Verrazano Nursing And Post-acute Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Staten Island, New York.
- Location
- 100 Castleton Avenue, Staten Island, New York 10301
- CMS Provider Number
- 335273
- Inspections on file
- 18
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Verrazano Nursing And Post-acute Center during CMS and state inspections, most recent first.
A resident with a history of mood disorder and anxiety informed a nurse supervisor of an intent to report abuse, which was relayed to the facility's MD. Despite this, neither the MD nor the nurse supervisor reported the abuse allegation to the DON or Administrator, and no documentation was made to state authorities as required by policy.
The facility failed to document the offering and education of COVID-19 immunizations for several residents, as required by their policy. Despite assessments indicating up-to-date immunization statuses, there was no evidence to support this. A transition in responsibility for monitoring immunizations contributed to this lapse.
The facility failed to offer and educate residents on Pneumococcal and Influenza immunizations, as required by their policies. Five residents were not provided with documented evidence of being offered or educated on these vaccines. The deficiency was due to a lapse in the immunization program following a personnel transition, resulting in residents not being up to date on their immunizations.
The facility failed to comply with the 2012 NFPA 101 Life Safety Code by installing alcohol-based hand rub (ABHR) dispensers directly above ignition sources, such as electrical outlets, in various corridors. This was observed during a recertification survey and confirmed through staff interviews.
The facility's egress stairs in both the East and West stairwells were found to lack the required contrasting colored marking stripe along the handrails, as per 2012 NFPA 101 standards. This deficiency was identified during a life safety survey, and staff acknowledged the issue.
The facility failed to develop comprehensive care plans for three residents, including one on diuretics, another receiving medical treatment, and a third on hospice care. The care plans lacked necessary focus, goals, and interventions, as confirmed by nursing staff and the Director of Nursing.
During a life safety survey, it was found that the facility did not have a sprinkler head on the basement side of a door interrupting the East stair on the first floor landing. This deficiency was acknowledged by the Maintenance Director, Administrator, and Environmental Services Director, violating NFPA standards.
A resident with cognitive impairments was physically abused by a CNA in the dining room after the resident threw water on the CNA. The incident was captured on video, showing the CNA slapping the resident. The facility's abuse prevention policy was not effectively implemented, leading to the incident being reported and investigated. The CNA was removed from the schedule following the investigation.
A resident developed a stage 4 pressure ulcer due to the facility's failure to implement a care plan and provide timely treatment. Despite being at mild risk, the resident's condition was not properly monitored, leading to infection and hospitalization. Staff interviews revealed communication lapses and high turnover as contributing factors.
The facility failed to report the results of an investigation involving alleged abuse between two residents to the State Survey Agency within the required 5 working days. The follow-up report was submitted 10 days after the incident, exceeding the mandated timeframe.
The facility failed to thoroughly investigate an alleged abuse incident involving two residents. The investigation did not include statements from staff members who may have witnessed the incident, and the conclusion was based solely on interviews with the residents involved.
A resident with serious mental illness was admitted without a completed PASRR screening. The facility staff failed to review preadmission documents properly, resulting in an incomplete screening process and lack of necessary evaluations before admission.
The facility failed to develop and implement comprehensive care plans for two residents following an allegation of sexual abuse. Despite the grievance form indicating no reasonable suspicion, no care plans were documented to address the abuse allegation.
A resident with multiple diagnoses was discharged without an effective discharge plan, despite the facility's social services team acknowledging their responsibility. The discharge process was complicated by pending guardianship proceedings, and no discharge care plan was created during the resident's stay.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse made by a resident was reported immediately to the appropriate authorities as required by policy and regulation. Specifically, a resident with diagnoses including mood disorder and anxiety informed a Registered Nurse Supervisor that they would tell a doctor at an outside appointment that they had been abused in the facility. The Registered Nurse Supervisor relayed this information to the facility's Medical Doctor, who later documented the resident's claim of abuse in a progress note. Despite this, neither the Medical Doctor nor the Registered Nurse Supervisor reported the allegation to the Director of Nursing or the Administrator, and there was no documentation that the incident was reported to the New York State Department of Health. The facility's policy required immediate reporting of all abuse allegations to the Administrator and Director of Nursing, and to the State Department of Health within two hours if serious bodily injury or abuse was involved. Review of records showed no incident or accident reports were initiated regarding the resident's complaint, and the Director of Nursing and Administrator were unaware of the allegation until months later. Interviews confirmed that the involved staff did not follow reporting procedures, and the required notifications and documentation were not completed at the time of the allegation.
