Waterview Heights Rehabilitation And Nursing Cente

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents returning from the hospital or emergency department were assessed, that discharge instructions were reviewed, and that new orders were carried out for multiple residents. For one resident with quadriplegia, bladder dysfunction, benign prostatic hyperplasia, severe cognitive impairment, and an indwelling suprapubic catheter, the resident returned from the ED after the catheter was evaluated and urine was sent for culture, but there was no documented evidence of a return assessment, review of ED treatment, physician notification, or follow-up on the urine culture when the resident came back to the facility. That same resident later had a prescription for amoxicillin-clavulanate from the ED that was not documented as communicated to the physician, and the medication administration record did not show doses being given. The resident was later hospitalized with a worsening urinary tract infection. Another resident with UTI, hematuria, and acute kidney failure returned from the hospital with discharge instructions for urology follow-up, a basic metabolic panel in one week, and amoxicillin for enterococcus UTI, but there was no documented evidence that the ED treatment was reviewed on return, and the ordered labs and urology appointment were not documented as completed or scheduled before the resident was later sent back to the ED for hematuria. Additional residents had similar gaps in post-hospital care. One resident returned after an ED visit with instructions to stop acetaminophen, but three doses were administered before the order was discontinued. Another resident returned from the ED with a recommendation for gastroenterology follow-up, but there was no documented evidence that the appointment was scheduled. A resident who returned from the ED after abdominal pain and a UTI diagnosis had no documented review of the ED treatment, and another resident returned from the hospital with an antibiotic ordered twice daily but did not receive the bedtime dose on return or the morning dose the next day. The report also states there was no documented evidence of facility policies related to readmission procedures.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision to prevent accidents for residents at risk for elopement and falls. Resident #100 had dementia with psychotic disturbance and Parkinson’s disease, was cognitively severely impaired, and was identified as at risk for elopement with a wander alert device in place. On 10/18/2025, the resident was observed outside the facility attempting to open car doors in the parking lot and was redirected back inside. The incident record documented the resident had been last seen wandering on the unit shortly before being found outside, but there was no documented review of the care plan, no documented summary of the incident, and no documented report to the New York State Department of Health. The resident was placed on 30-minute checks by provider order, but those checks were discontinued the same day and one-hour checks were started without a documented order. The resident was later observed attempting to exit through stairwell doors, and staff were observed silencing door alarms without checking the area for residents. Testing also showed the wander alert system did not consistently alarm at stairwell doors. Resident #34, who had diagnoses including repeated falls and unsteadiness on feet, was at risk for falls and had a care plan directing non-skid socks while out of bed. After an unwitnessed fall on 11/13/2025, the resident was found on the floor with blood from the scalp and a scalp laceration. The medical provider ordered neurological checks for at least 72 hours, but there was no documented evidence that the neurological checks were completed as ordered. The resident was also observed out of bed on multiple occasions without the non-skid socks that were included in the care plan and Kardex. Resident #44 had dementia, glaucoma, and a history of falling, with severe cognitive impairment and multiple prior falls. The resident experienced repeated unwitnessed falls on 09/16/2025, 09/18/2025, 11/24/2025, and 12/08/2025. The record showed incomplete fall investigations, no documented review or revision of fall interventions after recurrent falls, and missing or incomplete neurological checks after some incidents. The resident’s care plan called for interventions such as appropriate footwear, bilateral floor mats, and investigation of the cause of falls, but observations showed the resident was repeatedly in bed or in a chair without the floor mats in place and with the bed not always in the low position.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

F684 - Quality of Care: When Residents #33, #42, #90, #179, #204, and #209 returned from a hospital or emergency department visit, nursing did not assess them, the physician was not made aware, and hospital recommendations for medical management were not reviewed or addressed. The facility did not have a process in place for residents returning from the hospital or emergency department to follow up on treatment, order or stop necessary medications or diagnostic testing, and/or schedule follow-up visits. This affected residents returning from the hospital or emergency department, and actual harm occurred to Resident #209. F677 - Activities of Daily Living: Resident #132 was not assisted with showering, incontinence care, personal hygiene, and getting out of bed as planned. F689 - Free of Accident Hazards/Supervision/Devices: Residents #34, #44, and #100 were not provided supervision to prevent accidents. Resident #100 eloped from the facility undetected. Resident #34 was at risk for falls, was not wearing no-skid socks as care planned, and did not have neurological checks completed following a fall. Resident #44 was at risk for falls, was not provided fall interventions as planned, interventions were not reviewed or revised after recurrent falls, neurological checks were not completed as ordered, and the falls were not thoroughly investigated. F865 - QAPI Program: The facility did not implement and maintain approved plans of correction from the prior extended recertification survey for multiple cited areas, including resident rights, environment, quality of life, ADL care, quality of care, pressure ulcers, accident hazards, dialysis, drugs and biologicals, nutrition, food safety, administration, disclosure, and infection control.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the interdisciplinary team determined whether a resident’s ability to self-administer medications was clinically appropriate. The resident had diagnoses including diabetes, depression, and high blood pressure, was documented as cognitively intact on the MDS, and had physician orders allowing self-administration of oral medications, insulin, and blood glucose checks. However, there was no documented evidence that the resident was assessed for the ability to safely self-administer medications, and the care plan did not document self-administration of medications or blood glucose monitoring. During observations, expired and discontinued medications were found in the resident’s private room, including blister packs of selegiline and losartan in a bathroom cabinet. An insulin pen was observed on the bedside table, along with used insulin needles stored in a fabric bag. On later observations, capped used needles remained in the fabric bag hanging from the over-the-bed tray table while the resident was in bed. The resident stated the needles in the bag were used and that nursing staff would bring a sharps container for disposal, while the sharps container and expired medications remained in the cabinet. Staff interviews indicated the resident had been self-administering medications since admission and was keeping blister packs at the bedside. An LPN stated the resident did their own blood glucose checks and administered their own insulin, and the unit manager stated the resident should not have expired or discontinued medications at the bedside and should not be keeping needles in the pouch. The assistant DON stated a self-administration assessment should be completed quarterly and was not aware that one had not been done for the resident.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a dependent resident received the necessary assistance with activities of daily living to maintain grooming and personal hygiene. The resident had multiple sclerosis, cerebral palsy, and depression, was cognitively intact, and was dependent for all ADLs. The care plan identified the resident as dependent for transfers, toileting, dressing, personal hygiene, and showering/bathing, with a mechanical lift and shower bed required for safety, and also identified the resident as incontinent of bowel and bladder with brief checks and changes every 2 to 4 hours as needed. During observations and interviews, the resident was repeatedly found in bed in a hospital gown, with greasy hair and facial hair that had grown into a beard and mustache. The resident stated they preferred short hair, wanted to be clean shaven, and felt staff did not listen to their needs. They reported they had to request care rather than it being offered, did not know their shower day, and felt they were not important enough to worry about. The resident also stated they asked daily to get up in a chair but were only getting up about once a week, and that the first shower they received after moving to the unit occurred only after several days on the unit. The record and observations showed inconsistent and delayed ADL care, along with documentation that did not match the resident’s condition or the timing of care. Several CNA flow sheets documented showers, shaving, brief changes, and transfers at times when the resident was still observed in bed or waiting for care, and one day had no ADL care documented on the day shift except a single brief change. Staff interviews indicated that care was sometimes documented at the end of the shift, that residents should be offered shaving daily and getting out of bed daily, and that staffing shortages made it difficult to complete care. The resident stated they felt abandoned and that staff made negative comments when providing care. The DON, LPN, CNAs, and physician all acknowledged that dependent residents should receive the assistance needed and that documentation needed to be accurate.