident, pulled the resident into a wheelchair despite resistance, and left the resident on the floor unattended for several minutes after a fall, and when another resident with severe cognitive impairment sustained facial bruising after being turned in a way that caused impact with a wall. Multiple residents in this CNA’s assignment had unexplained or roughly handled-related bruises, yet staff initially attributed injuries to resident behaviors, environmental factors, or the need for additional education rather than potential abuse. Nursing leadership and other staff did not promptly recognize, report, or fully investigate these events as possible abuse or neglect until a pattern of injuries and video review later revealed neglectful handling and failure to remain with the fallen resident.
A resident with Parkinson’s disease and dementia, who was cognitively intact for daily decisions, was observed on video standing unsupervised in a room when a CNA entered without knocking and repeatedly pulled the resident into a wheelchair despite visible resistance, nearly causing a fall. The CNA then pulled the wheelchair backwards into the hallway; while moving, the resident stood and fell to the floor. The CNA walked away, leaving the resident on the floor alone for about two minutes before returning with a Hoyer lift but did not remain at the resident’s side. An LPN and the ADON then attended to the resident; the ADON performed only a limited ROM check of the arms and had the resident bend the knees, with no documented full ROM assessment of the legs, and the resident was manually lifted from the floor by the arms into the wheelchair instead of being transferred with the Hoyer lift as required by the facility’s post-fall policy.
A deficiency occurred when the facility’s QAA/QAPI program and Supervised Care process were not implemented as required by facility policy to address repeated care concerns and adverse events involving a CNA. One resident with dementia and other comorbidities developed a nasal bruise after an incident during personal care, and another resident with Parkinson’s disease and dementia was mishandled by the same CNA, as shown on video, resulting in a fall and the resident being left on the floor unattended. Despite a policy requiring clear documentation, staff notification, active supervision, and auditing under Supervised Care, the CNA’s Supervised Care form contained only vague "care concerns," had signature irregularities, and there was no evidence of actual supervision or audits. The DON identified increased bruising, injuries, and falls on the CNA’s shift and discrepancies between the CNA’s reports and other information, yet these issues were not effectively brought through the QAA/QAPI process, and the Administrator reported that the investigation and concerns were not discussed in the QAPI meeting while present, demonstrating a failure to use established quality systems to monitor, investigate, and correct identified deficiencies in care and resident safety.
A resident with severe cognitive impairment and dysphagia was served regular chicken tenders instead of the required minced consistency after a CNA swapped meal plates among three residents, despite warnings from another aide. The resident choked and required immediate intervention. Facility policies and staff interviews confirmed that the CNA failed to follow the care plan and meal ticket instructions, resulting in neglect.
A resident with severe cognitive impairment was found with unexplained bruising near the eye, which was observed and discussed by multiple staff members, including RNs, NPs, and the medical director. Despite facility policy and state regulations requiring immediate reporting of injuries of unknown origin, the incident was not reported to the DON, administrator, or state health department within the mandated timeframe.
Two residents experienced incidents involving improper care—one was fed the wrong food consistency and choked after a CNA swapped meal trays, and another developed a bruise of unknown origin that was not promptly or thoroughly investigated. In both cases, the facility did not follow its own investigation protocols, failed to interview all relevant staff, and did not fully determine the circumstances or rule out abuse or neglect, as confirmed by leadership and staff interviews.
A resident with severe cognitive impairment and total dependence for toileting and bed mobility did not receive the required two-person assistance during incontinence care, as specified in their care plan. A CNA provided care alone, contrary to facility policy and staff expectations, despite clear documentation and staff awareness that two-person assistance was necessary for the resident's safety.
A resident with multidrug-resistant organism (MDRO) in their urine was on Enhanced Barrier Precautions, but staff failed to wear a gown during incontinent care as required. Although signage and PPE were present, staff were unclear about which resident required precautions, and the facility lacked specific written policies for Enhanced Barrier Precautions and other transmission-based precautions, leading to inconsistent infection control practices.