Failure to Document COVID-19 Immunization for Residents
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 immunization, as observed during the Recertification Survey. This deficiency was identified in five residents who were sampled for immunizations. There was no documentation available regarding the screening, administration, declination, or education on the COVID-19 immunizations for these residents. The facility's policy required that all residents and their representatives be provided with education about the COVID-19 vaccination, and their decision to accept or decline the vaccination should be documented in the COVID Vaccination Care Plan. However, the facility was unable to provide evidence that these steps were followed for the sampled residents. The residents involved had varying levels of cognitive impairments, ranging from moderate to severe, and their Minimum Data Set assessments indicated that their COVID-19 immunization statuses were up to date. Despite this, the facility could not provide documentation to support these claims. Interviews with the Infection Preventionist and the Director of Nursing revealed that the responsibility for monitoring resident immunization statuses had transitioned from a former nurse to the Director of Nursing. This personnel change led to a lapse in maintaining the immunization program, resulting in the deficiency observed during the survey.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 and will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). The MDS Coordinator responsible for coding MDS comprehensive assessment on covid immunization was educated on improperly coding MDS (3/31/25). All Licensed nurses responsible for offering and educating residents the Covid vaccine were educated and re-inserviced on failure to offer, screen educate and document in the COVID Vaccination Care Plan (3/31/25). II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered COVID-19 vaccine upon admission with documentation in EMR related to the screening, administration or declination, and education on the COVID-19 immunizations. An audit was completed by the DNS on the COVID-19 Vaccination to ensure that all current residents in house were offered the COVID-19 Vaccination with signed consent/declination and education on file. Any identified issues will be addressed (3/25/25). III. Systemic Changes: The Policy and Procedure for COVID-19 Vaccination Administration for Residents was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received a re-inservice/education on ensuring that all residents are offered the COVID-19 vaccine upon admission. A matrix tracker was created to monitor the COVID-19 Vaccination status of all residents. Newly appointed Infection Control nurse was inserviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Covid vaccine, if appropriate, and vaccine status documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the COVID-19 vaccine upon admission. The DNS will conduct this audit weekly for 3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person responsible: DNS Date: 4/25/25
Failure to Offer and Educate on Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered and educated on Pneumococcal and Influenza immunizations, as required by their policies. This deficiency was identified during a recertification survey, where it was observed that five residents were not provided with documented evidence of being offered or educated on these immunizations. Specifically, Resident #23 was not offered or educated on the Influenza immunization, and Residents #11, #23, #57, #84, and #93 were not offered or educated on the Pneumococcal immunization. The facility's policies, last reviewed in 2023 and 2024, respectively, require that all residents be educated and offered these vaccines to prevent infections and reduce associated morbidity and mortality. The deficiency was attributed to a lapse in the facility's immunization program due to a personnel transition. The Director of Nursing, who assumed responsibility for monitoring resident immunization statuses after a nurse left the facility, acknowledged falling behind on maintaining the program. This oversight resulted in the sampled residents not being up to date on their immunizations. The report highlights that the facility was unable to provide documented evidence of the residents' immunization statuses or any medical contraindications that would prevent them from receiving the vaccines.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the Influenza vaccine. Education on benefits and potential risk was provided. Consent was received. Influenza vaccine was administered on (MONTH) 17th, 2025. Family and MD were informed. 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Declination was received secondary to resident’s hospice status. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered the Influenza and Pneumococcal vaccine upon admission and annually and provided with educational material for review. An audit of the entire house was completed by the DNS on the Influenza and Pneumococcal Vaccination to ensure that all new admission and readmissions were offered the Influenza vaccine for the 2024-2025 flu season and Pneumococcal Vaccination with signed consent/declination and education on file. All identified issues were addressed (3/26/25). The facility will ensure that each resident that was offered the Pneumococcal and Influenza immunizations will be followed with documented evidence in EMR to validate compliance. III. Systemic Changes: The Policy and Procedure for Conducting the Influenza Vaccination Program for Residents was reviewed by the DNS and found to be in compliance. The Policy and Procedure for Pneumococcal Vaccination for Residents was reviewed by the DNS and found to be in compliance. On 3/31/2025 all RNs and LPNs received in-service/education on ensuring that all residents are offered the influenza vaccine during the flu season and offered the pneumococcal vaccine upon admission if they meet the criteria and documented in EMR. A matrix tracker was created to monitor the Influenza and Pneumococcal vaccination status of all residents. Newly appointed Infection Control nurse was in serviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring, documenting and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Flu and Pneumococcal vaccine, if appropriate, and documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the Influenza and Pneumococcal vaccine upon admission and annually. The DNS will conduct this audit weekly x3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25
Improper Installation of ABHR Dispensers Near Ignition Sources
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101 Life Safety Code regarding the installation of alcohol-based hand rub (ABHR) dispensers. During a recertification survey, it was observed that ABHR dispensers were installed directly above ignition sources, specifically electrical outlets, in several locations within the facility. These locations included corridors on the second to fourth floors near specific room numbers, as well as in the corridor outside of the kitchen on the first floor. This installation violates the requirement that ABHR dispensers should not be placed directly over or within one inch of ignition sources. The deficiency was confirmed through staff interviews during the survey process.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action The alcohol-based hand rub dispensers on first floor near kitchen, on second floor near room [ROOM NUMBER], on third floor near 309, on fourth floor near 409 were removed and placed away from ignition sources (3/14/25). Identification of others All residents have the potential to be affected by this deficient practice. A complete audit of the entire building was completed to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources (3/14/25). No other issues were identified. All Maintenance Staff will be in serviced on the importance of ensuring that all Alcohol Based Dispensers shall not be installed above an ignition source within a 1 in. radius from an ignition source (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on placement of Alcohol-Based Hand-Rub Dispensers. Alcohol-based hand-rub dispensers shall be protected in accordance with 8.7.3.1. All Maintenance staff will be in serviced on the importance of ensuring that appropriate placement of the Alcohol Based Hand-Rub Dispensers. All Alcohol Based Dispensers shall not be installed in the following locations: (a) Above an ignition source within a 1 in. (25 mm) horizontal distance from each side of the ignition source (b) To the side of an ignition source within a 1 in. (25mm) horizontal distance from the ignition source (c) Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that the alcohol-based hand rub (ABHR) dispensers were not installed directly over or within 1 inch of ignition sources complying with requirements of 2012 NFOA 101. There will be a visual check of all alcohol-based hand rub (ABHR) dispensers weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person Maintenance Director is responsible. 4/25/25- date of correction.
Egress Stairs Handrail Marking Deficiency
Penalty
Summary
The facility failed to maintain egress stairs in accordance with the 2012 NFPA 101 standards. During a life safety survey conducted on March 13, 2025, it was observed that the handrails in both the East and West stairwells lacked the required contrasting colored marking stripe along the entire length of the stairwells. This deficiency was noted between 9:00 am and 12:00 pm. The absence of the marking stripe was confirmed through observation and staff interviews, where the Director of Environmental Services and Director of Maintenance acknowledged the issue and stated that the rails would be painted.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 Immediate Corrective Action All handrails and handrail extensions were marked with a solid and continuous marking in egress stairs in both of the facility's stairwells (3/17/25). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all egress staircases was audited to ensure that it was maintained in accordance with 2012 NFPA 101 and that the handrails are painted with the required contrasting colored marking with a 1-inch width horizontal stripe for the length of the stairwell (3/17/25). All stairwell handrails have been painted with a 1-inch horizontal stripe to meet NFPA 101 egress requirements (3/17/25). All Maintenance staff will be in serviced on the importance of ensuring that all handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. Systematic Changes The Maintenance Director and Administrator reviewed the 2012 NFPA 101 manual and created a policy on Means of Egress Requirements. All Maintenance staff will be in serviced on the Means of Egress Requirements policy of Exit Stair Handrails (3/31/25). All handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the following requirements: (1) The marking stripe shall be applied to the upper surface of the