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with a left lower leg fracture, peripheral vascular disease, and diabetes who was assessed as dependent for transfers and bed mobility and at high risk for pressure ulcers. The resident had a physician order for a left knee immobilizer to be removed every evening shift for skin integrity assessment and hygiene, and the care plan addressed an actual pressure ulcer and an unstageable wound of the left ankle. The orthopedic consultation documented the immobilizer was to be used for 6-8 weeks with non-weight bearing at all times. The resident developed an unstageable pressure wound on the back of the left ankle, and the initial wound evaluation documented the immobilizer caused friction and pressure to that area with necrosis. The physician noted the wound was most likely caused by the immobilizer, and another physician stated the wound was caused by the metal bar on the immobilizer rubbing while the resident was in bed. Although the treatment administration record documented daily immobilizer removal and skin checks, there was no documented evidence of refusals, while staff interviews and the resident stated the brace was not removed and refusals should have been documented. Staff also stated that if skin checks were not performed, it needed to be documented.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Resident #34 maintained acceptable nutritional status. Resident #34 had diagnoses including abnormal weight loss, dysphagia, and altered mental status, and the comprehensive care plan identified the resident as at risk for malnutrition and/or nutritional problems related to cognitive impairment, swallowing difficulty, need for a mechanically altered diet, and significant weight changes. The resident’s weight record showed repeated weight loss over several months, including 7.7% loss in three weeks, 9.5% loss in three months, 8% loss in one month, and 16.5% loss in six months. The registered dietitian documented unplanned weight loss and requested weekly weights for four weeks, but there was no documented physician order for weekly weights, no documented weekly weights, and no evidence that the comprehensive care plan was updated to include weekly weights. Staff interviews showed the dietitian sent electronic notifications about weight changes and needed weights to nursing leadership, and nursing leadership stated weekly weights required a physician order and should have been obtained when requested. The resident did not have documented weekly weights, and staff were unaware of any weight refusals.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide outside professional services when it did not employ a qualified professional to furnish the required service for one resident. Resident #17, who had diagnoses including sciatica and liver disease, had an assessment documenting intact cognition, independence with most activities of daily living, scheduled pain medications, and constant pain affecting sleep. A physician note documented complaints of pins and needles in both lower extremities and recommended a neurology follow-up for ongoing headaches and neuropathic pain, but there was no documented evidence that a neurology appointment was scheduled. Later physician and nurse practitioner notes continued to document intractable headaches and neuropathic pain in both legs, with the resident still waiting for a neurology appointment. A neurology referral order was entered for worsening headaches and signed off as completed by an LPN, yet the resident stated they were supposed to see a neurologist but did not have an appointment. Staff interviews indicated the unit clerk who scheduled appointments was not working when the consult was pending, and the physician stated outside appointments were expected to be scheduled after orders were entered and staff would be notified if there was a delay.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Surveyors observed the kitchen in disrepair, including cracked, missing, and uneven floor tiles, worn grout, peeling areas with exposed subflooring, damaged door thresholds, debris embedded in recessed grout lines, soil and grime along wall edges and in corners, and accumulated residue beneath kitchen equipment. Corrosion and buildup were also visible on plumbing beneath sinks and dishwashing equipment, and damaged shelving was present in the dry storage area. Surveyors also observed personal items stored on shelving with clean food service equipment, and frozen meat stored on a freezer shelf directly above uncovered pizza shells. The facility’s Food Storage policy required food to be stored to prevent contamination and cross-contamination, including raw animal foods on lower shelves and protected during storage. The Food Safety and Food & Nutrition Services Responsibilities policies stated kitchen environments and food storage areas were to be maintained in sanitary, clean, and safe condition, and the Hours of Operation policy required daily cleaning of food preparation and service areas. During interviews, the Director of Food Service stated environmental and maintenance staff were responsible for deep cleaning and physical repairs, but no current work orders had been submitted for the kitchen conditions. The Director stated floors were swept and mopped daily, but deep scrubbing and floor repairs were not completed routinely, and poor repair of some floor surfaces made effective cleaning difficult. The Director also stated storing meat above an unsealed box of pizza shells was not consistent with standard storage practice and could cause cross contamination. The Director of Maintenance and Environmental Services stated they were responsible for oversight of kitchen maintenance, relied on staff notification for issues, and were not aware of any recent work orders. The Administrator stated weekly kitchen audits focused on food temperatures, outdated food, and cleanliness of high-use equipment, and that flooring integrity and plumbing conditions were not a primary focus of those audits.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Administration failed to ensure the facility was operated in a manner that used its resources effectively and efficiently to support residents’ highest practicable physical, mental, and psychosocial well-being. The report states that policies and procedures were not properly identified, communicated, or consistently implemented, and that administration was not aware of the extent of the deficient practices cited. Deficiencies were identified in accident prevention, quality of care, ADL care for dependent residents, pressure ulcer prevention and treatment, quality of life, and infection prevention and control. The facility failed to ensure adequate supervision to prevent accidents for three of seven residents reviewed. One resident eloped in October 2025 after the wander alert system was reported not to be functioning correctly, and the resident was found outside. The Administrator stated that all doors on the second and third floors were supposed to alarm when a resident with a wander alert device approached them, that staff could shut off the alarms at the nursing station, and that the elopement was not reported to the NYS DOH because the reporting deadline had passed by the time the facility learned of the incident. The Administrator also stated they were not made aware the resident had been unattended in the parking lot until the following Monday. The facility also failed to ensure proper handling of hospital and emergency department returns, with paperwork not always received or reviewed, orders not consistently entered, and assessments not reliably completed within 24 hours. The Administrator stated there should have been a progress note when residents returned, that leadership used a text communication system for resident movement, and that they were not aware of hospital return issues for several residents. In addition, the facility did not follow up on a resident whose condition worsened and required hospitalization after antibiotics were missed, and there were no complete and thorough investigations for another resident’s falls. The Administrator stated the DON was responsible for investigations but was not completing them timely.