A resident identified as full code was found unresponsive by an LPN, who notified an RN. The RN assessed the resident, determined death, and did not check code status or initiate CPR as required by facility policy. Both staff failed to follow protocols for identifying code status and starting CPR, resulting in a delayed response. Nurse supervisors later initiated CPR, but the attempt was unsuccessful.
A CNA threw a water bottle at a resident with dementia, striking them on the back, while another CNA witnessed the event and intervened. There was a delay in removing the offending CNA from resident care, as staff did not immediately call security or remove the individual, contrary to facility policy. The resident was later assessed and found to have no signs of distress.
Resident Left on Floor After Fall and Rough Handling by CNA
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to dignity, respect, and care in a manner that promotes quality of life. The facility’s own Resident Handbook states that residents have the right to dignity, respect, a comfortable living environment, quality care without discrimination, freedom of choice, privacy, freedom from abuse and restraints, and the ability to exercise their rights without fear of reprisals. The resident involved had diagnoses including Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. An MDS dated 08/08/2025 documented that this resident could be understood, could understand others, and had intact cognition for decisions of daily living. Care plans directed staff to encourage the resident to ask for assistance, orient the resident to changing surroundings, respect the resident’s right to refuse activities, initiate conversation frequently, maintain preferred independent leisure activities, provide escort or transportation as needed, and, for falls, to investigate the cause of any fall immediately, provide reality orientation, keep the resident in a high-profile area when possible, and report unsafe behavior to nursing. On the date of the incident, an incident report documented that a CNA observed the resident standing in their room, assisted them to their wheelchair, and that when exiting the room the resident grabbed the wall handrail and pulled themselves from the wheelchair. The CNA’s written account stated that while attempting to reseat the resident, the resident needed to be lowered to the floor to prevent a fall, and that the resident’s self-propelled standing from the wheelchair was attributed to gastric distress. However, the facility’s abuse investigation, which included video footage, showed that the CNA entered the resident’s room without knocking, placed hands on the resident’s arms, and pulled the resident into the wheelchair while the resident appeared to resist. The resident stood again and was again pulled into the wheelchair, nearly missing the chair and almost falling. The video further showed the CNA pushing the resident in the wheelchair while the resident attempted to block the front wheel with their foot, then turning the wheelchair to move it backwards into the hallway. As the wheelchair was being pulled backwards, the resident stood up and fell to the floor onto their side. The CNA appeared to throw their hands down at their sides and then walked away, leaving the resident lying on the floor. The resident remained alone on the floor for approximately two minutes before the CNA returned in the camera’s view with a mechanical lift, walked past the resident, spoke briefly, and then stood in a nearby doorway at least five feet away. The resident was left unattended on the floor for a minimum of four minutes between 10:49 a.m. and 10:53 a.m. before nursing staff, including an LPN and the Assistant Director of Nursing, arrived and began interacting with and assessing the resident. Interviews with the RN unit manager, the Assistant Director of Nursing, and the Director of Nursing confirmed that staff were expected to treat residents with respect and dignity, that physical redirection was not acceptable, that a CNA who lowered a resident to the floor should stay with the resident and obtain help via call bell or by calling out, and that it was not appropriate to leave a resident unattended on the floor for multiple minutes. The DON stated that the CNA’s actions were not acceptable and not in line with expectations for kind and dignified treatment.