handrail or be a material integral with the upper surface of the handrail for the entire length of the handrail, including extensions. (2) Where handrails or handrail extensions bend or turn corners, the marking stripe shall be permitted to have a gap of not more than 4 in. (100 mm). (3) The marking stripe shall have a minimum horizontal width of 1 in. (25 mm), which shall not apply to outlining stripes listed in accordance with UL 1994, Standard for Luminous Egress Path Marking Systems. (4) The dimensions and placement of the marking stripe shall be uniform and consistent on each handrail throughout the exit enclosure. QA The Maintenance Director and Administrator developed an audit tool to ensure that all exit stair handrails and handrail extensions shall be marked with a solid and continuous marking stripe and meet all of the NFPA requirements. There will be a visual check of all exit stairwell handrails weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25 - date of correction.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for three residents during a recertification survey. Resident #28, who had diagnoses including hypertension and was prescribed a diuretic, did not have a comprehensive care plan addressing the use of the diuretic. The cardiac care plan initiated for this resident lacked focus, goals, and interventions. Registered Nurse #3 confirmed the absence of a comprehensive care plan for the diuretic medication. Resident #79, who was receiving medical treatment three times a week, had a care plan initiated but it lacked necessary interventions, rendering it incomplete. Registered Nurse #4 acknowledged the missing interventions in the care plan. Resident #93, who was severely cognitively impaired and receiving hospice care, did not have a comprehensive care plan related to hospice services. Registered Nurse #4 stated that hospice care plans were not developed at the facility, and communication was maintained through progress notes instead. The Director of Nursing confirmed that comprehensive care plans should be developed for hospice care and that care plans lacking goals or interventions were not considered complete. The facility's policy required an interdisciplinary team to develop individualized care plans to maximize residents' functional potential and quality of life.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Correction: 1) Resident #28 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for the use of diuretics. 2) Resident #79 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for [MEDICAL TREATMENT] care. 3) Resident #93 chart was reviewed by the DNS on (MONTH) 18th, 2025 and a complete comprehensive care plan with a focus, goal and interventions were initiated for hospice care. 4) The RN Supervisor #3 who was responsible for initiating comprehensive care plans for resident #28 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. 5) The RN Supervisor #4 who was responsible for initiating comprehensive care plans for resident #79 and #93 was counseled and educated regarding the policy on Comprehensive Care Planning on (MONTH) 19, 2025. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that for all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status and initiated and updated as needed. An audit was completed by the DNS on all outstanding comprehensive care plans on all residents on our current census to ensure that all diagnosis, services, plan of care and medications have an active complete comprehensive care plan including goals. Any identified issues will be addressed (4/25/25). III. Systemic Changes: The Policy and Procedure for Comprehensive Care Plan was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received in-service/education on initiating and updating comprehensive care plans upon admission/re-admission or change in status on all active diagnosis, service, plan of care and medications, a complete comprehensive care plan is initiated upon admission/readmission or change in status is initiated and updated as needed. All new and re admissions will be reviewed within 24 hours of admission. All charts will be reviewed by IDT to ensure that a comprehensive care plans were developed for each residents diagnosis, services, plan of care and medications. All in house residents charts will be reviewed by IDT prior to quarterly, annual and significant change care plan meetings to ensure compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have a complete comprehensive care plan with a focus, goal and interventions initiated that will address all active diagnosis, service, plan of care and medications. The DNS will conduct an audit weekly x3 months. Any identified issues related to a delay in care planning results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25
Sprinkler System Deficiency in Stairwell
Penalty
Summary
The facility failed to ensure that sprinkler heads were installed in all required areas of the building, specifically on the basement side of a door interrupting the East stair on the first floor landing. This deficiency was identified during a life safety survey conducted on March 13, 2025, at approximately 10:15 am. The absence of a sprinkler head in this location was observed and acknowledged by the Maintenance Director, Administrator, and Environmental Services Director. The requirement for sprinkler systems is outlined in the 2012 NFPA 101 and 2010 NFPA 13 standards, which mandate that sprinklers be provided on each side of separations in noncombustible stair shafts.