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective QAPI program and did not implement or sustain the approved plans of correction from the prior Extended Recertification Survey for multiple cited areas, including Resident Rights/Exercise of Rights, Safe/Clean/Comfortable/Homelike Environment, Quality of Life, ADL Care, Quality of Care, Pressure Ulcer prevention and treatment, Accident Hazards/Supervision/Devices, Dialysis, Food/Nutrition services, Administration, Disclosure/Good Faith Attempt, and Infection Control. The undated QAPI plan stated that the program was intended to evaluate residents’ experience of services, integrate and coordinate all direct and indirect services, and monitor trends in nursing, food and nutrition, infection control, physician services, housekeeping and laundry, pharmaceutical services, and rehabilitation services. The Administrator stated the QAPI committee met monthly and reviewed high-risk, high-volume, and problem-prone areas using audits and feedback from staff, residents, and families, and that performance improvement plans were in place for dignity, environment, professional standards, weekly ADL audits, pressure ulcers/wounds, accidents, food services, medication storage, and infection control. Despite those stated processes, survey findings showed multiple unresolved deficiencies affecting resident care and facility operations. The facility did not ensure residents had a dignified existence in a safe, clean, sanitary, and homelike environment, and did not provide an environment that supported and enhanced quality of life for two residents. These findings were cited as Immediate Jeopardy. The facility also failed to ensure dependent residents received necessary ADL services to maintain grooming and personal hygiene for one resident, resulting in psychosocial harm. In addition, the facility failed to ensure treatment and care were provided in accordance with professional standards for six residents, including care related to pressure ulcer prevention and treatment for two residents. The survey further found that the facility did not provide adequate supervision to prevent accidents for three residents related to elopement and falls, which was cited as Immediate Jeopardy. The facility also failed to ensure a resident requiring dialysis received services consistent with professional standards, failed to provide palatable food and drink at an appetizing temperature, failed to maintain kitchen and food storage practices in a sanitary manner, failed to administer the facility in a way that enabled effective and efficient use of resources to attain or maintain resident well-being, and failed to maintain an infection prevention and control program for five residents. During interview, the Administrator stated they were not aware of identified concerns regarding quality of care related to hospitalizations, emergency room visits, and nursing documentation.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an infection prevention and control program for residents on transmission-based precautions and for staff influenza vaccination compliance. The report identified deficiencies involving six residents and five staff members, including failures related to hand hygiene, glove use, personal protective equipment, precaution signage, and mask use by unvaccinated staff. The facility policies reviewed required enhanced barrier precautions with gown and glove use for high-contact care, droplet precautions with signage posted outside the room, and influenza vaccination documentation or masking for unvaccinated employees. Resident #10 had diagnoses including a left lower leg fracture, peripheral vascular disease, and diabetes, and had an unstageable wound of the left ankle with enhanced barrier precautions ordered. During wound care, an LPN entered the room with a surgical mask and gloves, used scissors to cut off the old dressing, placed the scissors on the table next to clean supplies, used gloved fingers to remove dressing stuck to the wound bed, and then continued the dressing change without changing gloves. The LPN applied antiseptic gel with a gloved finger, used the same scissors to cut alginate for the new dressing, and completed the wound care. The LPN stated they should have removed the gloves after removing the old dressing, washed their hands, put on clean gloves, and not used the same scissors from dirty to clean. The infection control nurse stated hand hygiene was expected before starting a dressing change, between glove changes, and after completion, and the physician stated an infected pressure ulcer in a resident with diabetes and vascular disease had a higher risk of infection. Resident #77 had kidney disease and diabetes, severe cognitive impairment, and received dialysis. The care plan and physician order required enhanced barrier precautions every shift, but no precaution signage was posted outside the room on multiple observations. Staff interviewed stated they did not believe the resident was on transmission-based precautions because no sign was posted, and one RN thought the order might be wrong because it was from the prior year. The nurse manager later stated the resident was on enhanced barrier precautions because of a dialysis catheter and that staff should have known from the order and care plan. Residents #188 and #192 tested positive for COVID-19 and did not have droplet precaution signage posted outside their rooms, and staff were observed entering without appropriate PPE. Resident #217 was on enhanced barrier precautions and staff were observed providing care without appropriate PPE. Resident #17 was on droplet precautions and staff were observed entering without appropriate PPE. The report also documented multiple staff members in resident areas wearing masks improperly or not wearing them, including CNAs, an RN manager, and LPNs who were unvaccinated for influenza or had no documentation of vaccination or declination.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program in the main kitchen, and roaches were observed in multiple areas of the kitchen environment. The facility policy on pest control stated that it would implement a continuing and effective pest control prevention and monitoring program to keep the facility as pest and rodent free as possible. Third-party pest control reports documented repeated treatment activity in February 2026, including preventive applications near the dishwasher area and bathroom wall, treatment for German roaches in the kitchen, and a note that moderate activity was seen with heavy activity underneath the garbage disposal by the dishwasher. The vendor also identified the hole in the wall as a focus problem and recommended keeping the area dry and removing garbage at closing. Despite these findings, roaches were still observed in the main kitchen on 03/02/2026. Surveyors observed over 25 dead roaches and three crawling roaches in the women's bathroom, one dead roach near the microwave and cases of thickened juices, and several roaches on the floor, wall, and ceiling inside the dish room, including one roach dropping from the ceiling. Record review also showed the kitchen food disposal where the main roach concerns were was still being used even though it was broken, and the pest control technician noted that continued use would provide a constant source for roaches. During interviews, staff stated maintenance had to replace the garbage disposal pipe, the exterminator had asked to keep the hole open, fans had not been used as expected, and the area had leaks in the wall pipes with food going into the wall.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure residents had a dignified existence in a manner and environment that promoted quality of life for two residents and for five resident rooms reviewed. The report states that the facility policy on dignity required residents to be cared for in a manner that promoted quality of life, dignity, respect, and individuality, and that staff should keep residents informed and oriented to their environment, explain procedures before performing them, and tell residents in advance if they were going to be taken out of familiar surroundings. Resident #8 had diagnoses including Alzheimer's disease. The resident's MDS documented severely impaired cognition, no wheelchair use, no walking, and dependence for transfers. The care plan identified risk for functional decline in mobility and self-care related to weakness and cognition, with interventions including dependence with wheeling 50 and 150 feet and encouragement to use appropriate assistive devices. The resident was observed on multiple occasions seated in a padded reclining wheelchair and transported down the hallway toward the dining room while facing backwards. Resident #5 had diagnoses including schizophrenia and bipolar disorder. The resident's MDS documented severely impaired cognition, dependence for all ADLs, and no wheelchair use or walking. The care plan identified the resident as requiring assistance with self-care and mobility related to confusion and limited mobility, with interventions including dependence with wheeling 50 and 150 feet and encouragement to fully participate with each interaction. The resident was observed multiple times being transported in a padded reclining wheelchair while facing backwards, including into and through the dining room and down the hallway. In addition, five resident rooms were observed to be unclean and not homelike, including odors consistent with feces and urine, stained or stripped mattresses, missing sheets, a fly on a resident's leg, empty containers and clutter, scuffed and chipped furniture, a torn sheet used as a window covering, a torn bed sheet, and a soiled privacy curtain.