Failure to Protect Residents From Abuse and Neglect by CNA and Inadequate Investigation of Injuries
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse, neglect, or mistreatment of residents and to adequately investigate and respond to incidents involving a CNA’s handling of residents. The facility’s Abuse & Neglect Policy, updated on 04/03/2025, stated that residents had the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation, and involuntary seclusion. Despite this policy, an abbreviated survey found that two of four residents reviewed for abuse, neglect, or mistreatment were not protected from willful infliction of abuse, neglect, or mistreatment. The facility did not fully investigate an incident on 08/02/2025 in which CNA #1 lowered Resident #1 to the floor, and later-obtained video footage showed abusive handling and the resident being left on the floor unattended for several minutes. Resident #1 had diagnoses including Parkinson’s disease with dyskinesia and fluctuations, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An MDS dated 08/08/2025 documented that this resident could understand and be understood and had intact cognition for decisions of daily living. An incident report dated 08/02/2025 documented CNA #1’s account that the resident stood in their room, was assisted into a wheelchair, and, while being taken from the room, grabbed the wall handrail and lifted themselves up, prompting the CNA to lower the resident to the floor to prevent a fall. However, video footage from 08/02/2025 showed CNA #1 entering the resident’s room without knocking, pulling the resident into the wheelchair despite resistance, repeating the maneuver with a near fall, and then moving the wheelchair backward while the resident attempted to block the wheel with their foot. The footage showed the resident standing and falling to the floor on their side, after which CNA #1 gestured toward the resident, walked away, and left the resident on the floor alone for approximately two minutes before returning briefly with a mechanical lift and then leaving again. The resident remained on the floor for about four minutes total before a nurse arrived, and the review of the video concluded that CNA #1 neglected the resident by walking away after the fall. Resident #3 had diagnoses of unspecified dementia with other behavioral disturbances, hypothyroidism, and major depressive disorder. An MDS documented that this resident was usually able to understand others, was usually understood, and was severely cognitively impaired. The care plan indicated the resident required one-person assistance for bed mobility and ADLs and had a history of hitting and screaming at staff and resisting care, with interventions such as allowing time to de-escalate, reapproaching if refusing care, and placing a soft object in the resident’s hands if combative. An incident report dated 08/01/2025 documented a blue/gray bruise on the resident’s nose, with contributing factors listed as poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and resting their head on a table when fatigued. However, the ADON documented that CNA #1 had previously provided personal care and turned this resident in a way that caused them to hit their face on the wall, causing injury. The facility attributed the injury to environmental and resident factors and did not treat the event as potential abuse, instead viewing CNA #1 as needing more education on bed mobility. The facility’s broader investigation, dated 08/15/2025 through 09/03/2025, showed that CNA #1 was suspended after being possibly responsible for multiple injuries on more than one resident in their care assignments. On 07/19/2025, a bruise and abrasion on Resident #2’s forehead were attributed to rough handling during bed mobility. On 08/01/2025, bruising on the right side of Resident #3’s face and around the eye and nose was attributed to another CNA rolling the resident into the wall and to ill-fitting glasses. On 08/15/2025, bruising on Resident #4’s neck, appearing multiple days old, was attributed to the resident being resistive to care. Interviews with nursing leadership and staff showed that, at the time of the incidents, they did not suspect abuse by CNA #1, did not immediately remove the CNA from resident care, and did not fully investigate the events as potential abuse or neglect until a pattern of injuries and video review prompted further scrutiny. The DON and ADON acknowledged that the actions captured on video were not acceptable and that leaving a resident unattended on the floor for multiple minutes was not appropriate, but these acknowledgments occurred after the events that led to the deficiency. Interviews also revealed gaps in immediate reporting and investigation. CNA #1 stated they gave a verbal statement on the day of Resident #1’s fall but were unable to enter a written statement into the computer and that no written statement was taken from them at that time. LPN #4 reported being told by CNA #1 that the resident had been ambulating when they were not supposed to and did not suspect the explanation was inaccurate, despite the later video evidence. The ADON described that if there had been any indication from Resident #1 of an issue with CNA #1, they would have handled the situation differently, such as interviewing the staff member privately or changing assignments, but this did not occur at the time. The DON and Administrator described that video footage was typically reviewed only for certain types of incidents, such as falls with injuries or resident-to-resident issues, and that no staff raised concerns about CNA #1 until the DON began questioning employees. These actions and inactions contributed to the failure to protect residents from abuse and neglect and to promptly and thoroughly investigate potential mistreatment as required by regulation.