Plan Of Correction
Plan of Correction: Approved March 29, 2025 Immediate Corrective Action A sprinkler head was installed on the basement side of the door ( ). Identification of others All residents have the potential to be affected by this deficient practice. An audit of all areas of the building was completed to ensure that where noncombustible stair shafts are divided by walls or doors, sprinklers are provided on each side of the separation. (3/27/25) No other issues were found. All Maintenance staff will be in serviced on the importance of ensuring that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation (3/31/25). Systematic Changes The Maintenance Director and Administrator reviewed the NFPA 101 manual and created a policy on the installation of Sprinkler Systems in residential occupancies up to and including four stories in height. All Maintenance staff will be in serviced on the policy which states that where noncombustible stair shafts are divided by walls or doors, sprinklers are to be provided on each side of the separation in accordance with 2010 NFPA 13 8.15.3.2.2 (3/31/25). QA The Maintenance Director and Administrator developed an audit tool to ensure that Sprinkler Systems in residential occupancies where noncombustible stair shafts are divided by walls or doors, that sprinklers are provided on each side of the separation. There will be a visual check of all noncombustible stair shafts that are divided by walls or doors and ensure that sprinklers are provided on each side of the separation weekly for 3 months. All negative findings will be brought to the Maintenance Director and reported to the Administrator and addressed immediately. All findings will be reported to the QA committee quarterly. The QA committee will determine a schedule for ongoing audits if deemed necessary. Date of correction/responsible person: Maintenance Director is responsible. 4/25/25- Date of Correction.
Resident Abuse by CNA in Dining Room
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The incident occurred in the dining room when the resident threw a cup of water on the CNA's back, prompting the CNA to retaliate by slapping the resident on the back of the neck. This action was captured on the facility's video footage. The resident, who was moderately cognitively impaired with diagnoses including Non-Alzheimer's Disease, Bipolar Disorder, and Major Depressive Disorder, did not sustain visible injuries or report pain following the incident. The facility's policy on abuse prevention, which includes components such as screening, training, prevention, identification, investigation, protection, and reporting/response, was not effectively implemented in this case. The incident was reported by another CNA to the facility's Scheduler, who then informed the Director of Nursing. An investigation was initiated, and the video footage confirmed the physical abuse. The Director of Nursing and the Administrator were involved in reviewing the incident, and law enforcement was contacted, although they determined the act to be harassment rather than a criminal offense. Interviews conducted during the survey revealed discrepancies in the accounts of the incident. The CNA involved denied hitting the resident, while another CNA reported hearing yelling but did not witness the physical altercation. The Director of Nursing confirmed that the CNA slapped the resident and identified the cause of the incident as the resident's upset reaction to the television being turned off during mealtime, a routine practice in the facility. The facility concluded that abuse had occurred, and the CNA was removed from the schedule.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to ensure that Resident #2 received timely and appropriate care to prevent and treat a pressure ulcer. Despite being identified as at mild risk for developing pressure ulcers, Resident #2 did not have a care plan in place to address this risk. The resident developed an unstageable pressure ulcer on the sacrum, which was not promptly assessed or treated, leading to a stage 4 pressure ulcer with infection and subsequent hospitalization. Resident #2 was admitted with diagnoses including Peripheral Vascular Disease, schizoaffective disorder, and Delusional Disorders. The resident was moderately cognitively impaired and required extensive assistance with daily activities. Initial assessments indicated intact skin and a mild risk for pressure ulcers, but no care plan was developed to mitigate this risk. Weekly skin assessments failed to document the pressure ulcer until it was unstageable, and there was no evidence of treatment or physician orders for the ulcer until several days later. Interviews with staff revealed a lack of communication and responsibility in managing Resident #2's condition. Registered nurses and the Director of Nursing were unaware of the pressure ulcer until it had significantly worsened. The facility did not have a wound care nurse at the time, and high turnover among nursing staff contributed to the oversight. The attending physician and wound care consultant both indicated that the pressure ulcer was preventable with proper measures in place, but these were not implemented, resulting in harm to the resident.