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents resided in a safe, clean, sanitary, and homelike environment in multiple resident rooms and common/support areas. Observations on 12/02/2025 found a room with an odor consistent with feces and a mattress with a dark brown stain, another resident sleeping on a mattress without sheets with a fly on the resident's leg and empty beverage containers and a partially full cup on the bedside table, and an unoccupied room with a stripped bed and exposed mattress that had a strong urine odor. Additional room observations identified strong urine odors, scuffed and chipped furniture, a sheet tied to a curtain rod and used as a window covering, a torn bed sheet, and a soiled privacy curtain. Further observations on 12/03/2025 and 12/09/2025 identified environmental and sanitation concerns across units. Posted activity calendars in North 1 and [NAME] 1 reflected prior months, the South 1 medication room sink area was heavily soiled with visible residue and debris, and North 1 hallway flooring showed significant wear, discoloration, staining, cracked and chipped tiles, separations, uneven transitions, worn paint, and deteriorated lower walls. The North 1 dirty utility room door was marked with black marker. In the South 2 clean utility room, a used hairbrush with hair debris, a cloth garment, an empty soda can, cardboard boxes on the floor, dirt and residue on cabinets and shelving, and a winter coat stored on clean sheets were observed. A soiled incontinence brief was also seen on the floor in a resident room, and another resident room had missing paint, scuff marks, scratches, discoloration near an outlet, and an activity calendar that was dark and not legible. Additional observations in dining and utility areas showed rust and corrosion on the South 2 ice machine piping, peeling paint and residue on pipes, a stained floor, a plumbing connection wrapped with paper towels, and medication packaging, caps, personal drink containers, and residue on the ice machine surface. On 12/11/2025, the South 1 dining area ice machine had flexible tubing attached with plastic ties, an open funnel-style drain emptied into a plastic-lined trash receptacle containing dark liquid debris, and the surrounding floor tiles had discoloration, staining, accumulated dirt, moisture exposure, and rotted peeling baseboard. Interviews confirmed the South 1 medication room sink condition did not meet expected cleanliness standards, the clean utility room should contain only clean resident-care items and no personal items or beverages, and environmental issues were identified through staff reports without a formal inspection schedule or routine environmental audit process.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide ongoing, resident-centered activity programs for residents with identified interests and preferences, and failed to maintain unit-based activity programming on multiple units. The deficiency involved Residents #9, #104, and #184, as well as the South 3, North 1, and [NAME] 1 units. The facility’s activity policy stated programs were to be designed to meet each resident’s interests and support physical, mental, and psychosocial well-being, with activities offered based on the resident-centered assessment and preferences. Resident #9 had diagnoses including dementia, depression, and anxiety, and the MDS documented severe cognitive impairment and preferences for books, music, favorite activities, animals, group activities, and religious services. The care plan documented that the resident attended activity programs of interest/choice and could engage in television, walking on the unit, socializing, 1:1 visits, and outside time, with interventions to invite and escort the resident to activities and provide reminders and encouragement. The recreation quarterly assessment documented participation in small groups, large groups, and 1:1 activities, with a preference for on- and off-unit programs, the resident’s room, and outside settings. Despite this, the resident was repeatedly observed pacing the hallways without staff interaction and was not observed engaged in any activities, including during a live musical activity in the main lobby. Resident #104 had diagnoses including dementia, adult failure to thrive, and wandering. The MDS documented severe cognitive impairment and that it was very important to listen to music, keep up with the news, and do favorite activities; the recreation assessment identified interests including Bingo, books, cards, fresh air, movies, music, pet visits, spiritual/religious activities, and television/radio, with preference for small groups, large groups, and 1:1 settings. The care plan documented activity participation and interventions to invite and escort the resident to activities and provide reminders and encouragement. However, the resident was repeatedly observed pacing the hallway or sitting alone without interaction, and during interviews stated they liked music, dancing, polka, fast dance, guitar, and bongos, and reported there were no music activities at the facility. The resident was not present during the observed live musical activity in the main lobby. Resident #184 had diagnoses including dementia, depression, and anxiety. The MDS documented moderate cognitive impairment and preferences for books, music, animals, favorite activities, fresh air, and religious services. The record contained an unsigned recreation assessment identifying interests such as Bingo, current events/history, fresh air, movies, music, pet visits, spiritual/religious activities, and television/radio, but there was no documented evidence of a person-centered comprehensive care plan that included the resident’s activity preferences and no documented quarterly recreation assessment. The resident was repeatedly observed sitting or sleeping in a wheelchair in the hallway without interaction and was not present during the live musical activity in the main lobby. Staff interviews further documented that unit activities were not occurring on South 3 during the survey period. A CNA stated they had not seen activities on the unit, an LPN stated there were not currently any unit activities because there was COVID in the building, another CNA stated activities were held on the first floor and not on the unit, and an activity aide stated they had not done any unit-specific activities on South 3 for the past couple of weeks. The Director of Activities stated there should be unit-specific activities and that each resident was supposed to be invited to each activity every day. The survey also found no unit-specific activities conducted on South 3 from 12/02/2025 through 12/11/2025, the posted activity calendar on North 1 reflected November, and the activity calendar on [NAME] 1 reflected October.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an alleged elopement involving a cognitively impaired resident was reported immediately to the State Agency in accordance with State law. Resident #100 had diagnoses including dementia with psychotic disturbance and Parkinson's disease, had severely impaired cognition with fluctuating disorganized thinking and inattention, and was identified in the care plan as being at risk for elopement related to a change in environment and cognitive impairment. Interventions included checking the wander alert device each shift and monitoring the bracelet and device location. On 10/18/2025, Resident #100 was last seen wandering on the unit and was later observed outside by a CNA/concierge attempting to open car doors. The resident was redirected back inside, the supervisor, DON, and NP were notified, and an incident report documented that the wander alert device was checked and functioning, with the resident placed on one-hour checks. The incident report was signed off by the DON on 11/26/2025, but there was no documented evidence that the elopement was reported to the New York State Department of Health. During interviews, the DON stated the incident should have been reported within two hours, while the Administrator stated they were not made aware the resident was unattended in the parking lot until the following Monday and that the elopement was not reported because the reporting deadline had passed.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #121 was screened for a mental disorder or intellectual disability prior to admission, and the PASRR documentation was incomplete. The New York State Department of Health Form 695 documented that the resident had a serious mental illness, but the sections for Level II referrals and Level II recommendations were left blank, and there was no signature showing that a qualified screener completed the form. There was also no documented evidence that a Level II referral was completed for the resident. Resident #121 was admitted with diagnoses including anxiety, alcohol abuse history, and other psychotic disorder. The resident’s hospital discharge instructions documented admission for mental health stabilization and support after being found walking down the street in underwear and experiencing auditory hallucinations telling them to remove clothing. The discharge diagnosis was psychotic disorder. The care plan documented psychosis-related functional decline risk and later documented behavioral symptoms including socially inappropriate and verbally abusive behavior, physical aggression, accusatory statements, and racial slurs, but it did not document that the resident required a Level II screening for serious mental illness. Additional records showed the resident had escalating behavioral concerns after admission, including verbal aggression, physical intimidation, refusal of medication, and an emergency room transfer for aggressive and abusive behavior toward staff. Physician documentation noted the resident had been stabilized on the behavioral health unit and would benefit from social services, therapeutic recreation, and psychology support. Interviews with Social Work staff and the Director of Social Services confirmed the resident did not have a completed Level II screen and that they were not sure whether the resident required one, despite the resident having come from inpatient psychiatry for hallucinations and delusions.