Failure to Perform Complete Post-Fall Assessment and Safe Transfer After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-centered care and to follow its own post-fall policy and professional standards when responding to a fall. The facility’s Post Fall Routine policy required that an RN assess the resident for injury and provide emergency treatment as necessary, that all residents be assisted off the floor with a Hoyer lift (with limited supervisory discretion), and that residents be monitored and assessed for injury, including range of motion, before being moved. For the fall event in question, video footage and interviews showed that these requirements were not followed, and that a complete assessment, including full range of motion, was not performed before the resident was manually lifted from the floor and placed in a wheelchair. The resident involved had Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. The MDS documented that the resident could be understood, could understand others, and had intact cognition for daily decision-making. The resident’s care plans addressed falls, vision, and activity participation, including interventions such as investigating the cause of falls immediately, providing reality orientation, maintaining the resident in high-profile areas when possible, and reporting unsafe behavior to nursing. On the day of the incident, video footage showed the resident standing unsupervised in their room when a CNA entered without knocking, placed hands on the resident’s arms, and pulled the resident into a wheelchair despite apparent resistance. The CNA repeated this action when the resident stood again, nearly causing a fall as the resident almost missed the wheelchair. The video further showed the CNA pushing the resident in the wheelchair, with the resident attempting to block the front wheel with their foot. The CNA then turned the wheelchair and pulled it backwards into the hallway; while the wheelchair was moving, the resident stood up and fell to the floor onto their side. Contrary to the CNA’s written account, there was no video evidence of the resident grabbing a handrail and pulling themselves from the wheelchair. After the fall, the CNA appeared to throw their hands down and walked away, leaving the resident on the floor alone for approximately two minutes before returning with a Hoyer lift, then again standing away from the resident. An LPN arrived to attend to the resident, followed by the Assistant DON, who spoke with the resident and performed only a limited range of motion assessment on the resident’s arms and had the resident bend their knees. Without documented evidence of a full range of motion assessment, particularly of the legs, the Assistant DON and LPN manually lifted the resident from the floor by the arms and placed them in the wheelchair, instead of using the Hoyer lift as required by policy. Interviews with the DON and Assistant DON confirmed that a full assessment, including range of motion and pain assessment, was expected after a fall and that leaving a resident unattended on the floor for multiple minutes and manually lifting them in this manner was inconsistent with facility expectations and policy.
Failure of QAA/QAPI and Supervised Care Processes to Address Staff Care Concerns and Adverse Events
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assessment and Assurance (QAA)/Quality Assurance Performance Improvement (QAPI) program functioned as described in its own policies to identify, analyze, and correct quality problems, including adverse events and staff performance concerns. The facility’s QAPI policy required consistent data collection, monitoring, and analysis of care and services, including adverse event tracking and implementation of action plans to prevent recurrence. Despite this, the facility did not ensure that the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies, and did not implement written policies and procedures for feedback, data collection systems, and monitoring related to performance improvement plans, staff correction, and resident safety. One resident, identified as having unspecified dementia with behavioral disturbances, hypothyroidism, and major depressive disorder, was found on an incident report to have a blue/gray bruise on the nose. The report attributed contributing factors to poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and the resident resting their head on the table when fatigued. The report also documented that a CNA described the resident as difficult during care, stated the resident swung their hands during personal care, and hit their head on the wall while rolling over, though the CNA reported not seeing an injury at that time. This event triggered the use of the facility’s “Supervised Care” process for the CNA, but the documentation and implementation of that process did not follow the facility’s own Supervised Work and Supervised Care policy, which required clear documentation of reasons, staff notification, and ongoing supervision and auditing until the staff