Failure to Timely Report Investigation Results of Alleged Abuse
Penalty
Summary
The facility did not ensure that the results of all investigations of alleged violations involving abuse were reported to the State Survey Agency within 5 working days of the incident. This deficiency was evident for two residents reviewed for abuse. Specifically, the facility received a report that one resident inappropriately touched another resident. The initial incident report was submitted to the New York State Department of Health on the same day the staff was made aware of the incident. However, the follow-up investigation report was not submitted until 10 days later, which exceeded the required 5 working days timeframe. The facility's policy on Accident and Investigation Reporting, last reviewed on 10/20/2023, documented that the Director of Nursing (DON) and Administrator are responsible for investigating allegations and reporting findings within 5 working days. Interviews with the current DON and Administrator confirmed that the responsibility for reporting abuse allegations lies with the DON. Despite this, the follow-up report for the incident involving the two residents was delayed, leading to non-compliance with the state regulations.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. Specifically, the facility received a report that one resident inappropriately touched another resident. Although the facility initiated an investigation, it did not gather statements from staff members who may have potentially witnessed the allegation. The investigation was primarily based on interviews with the two residents involved, and the Director of Social Services concluded that the allegation was unfounded without interviewing frontline unit staff members. The facility's policies on Abuse Prevention and Accident and Incident Investigation and Reporting require thorough investigations, including obtaining statements from all relevant staff. However, the Director of Social Services did not interview the staff in the unit where the incident allegedly occurred, and the Director of Nursing, who was responsible for conducting a thorough investigation, had recently started working at the facility and was not involved in the initial investigation. The Administrator confirmed that it was the responsibility of the nursing supervisor on duty to initiate the investigation and gather statements from the staff present at the time of the alleged incident.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASRR) for individuals with mental disorders or intellectual disabilities was completed prior to admission. This deficiency was identified during an abbreviated survey, where it was found that a resident with diagnoses including Major Depressive Disorder and Schizophrenia was admitted without a completed Level I and Level II PASRR screening. The resident's Screen Form Department of Health-695 was dated after the admission date and was incomplete, lacking necessary responses to questions that would trigger a Level II evaluation. Additionally, the form was not signed by the resident or their legal representative, and there was no documented evidence of a Level II screening being conducted prior to admission. Interviews with facility staff revealed systemic issues in the preadmission screening process. The Director of Social Service admitted that preadmission documents were not reviewed before residents were admitted and that they were unsure how to proceed if the hospital did not complete the necessary forms. The Director of Admissions confirmed that it was their responsibility to ensure the completion and review of the Patient Review Instrument and Screen Form before admission. However, they acknowledged that the form for the resident in question was signed and dated after the admission, and critical questions were left unanswered, resulting in an incomplete screening process. The Administrator stated that the Director of Admissions was responsible for reviewing the Patient Review Instrument and Screen Form prior to admission to ensure appropriate placement. However, the Administrator did not personally review these documents, delegating the clinical review to the Director of Nursing. This lack of oversight and failure to adhere to the facility's policy led to the resident being admitted without the required PASRR evaluations, highlighting significant lapses in the facility's admission procedures.
Failure to Develop and Implement Abuse-Related Care Plans
Penalty
Summary
The facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident, as required by their policy. This deficiency was identified during an Abbreviated Survey, where it was found that two residents, who were reviewed for abuse, did not have a care plan related to abuse developed following an allegation of sexual abuse. Specifically, Resident #4 reported being sexually abused by Resident #5, but no care plan was created for either resident to address this allegation. Resident #4, who has diagnoses of Panic Disorder and Generalized Anxiety Disorder, and Resident #5, who has diagnoses of Acquired Absence of Right Leg Above Knee and Major Depressive Disorder, were both cognitively intact according to their Minimum Data Set assessments. Despite the grievance form documenting that there was no reasonable suspicion from the investigation, the facility failed to document any care plan addressing the abuse allegation. The Director of Nursing, who was new to the facility, stated that it was the responsibility of the Registered Nurses on duty to initiate and update care plans as soon as an abuse allegation was made.
Failure to Develop Effective Discharge Plan
Penalty
Summary
The facility failed to ensure an effective discharge plan was developed for a resident, focusing on the resident's discharge goals and preparation for post-discharge care. The resident, who had diagnoses including Failure to Thrive, Major Depressive Disorder, Bipolar Disorder, and Schizophrenia, was admitted to the facility and later discharged to the community without a discharge care plan. Despite the resident's intact cognition and limited assistance needs, no active discharge planning was documented in the Minimum Data Set, and a discharge care plan was not initiated during the resident's stay from admission to discharge. The facility's social services team, including the Director of Social Service and the Assistant Social Worker, acknowledged their responsibility for developing and implementing the discharge care plan but failed to do so. The resident's discharge process was complicated by pending guardianship proceedings, and although the resident expressed a desire to leave the facility and was eventually discharged to supported housing, the necessary discharge care plan was not created. Interviews with the social services staff revealed a lack of clarity and action regarding the discharge planning process, leading to the identified deficiency.
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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