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents with limited range of motion received the ordered contracture management devices and related services. The deficiency involved Resident #132, who had diagnoses including multiple sclerosis, cerebral palsy, and muscle wasting, and Resident #170, who had diagnoses including spinal stenosis, rheumatoid arthritis, and muscle weakness. Both residents had care plans and physician orders for splints or contracture devices intended to address limited mobility and contractures. For Resident #132, the record showed orders for a left-hand carrot orthotic and bilateral ankle contracture boots to be removed daily for skin checks and hygiene and then reapplied. The resident was observed on multiple occasions without the ordered left-hand carrot splint and at times without the bilateral ankle boots, which were found on a nightstand, in a recliner, or on top of a dresser instead of on the resident. The resident stated the hand splints kept the fingers from curling into the palm and reported that the hand was getting worse and closing. Documentation on the nurse aide flow sheets and treatment records was inconsistent, with entries indicating the splints were in place when observations showed they were not. For Resident #170, the record showed orders for bilateral resting hand splints to be applied and removed by staff, with skin checks and hygiene care. The resident was repeatedly observed in bed without the splints on either hand, and there was no documented evidence that the resident refused the devices. Staff interviews reflected confusion about who was responsible for applying and removing the splints, and nursing documentation showed the splints were charted as completed even when they were not observed in place. The occupational therapist stated that if a resident was not wearing the ordered splint, the contracture could worsen, and the assistant director of nursing stated the resident should have been referred to OT if the splints were not being worn.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents receiving enteral nutrition were provided tube feeding and water flushes as ordered. There was no documented facility policy addressing enteral feeding administration. The deficiency was based on record review, observations, and interviews showing that one resident’s tube feeding formula was not administered at the ordered rate and another resident’s ordered enteral water flushes were not delivered as prescribed. One resident had cerebral palsy, dysphagia, recurrent ileus, severely impaired cognition, and received nutrition through a feeding tube. The care plan and physician orders directed Nutren 2.0 at 30 mL per hour for a total of 600 mL over 20 hours, with water flushes and monitoring for tube placement, residuals, and gastrointestinal symptoms. During observations, the feeding was found running at 60 mL per hour instead of the ordered 30 mL per hour. The pump showed 344 mL infused when the nurse stopped the feeding to give medications, and the nurse stated the rate should have been checked and the provider notified because the resident was not tolerating higher rates. The resident coughed up a white substance during medication administration, and the nurse later stated the feeding had been running incorrectly. The second resident had dementia, cerebrovascular disease, dysphagia, and received most nutrition and fluid intake through a feeding tube. Orders required Isosource 1.5 at 55 mL per hour and free water flushes of 60 mL every 2 hours. During observation, the water flush bag was almost completely full with a little over 1000 mL, while the pump showed zero mL infused for water flushes and the feeding pump was set to run at 55 mL per hour. The MAR only had a documentation area for one shift, and the unit manager stated signing the flush order confirmed the resident received the flushes as ordered, though she was unsure of the actual bag level or pump setting. The dietitian stated they were not notified that the resident had not received the ordered water flushes.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Safe, appropriate dialysis care/services were not provided for a resident with end stage renal disease, diabetes, severe cognitive impairment, and dependence on renal dialysis. The resident’s care plan required hemodialysis and monitoring for signs and symptoms of infection at the access site, obtaining vital signs and weight per protocol, and encouraging attendance at scheduled dialysis appointments. Physician orders also directed staff to check the hemodialysis catheter in the right chest every shift and document abnormal findings, and later ordered pre-dialysis and post-dialysis charting on dialysis days. The facility policy required a dialysis communication book for residents receiving outpatient dialysis, with pre-dialysis vital signs, labs, weight, access site evaluation, and relevant events documented before transport, and review of dialysis center communication after the resident returned. However, there was no documented evidence that the resident had a dialysis communication book or that facility communication sheets were provided to the dialysis center. The treatment administration record showed pre-dialysis and post-dialysis notes were to be completed, but for multiple dialysis days there was no documented evidence in the electronic medical record that the required pre-dialysis or post-dialysis notes were completed. Staff interviews showed inconsistent understanding of the dialysis communication process and documentation requirements. One RN stated residents were supposed to have a communication book and pre- and post-dialysis notes with vital signs, access site information, and weight, but the resident did not have a communication book and the RN was unsure why documentation was missing despite signing that it had been completed. An LPN manager stated the nurse was supposed to obtain vital signs and weight before dialysis but was unsure whether a communication book was required or what was sent to the dialysis center. The dialysis center RN manager stated they could not recall the resident being sent with a communication book or communication paperwork and reported that the center sent the resident back with a communication sheet after each treatment. The ADON/IP stated the nurse was responsible for completing pre- and post-dialysis evaluations and reviewing paperwork from the dialysis center, and that the nurse manager was responsible for ensuring these evaluations and ongoing communication occurred.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Drugs and biologicals were not stored in accordance with accepted professional standards for one resident who was cognitively intact and had diagnoses including diabetes, depression, and high blood pressure. The resident had a verbal physician order allowing self-administration of oral medications, insulin, and blood glucose checks, but there was no documented evidence that the resident was assessed for self-administration of medications. The resident’s room contained expired and discontinued medications, including a 30-day blister pack of selegiline 5 mg with a refill date of 01/2024 and a 30-day blister pack of losartan 100 mg with refill dates of 02/03/2025 and 03/02/2025, stored in the bathroom cabinet alongside a sharps container. During multiple observations, used insulin needles were found stored in a fabric bag near the resident’s bedside and hanging from the over-bed tray table, including six used needles on one observation and four used capped needles on another. The resident stated the needles in the felt bag were used and that nursing staff would bring a sharps container when needed. Staff interviews confirmed that discontinued medications should be removed from the room and that the resident should not have been keeping needles in the pouch, but expired or discontinued medications and used needles were still observed in the resident’s room.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food and drink were palatable, flavorful, and served at an appetizing temperature for one reviewed lunch tray. Facility policies required hot foods to be held above 135 degrees Fahrenheit and cold foods below 41 degrees Fahrenheit during holding, plating, and meal service, but the observed tray did not meet those standards. During the meal observation, Resident #2 agreed to have the lunch tray tested, and a replacement meal was immediately ordered. The tray ticket listed zucchini, but orange squash was served instead. Food temperatures taken in the presence of the RN Unit Manager showed corned beef hash at 109.2 degrees Fahrenheit, orange squash at 104.7 degrees Fahrenheit, diet ginger ale at 71.9 degrees Fahrenheit, pineapple at 57.2 degrees Fahrenheit, and tossed salad at 64.9 degrees Fahrenheit. The pineapple and ginger ale were described as warm and unappetizing. Earlier interviews also noted concerns about meal temperature, with one resident stating the food was never warm and the Ombudsman reporting that meal delivery was a resident concern because meals were cold. The Food Service Director stated that food temperatures were important to maintain food safety and palatability and that hot foods should be at least 135 degrees Fahrenheit while cold foods should be 41 degrees Fahrenheit or below.