member was deemed safe to perform their job. Another resident, with Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, was involved in an incident where the CNA reported that the resident stood from their wheelchair, grabbed a handrail, and had to be lowered to the floor to prevent a fall. However, video footage reviewed during the facility’s abuse investigation showed the CNA entering the resident’s room without knocking, physically pulling the resident into a wheelchair despite apparent resistance, nearly causing a fall, and later pulling the wheelchair backward while the resident stood, resulting in the resident falling to the floor. The CNA then walked away, leaving the resident on the floor for approximately two minutes before returning with a mechanical lift and then leaving again as an LPN began attending to the resident. This sequence of events, combined with prior concerns about bruising, injuries, and falls on the CNA’s shift, demonstrated that the facility’s systems for monitoring adverse events, reconciling staff accounts with objective evidence, and escalating concerns through QAA/QAPI were not effectively implemented. The facility’s Supervised Care policy required that any employee who failed to follow resident care, medication, or treatment policies, or whose care was under review, be placed on Supervised Care with documented job responsibilities, supervisory sign-off each shift, and Department Head review with notification to the Administrator if problems were identified. In this case, the Supervised Care form for the CNA listed only vague “care concerns,” lacked detailed reasons such as bruising or rough care, and had signature discrepancies, including a misspelled version of the CNA’s name that did not match other documents. There was no documented evidence that any actual auditing of the CNA’s care occurred, and the CNA stated they were never informed they were on Supervised Care and were not supervised while working. The DON later stated they did not believe the CNA was truly placed on Supervised Care and that the form may have been retroactively documented or not appropriately implemented. Additionally, the Administrator reported that the last QAPI meeting did not address this investigation while they were present, and the DON acknowledged that video footage was only reviewed reactively after an increase in bruising and incident reports, rather than as part of a systematic monitoring process. These facts show that the facility did not operationalize its QAA/QAPI policies to ensure consistent monitoring, investigation, and corrective action for identified quality and safety concerns involving staff performance and resident adverse events. Interviews further underscored the breakdown in the facility’s quality systems. The DON reported noticing a notable increase in incident reports of bruising, injuries, and falls on the unit and during the CNA’s shift, with discrepancies between the CNA’s accounts and other staff reports or observed injuries, yet there was no evidence that these concerns were effectively brought through the QAA process or resulted in a properly implemented Supervised Care plan. The Assistant DON described Supervised Care in this case as primarily an educational tool without one-to-one supervision, while the DON described Supervised Care as meaning the staff member should not be alone and should receive hands-on instruction and audits. The CNA denied being placed on Supervised Care and alleged the Supervised Care form signature was forged. The Administrator stated they were not aware of the care concerns surrounding the CNA until suspicions of multiple cases of abuse arose and acknowledged that the incident and related concerns were not discussed in the QAPI meeting while they were present. Collectively, these actions and inactions demonstrate that the facility did not follow its own policies for Supervised Care, did not consistently monitor and track adverse events and staff performance issues, and did not ensure that the QAA/QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies.
Neglect Due to Failure to Follow Dietary Consistency Leading to Choking Incident
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide failed to follow a resident's care plan regarding dietary meal consistency, resulting in the resident being served food of the wrong texture. The resident, who had diagnoses including dementia with agitation, chronic obstructive pulmonary disease, and bladder cancer, was assessed as cognitively severely impaired and required a mechanically altered diet with ground meats due to dysphagia and impaired swallowing. The resident's care plan and dietary assessments clearly indicated the need for a mechanical soft diet with minced meats, and the meal ticket on the resident's tray specified this requirement. During a supper meal, the Certified Nurse Aide intentionally swapped meal plates among three residents, providing the resident with regular chicken tenders instead of the required minced consistency. Despite being warned by another aide that the food was not the correct consistency, the aide proceeded to feed the resident the regular chicken. This resulted in the resident choking and requiring immediate intervention, including back thrusts and mouth sweeps, to clear the airway. Staff interviews confirmed that the aide did not read the meal ticket and failed to follow established procedures for obtaining alternative meals, such as contacting the kitchen. Facility policies and staff education materials emphasized the importance of following care plans, meal tickets, and dietary restrictions to prevent neglect and ensure resident safety. The incident was witnessed by multiple staff members, and statements from nursing and medical staff indicated that the aide's actions were negligent and directly led to the resident's choking episode. The failure to adhere to the resident's prescribed diet and established protocols constituted neglect as defined by facility policy.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin involving a resident was reported to the Administrator and the State Survey Agency within the required timeframe. According to facility policy, all incidents, accidents, and injuries of unknown source must be reported immediately, or no later than two hours after discovery, to the appropriate authorities. In this case, a resident with diagnoses including dementia, hypertension, and peripheral vascular disease was found to have discoloration and bruising below the right eye, which was first documented by a registered nurse as purpura. The resident was cognitively severely impaired and unable to recall how the injury occurred. Despite multiple staff members, including registered nurses, nurse practitioners, and the medical director, being aware of the injury over several days, the incident was not reported to the Director of Nursing, Administrator, or the New York State Department of Health within the mandated timeframe. Progress notes and staff statements indicated that the injury was observed, discussed among staff, and assessed by medical personnel, but the required notifications and reporting were not completed as per facility policy and state regulations. The facility's own documentation and staff interviews confirmed that the injury was of unknown origin and should have triggered immediate reporting. Interviews with facility staff, including the DON, Administrator, and Medical Director, revealed a consensus that the initial nurse who identified the injury should have reported it for further assessment and to the appropriate authorities. The failure to report the injury of unknown origin in a timely manner constituted a violation of both facility policy and state regulations, as all agreed that the incident met the criteria for mandatory reporting within 24 hours.
Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving potential abuse, neglect, or mistreatment, as required by its own policies and federal regulations. In the first incident, a resident with severe cognitive impairment and dysphagia was fed regular consistency chicken tenders instead of the prescribed mechanical soft, minced diet. This error occurred after a certified nurse aide intentionally swapped meal plates among three residents without verifying dietary restrictions, resulting in the resident choking and requiring emergency intervention. The facility's investigation did not determine where the incorrect food originated, nor did it include a review of the dietary plans or meal tickets for the other residents involved in the plate swap. Key staff, including the therapy director, nurse practitioner, and medical director, were unaware of the full extent of the incident, and the director of nursing acknowledged the investigation was incomplete. In the second incident, a resident with dementia and a history of behavioral symptoms was found to have a bruise of unknown origin below the right eye. Documentation showed that the discoloration was first noted as purpura by a registered nurse, but no provider assessment or investigation was initiated at that time. The facility's investigation began several days later, did not review all relevant progress notes, and failed to interview all staff assigned to the resident during the period when the injury could have occurred. Several staff members, including those who provided care during the relevant shifts, confirmed they were not interviewed as part of the investigation. Both the director of nursing and the administrator later acknowledged that the investigation was not thorough and did not follow the facility's established procedures for injuries of unknown origin. In both cases, the facility's failure to conduct comprehensive investigations meant that not all potential causes or responsible parties were identified, and the required steps to rule out abuse or neglect were not completed. The deficiencies were confirmed through staff interviews, record reviews, and direct admissions from facility leadership that the investigations were incomplete and did not meet policy or regulatory standards.