Penalty

Inspection fine: $304,450

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Medicare beneficiaries received the required Notice of Medicare Non-Coverage (NOMNC) CMS-10123 and appeal rights information before skilled services ended for two residents. Resident #224 was discharged from the facility to home, and there was no documented evidence that the resident or resident representative received the NOMNC prior to discharge. Resident #223 was discharged to the community on 11/05/2025, and there was also no documented evidence that the NOMNC or appeal rights information was issued to the resident or resident representative before discharge. The CMS form instructions state that a completed NOMNC must be delivered to beneficiaries receiving covered skilled nursing services at least two calendar days before Medicare-covered services end, or the second-to-last day of service if care is not provided daily. During an interview on 12/11/2025 at 1:28 PM, Business Office Associate #16, who was responsible for beneficiary notices, stated the required notices were not issued because of a staffing transition in the department responsible for medical records and beneficiary notifications. The associate stated they were newly assigned to the responsibility, had not been oriented on the process and requirements, and that the notices were inadvertently missed during the transition.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple deficiencies during the extended recertification survey, including failures in abuse/neglect prevention, incontinence care, quality of care, pressure ulcer management, accident hazard prevention, sufficient staffing, medication administration, and infection prevention and control. The facility did not provide adequate supervision for residents on aspiration precautions during meals, resulting in at least one resident receiving the incorrect liquid consistency as ordered by the provider. There was also insufficient nursing staff to meet residents' needs for showers, eating assistance, toileting, personal hygiene, and medication administration, as confirmed by staff interviews and record reviews. Significant medication errors were documented, with no evidence that numerous residents received essential medications such as insulin, antihypertensives, antiplatelets, antidepressants, antipsychotics, antibiotics, antirejection medications, and medications for kidney disease over several days. Medication administration audit reports revealed that large numbers of residents did not receive multiple medications on multiple days. Infection prevention and control failures included the lack of further testing for Legionnaires' disease in residents diagnosed with pneumonia, failure to implement water disinfection measures after positive Legionella samples, and failure to report high Legionella positivity rates in the potable water system to the state health department. Additional deficiencies included neglect, such as not providing recommended hand splints to a resident, resulting in lost range of motion, and leaving a resident incontinent for extended periods, leading to psychosocial harm and skin breakdown. There was also a delay in notifying a medical provider and initiating treatment for new pressure ulcers. These findings were determined to have caused or were likely to cause serious harm, with several deficiencies resulting in Immediate Jeopardy.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of all residents, resulting in unmet care needs across multiple units. Observations and interviews revealed that on several occasions, there was only one nurse and one certified nursing assistant (CNA) assigned to units with up to 40 residents. This staffing shortage led to residents not receiving essential care such as showers, assistance with eating, toileting, personal hygiene, and timely administration of medications. Multiple residents reported waiting extended periods for assistance, including one resident who waited over 24 hours for help after soiling their bed due to illness. Other residents were observed with unwashed hair, uncut nails, and unchanged soiled clothing for hours, and some were left in stool for over five hours. The lack of adequate staffing also resulted in significant medication errors, with audit reports confirming that over 190 residents did not receive multiple medications on several days. Staff interviews corroborated that medication passes were missed due to insufficient nursing staff, and the medical director confirmed that residents did not receive their medications timely or at all. The facility's own staffing records showed that on certain shifts, the staff-to-resident ratios were as high as one CNA or nurse for every 40 to 73 residents, far below the facility's stated minimums. Staff frequently reported being unable to provide more than minimal care, and residents requiring two-person assistance or mechanical lifts often remained in bed without care. Grievances and resident council meeting minutes documented ongoing complaints about lack of showers, delayed call light responses, and missed medications. Staff, including the staffing coordinator and DON, acknowledged the chronic understaffing and its impact on resident care. The facility's payroll and punch records further confirmed sporadic and inadequate staffing levels, particularly on weekends and during emergencies, such as weather-related events. These deficiencies were observed and verified by the survey team, leading to the declaration of Immediate Jeopardy due to the likelihood of serious harm or death for residents.

Removal Plan

• Staffing is evaluated and adjusted as needed at the beginning of each shift to meet needs and acuity of the resident population, and the facility assessment is updated to reflect changes such as the temporary closing of a resident unit to help meet staffing needs.
• The facility policy and procedure includes details for minimum and emergency staffing and if staffing levels fall below minimum, the Director of Nursing and Administrator are contacted for direction.
• All facility department heads, nursing supervisors and ancillary staff receive education related to the facility's emergency staffing plan prior to the start of their next scheduled shift.
• Staffing coordinator, nursing supervisors, nurse managers and the Minimum Data Set Coordinator verify receipt of education related to the emergency staffing plan.
• New hires include certified nursing assistants, licensed practical nurses, a licensed practical nurse unit manager, and a registered nurse admissions nurse.
• The facility provides staffing agency agreements.
• The facility plans events to increase staff morale and retention.
• Resident census and staffing numbers for each residential unit are verified and deemed appropriate to meet the care needs of the current resident population.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as evidenced by multiple instances where residents did not receive prescribed medications over several days. For example, one resident with a history of kidney transplant and chronic kidney disease did not receive critical medications such as prednisone, nifedipine, and cyclosporine due to pharmacy delays and order entry errors. There was no documentation that the physician was notified of these missed doses, and in some cases, medications were administered at incorrect frequencies due to transcription errors from hospital discharge summaries. Staff interviews confirmed that nurses were responsible for entering and verifying orders, but lapses occurred, resulting in missed or incorrectly administered medications. Other residents with complex medical conditions, including end-stage renal disease, diabetes, bipolar disorder, and high blood pressure, also experienced missed doses of essential medications such as insulin, antihypertensives, antipsychotics, antidepressants, antibiotics, and antiplatelets. Medication Administration Records (MARs) showed blank entries for multiple medications on several days, with no documentation explaining the omissions or indicating that the medical team had been notified. Residents reported going extended periods without receiving their medications, and staff interviews revealed that staffing shortages contributed to the inability to administer medications as ordered. A facility-wide audit of medication administration revealed that a significant number of residents did not receive multiple medications on multiple days, affecting nearly the entire resident population. The Director of Nursing and Administrator acknowledged awareness of the issue, attributing it to staffing challenges and lapses in oversight. The Medical Director confirmed that all prescribed medications were significant and that missing doses, especially of antirejection medications, was unacceptable. The deficiency was determined to have resulted in the likelihood of serious injury, harm, or death for all residents in the facility.

Removal Plan

• The medical team was notified of all residents who had medication errors (missed medications), medical assessments were in process and daily vital signs were initiated and will be ongoing.
• 100% of all onsite day and evening shift licensed nursing staff education was completed and included the facility's policies Administering Medications and Adverse Consequences and Medication Errors, the missed medication daily review process and proper communication of staffing emergencies related to coverage.
• Interviews with licensed nurses onsite were completed to verify the above education including the evening nurse supervisor. An attestation that 100% of all facility licensed nurses including agency nurses would be educated prior to their next shift.
• A facility wide Medication Administration Audit Report for every shift for any missed or omitted medications will be conducted by the Nursing Supervisor or the Director of Nursing (or designee).
• Interviews with facility Administrator, Director of Nursing and Corporate Director of Nursing were completed regarding a root cause analysis of significant medication errors as related to staffing issues and plans initiated to prevent ongoing issues including closing one resident unit down and increased agency presence in the facility as needed.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies related to both waterborne pathogen management and direct resident care practices. Specifically, the facility did not provide further testing for Legionnaires' disease for residents diagnosed with pneumonia, did not implement short-term water disinfection control measures after receiving positive Legionella test results in the potable water system, and did not report water samples exceeding 30% positivity for Legionella to the New York State Department of Health. These lapses were identified through record reviews and interviews, which revealed that seven out of ten water samples tested positive for Legionella at one point, and follow-up sampling was delayed. Additionally, there was no documentation of required disinfection measures, and key staff, including the Medical Director and Director of Nursing, were not informed of the positive Legionella results, preventing appropriate clinical follow-up for residents with pneumonia. In addition to water management failures, the facility did not ensure proper implementation of enhanced barrier precautions and standard precautions during resident care. For one resident with a suprapubic catheter and bowel incontinence, staff did not wear the required personal protective equipment (PPE), failed to perform hand hygiene or change soiled gloves after incontinence care, and placed the resident's catheter drainage bag directly on the floor without a barrier. Another resident with a nephrostomy tube was not placed on enhanced barrier precautions as ordered, and staff provided care without appropriate PPE or signage indicating the need for such precautions. A third resident, dependent on staff for toileting hygiene, received incontinence care from staff who did not change gloves or perform hand hygiene before touching clean linens and environmental objects. Interviews with staff confirmed a lack of adherence to infection control policies, with several staff members acknowledging that they did not follow required procedures for glove changes, hand hygiene, and PPE use. The Director of Nursing stated that residents with indwelling medical devices should be on enhanced barrier precautions and that staff should change gloves and wash hands after incontinence care. The absence of an infection preventionist contributed to inconsistent implementation of infection control measures, as responsibilities for signage and PPE availability were not clearly assigned.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision or assistive devices to prevent accidents for residents on aspiration precautions. Multiple residents with diagnoses such as dysphagia, dementia, and cognitive impairment were observed eating meals without the required supervision or assistance, despite care plans and physician orders specifying the need for direct supervision, upright positioning, and thickened liquids. In several instances, residents were left alone in their rooms while eating, were not properly positioned, or were given liquids that were not thickened as ordered, resulting in coughing and increased risk of aspiration. Staff interviews revealed a lack of awareness regarding which residents required aspiration precautions and inconsistent practices in meal preparation and supervision. Additionally, the facility's dietary and nursing staff did not consistently ensure that meal trays matched the prescribed diet consistencies. For example, one resident received regular coffee instead of thickened liquids, and staff were unaware of the resident's dietary needs. Observations showed that staff often left residents unsupervised during meals, even when care plans required direct supervision or assistance. Staff interviews indicated that supervision was sometimes limited to walking by rooms or peeking in, rather than providing the direct oversight required for residents at high risk of aspiration. The facility also failed to address physical hazards related to heating surfaces in resident areas. Radiator covers and heating units in multiple rooms and common areas were found to have surface temperatures well above 125 degrees Fahrenheit, with some exceeding 150 degrees. These hot surfaces were accessible to residents, including those with wandering behaviors, and were located near beds, dining tables, and common areas. Maintenance staff did not keep records of temperature checks and were unaware of the potential hazard, despite the proximity of residents to these hot surfaces.

Removal Plan

• Review of residents identified to be on aspiration precautions, medical records, physician orders and care plans.
• Educate nursing, dietary and therapy staff, unit clerks, and resident assistants on aspiration precautions, checking meal tickets against tray contents, how to properly supervise and assist residents on aspiration precautions, and the correct procedure for feeding and recognizing signs of aspiration. Complete and review post-tests.
• Director of Dietary (or designee) to review meal tickets during tray preparation, and licensed staff to verify the meal tickets against meal trays for accuracy prior to passing.
• Review lunch trays on units to ensure correct food item consistencies, and interview staff to verify knowledge of the process.
• Review unit binders containing lists of residents on aspiration precautions and guidance on diet consistencies.
• Observe kitchen/dietary staff preparing thickened liquids before meal trays leave the kitchen.
• Review the facility's Aspiration policy.
• Ensure trays of residents on aspiration precautions arrive separate from other trays (per the facility's removal plan) and inform staff of the new process. Interview staff to verify knowledge of the new process.