Failure to Provide Two-Person Assist for Dependent Resident's Incontinence and Bed Mobility Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia with agitation, generalized anxiety disorder, and major depressive disorder, who was assessed as cognitively severely impaired and totally dependent for toileting hygiene and bed mobility, did not receive care as outlined in their comprehensive care plan. The care plan, as well as the Certified Nurse Assistant Assignments Summary, specified that the resident required the assistance of two or more staff members for incontinent care and bed mobility due to their total dependence and risk for skin breakdown. However, during an observed episode of incontinence care, a single Certified Nurse Aide provided all care and repositioning without the required second staff member, despite the resident intermittently vocalizing during the process. Interviews with multiple staff members, including the CNA involved, another CNA, an LPN, an RN, the Director of Nursing, and the Administrator, confirmed that the expectation and documented plan of care was for two-person assistance for this resident's incontinent care and bed mobility. The CNA acknowledged not following the care plan and not requesting assistance, while all other staff interviewed stated they would have expected the care plan to be followed for the resident's safety. The facility's policy required comprehensive, person-centered care plans to be implemented as written, but this was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions and Lack of Transmission-Based Precaution Policies
Penalty
Summary
A deficiency was identified when staff failed to implement proper infection prevention and control practices for a resident on Enhanced Barrier Precautions due to the presence of extended-spectrum beta-lactamase-producing bacteria in their urine. During an observation, a Certified Nurse Aide provided incontinent care involving exposure to urine and feces without donning a gown, as required by the posted Enhanced Barrier Precaution signage. The signage clearly indicated that gloves and gowns were to be worn during high-contact resident care activities, such as dressing, hygiene, and changing briefs. The Certified Nurse Aide acknowledged awareness of the signage but was uncertain about which resident required precautions and did not follow the required protocol during care. Interviews with facility staff, including the Certified Nurse Aide, Registered Nurses, the Director of Nursing, the Infection Preventionist, and the Medical Director, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions. However, it was revealed that the facility did not have specific written policies and procedures for Enhanced Barrier Precautions or for other types of transmission-based precautions, such as airborne, droplet, and contact precautions. Staff reported relying on CDC guidelines and posted signage but lacked formalized facility policies to guide their actions. The resident involved had significant cognitive impairment, was frequently incontinent of bowel and bladder, and had a care plan indicating the need for staff to use personal protective equipment per the posted precaution card. Despite these documented needs and the presence of signage and PPE supplies, the lack of clear, facility-specific policies and procedures contributed to inconsistent implementation of infection control measures, as evidenced by the observed failure to use appropriate PPE during high-risk care activities.
Failure to Initiate Timely CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was a full code and found unresponsive. The facility's policies required that residents who had chosen CPR be clearly identified with green wristbands, stickers, and other visual cues, and that staff initiate CPR in accordance with the resident's advance directives and physician orders. Despite these protocols, when the resident was found unresponsive, both the LPN and RN involved did not immediately check the resident's code status or initiate CPR. The LPN discovered the resident unresponsive and notified the RN, who assessed the resident and determined the resident had expired without checking the code status or starting CPR. The RN then began the process of notifying the family and funeral home, and left the unit without calling a code or informing a supervisor or physician. It was only after the RN began charting and realized the resident was a full code that the issue was brought to the attention of nurse supervisors, who then initiated CPR, but the attempt was unsuccessful. Interviews and documentation revealed that both the LPN and RN were aware of the resident's full code status but did not follow facility policy or physician orders to initiate CPR. The delay in identifying the resident's code status and the failure to start CPR in a timely manner resulted in Immediate Jeopardy Past Noncompliance, with the potential for serious harm to the health and safety of all residents. The incident was attributed to staff not following established protocols for identifying code status and responding to unresponsive residents.
Delay in Removal of Staff Following Resident Abuse Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) threw a water bottle at a resident with non-Alzheimer's dementia, osteoarthritis, and age-related debility. The incident took place in a hallway near the nurses' station, where the resident, who had severe cognitive impairment but could communicate, was sitting in a wheelchair. The CNA first threw the bottle, missing the resident, then retrieved it and threw it again, striking the resident on the back and causing water to spray onto them. This act was witnessed by another CNA, who intervened by moving the resident away from the situation. Despite the immediate risk, there was a delay in removing the offending CNA from resident care. The witnessing CNA reported the incident to an LPN, who then attempted to locate a supervisor. During this time, the CNA who committed the abuse remained in the area, and staff did not immediately call security or remove the perpetrator from the unit. The LPN instructed staff to monitor the CNA until a supervisor arrived, at which point the CNA was finally removed from the facility by security. The facility's policy required immediate reporting and removal of staff suspected of abuse, but this protocol was not followed. Interviews with staff confirmed that there was confusion and hesitation in responding to the incident, resulting in a delay in protecting residents from further potential harm. The resident involved was assessed and showed no signs of physical or psychological distress following the event.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