• Observe staff supervising and assisting residents on aspiration precautions with meals.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple deficiencies related to neglect and insufficient care for residents, primarily due to inadequate nursing staff. Observations and interviews revealed that residents did not receive essential care such as showers, assistance with eating, toileting, personal hygiene, skin care, and timely administration of medications. Several residents were observed with unwashed hair, long uncut nails, and soiled clothing for extended periods. One resident was found incontinent for hours, with soiled linens and clothing, and staff were unable to recall when incontinence care was last provided. Staff consistently reported that low staffing levels made it impossible to meet all residents' needs, with some units having only one nurse and one aide for up to 40 residents. Residents with significant care needs, such as those requiring two-person assistance or mechanical lifts, often remained in bed and did not receive adequate care. One resident, who required hand splints to prevent loss of range of motion, was repeatedly observed without them, resulting in actual harm. Another resident developed two new stage two pressure ulcers, with no evidence that a medical provider was notified or treatments initiated until three days after the skin breakdown was identified. Staff interviews confirmed that medication passes were missed or delayed for many residents, with hundreds of residents not receiving multiple significant medications over several days due to lack of available nursing staff. The facility's own policies acknowledged the risk of neglect due to staffing deficiencies and required measures to address residents' needs. Despite this, staff and management interviews confirmed ongoing challenges with maintaining adequate staffing levels, leading to missed care, delayed or omitted medication administration, and insufficient supervision during meals for residents on aspiration precautions. Staff, residents, and family members all reported concerns about the inability to provide necessary care, and documentation supported that these deficiencies resulted in actual harm to residents, though not at the level of immediate jeopardy.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide treatment and care in accordance with professional standards for two residents. One resident with rheumatoid arthritis, spinal stenosis, and a history of falls was dependent on staff for all activities of daily living and had moderate cognitive impairment. Occupational therapy had recommended and trained staff to apply custom-made hand splints daily to maintain and improve hand range of motion. Despite these recommendations and documented progress during therapy, there was no documentation in the care plan, Kardex, or physician orders for the continued use of hand splints after discharge from therapy. Multiple observations confirmed the resident was not wearing splints, and interviews with staff revealed a lack of awareness and follow-through regarding the splint orders. The resident experienced a loss of range of motion, regressing to their initial condition upon admission, which was attributed to the lack of splint use and a breakdown in communication between therapy, nursing, and care planning staff. Another resident, recently readmitted with chronic kidney disease and a nephrostomy tube, did not have any orders or documentation for nephrostomy tube care or flushing upon admission. The treatment administration record showed no evidence of nephrostomy care, and observations revealed the tube was not properly dressed or secured. The resident was later found on the floor with a dislodged nephrostomy tube and was transferred to the hospital. Interviews with staff and the medical director confirmed that there should have been orders for dressing changes and tube flushing, and that the admitting nurse should have clarified care requirements with the provider. The facility was unable to provide documentation that nephrostomy care was included in the care plan or treatment record during the initial admission. Facility policies required that assistive devices and equipment recommendations be documented in the care plan and that nephrostomy tube care be based on physician orders, with staff responsible for monitoring and reporting issues. In both cases, the lack of proper documentation, communication, and follow-through led to residents not receiving care as recommended by professional standards and as required by facility policy.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with severe cognitive impairment, diabetes, and incontinence was identified as being at risk for pressure ulcers and had a care plan in place to minimize skin exposure to moisture and to monitor and report changes in skin status. Despite these interventions, the resident was repeatedly observed wearing wet clothing and lying on wet bedding with a strong odor of urine, indicating prolonged exposure to moisture. Staff failed to provide timely incontinence care, as the resident's wet clothing remained unchanged over several hours during multiple observations. On one occasion, staff observed an open area on the resident's buttock, but there was no documented evidence that a medical provider was notified or that any treatment was initiated for three days. The resident's medical and treatment records showed no documentation of skin impairment or treatment during this period. Interviews with staff revealed inconsistent accounts of when the skin breakdown was first noticed and whether it was reported to nursing staff. Some CNAs stated they notified a nurse, while others could not recall which nurse was informed. The nurse manager and the Director of Nursing were not made aware of the skin breakdown until days later. When eventually assessed by a nurse practitioner, the resident was found to have two stage 2 pressure ulcers. The facility's policy required daily skin inspections, prompt reporting, and documentation of changes, but these procedures were not followed. The delay in notification and initiation of treatment resulted in actual harm to the resident, as the pressure ulcers were not addressed in a timely manner.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple failures in the facility's main kitchen regarding food storage, preparation, and sanitation practices. Observations revealed that plates and warming covers were not properly air dried before being stacked, and kitchen floors were soiled with old grease and food debris. Food items in both the walk-in cooler and freezer were found undated and unlabeled, including a pan of jelly and a bag of donuts. Additionally, food items such as applesauce and thickened orange juice were stored directly on the floor in the dry storage room. Staff members with visible facial hair were observed working in the kitchen and dish room without wearing required beard guards. A stove top was found dirty with grease and food debris from previous meals, and a wall-mounted fan and ceiling tiles near the tray line were coated with heavy dust. Further observations included a carton of milk past its expiration date in a refrigerator, and trays of food containing perishable items left at room temperature on a counter. A container of yogurt labeled for a resident was also found sitting on a nurse's station counter at 83.1 degrees Fahrenheit. Dietary staff confirmed that foods should be labeled, dated, and stored properly, and that kitchen floors should be cleaned after each meal. However, these standards were not consistently followed, as evidenced by the conditions observed during the survey.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. Specifically, the administration did not ensure that residents on aspiration precautions were supervised during meals, resulting in Immediate Jeopardy for 33 residents. Additionally, the facility did not prevent significant medication errors, as audit reports revealed that a large number of residents did not receive multiple medications over several days, which was confirmed by staff interviews and record reviews. These failures resulted in Immediate Jeopardy and substandard quality of care for all residents in the facility. The facility also did not provide sufficient nursing staff to meet the needs of residents, as required to maintain their physical, mental, and psychosocial well-being. There were repeated deficiencies in ensuring that dependent residents received timely assistance with activities of daily living, such as bathing and grooming, with several residents reporting not having showers for weeks and being observed with unwashed hair, uncut nails, and unshaven. Furthermore, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, including failures related to hand splint use and nephrostomy tube care, which resulted in actual harm to at least one resident. The infection prevention and control program was also found to be deficient. The administrator was aware of positive Legionella results in the water system for an extended period but did not report this to the state health department, address the system issue, notify the medical director or DON, or ensure that residents with pneumonia were tested for Legionnaire's Disease. The administrator acknowledged awareness of some ongoing issues, such as insufficient staffing and medication errors, but was not aware of other care deficiencies and stated that audits were only being conducted quarterly.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and implement effective procedures and clear communication methods between the administrator and the governing body, resulting in multiple serious deficiencies. The Quality Assurance and Performance Improvement (QAPI) steering committee, which was supposed to include regional and corporate leadership, did not have their attendance documented at monthly meetings for several months. The QAPI committee was also not aware of several issues identified during the survey, and there was no corporate infection control oversight in place. Deficiencies included failure to provide adequate supervision to residents on aspiration precautions during meals, with incorrect liquid consistency provided to one resident, placing 33 residents at risk for serious harm or death. There were also significant medication administration errors, with no documented evidence that all residents received their prescribed medications over multiple days, including critical medications such as insulin, antihypertensives, antiplatelets, antibiotics, and others. Staff interviews confirmed that inadequate nursing staffing led to missed medication administration for the entire resident census. Additional deficiencies were identified in the areas of resident care and infection control. One resident did not receive recommended hand splints, resulting in loss of range of motion, and another did not have orders for nephrostomy tube care for an extended period. Infection control lapses included staff failing to use appropriate personal protective equipment and perform hand hygiene during care, improper handling of catheter drainage bags, and failure to implement required measures after Legionella was detected in the water system. The facility did not notify the health department or conduct follow-up testing as required, and residents with pneumonia were not tested for Legionnaires' disease per policy.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the implementation and maintenance of an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by the lack of good faith attempts to develop, implement, and sustain appropriate plans of action to address previously identified issues impacting resident safety and quality of care. Specifically, the facility did not follow through on the approved plans of correction from a prior survey for multiple areas, including resident rights, response to resident/family groups, environmental safety and cleanliness, activities of daily living for dependent residents, quality of care, pressure ulcer prevention and treatment, sufficient nursing staff, proper labeling and storage of drugs and biologicals, and sanitary food procurement and preparation. During the survey, it was found that the QAPI committee, led by the Administrator, met monthly and was aware of some issues such as staffing and kitchen sanitation. However, the committee was not aware of ongoing concerns in several other critical areas, including resident rights, group responses, environmental conditions, daily living care, pressure ulcer management, and infection prevention. This lack of awareness and follow-through resulted in repeat citations for the same deficiencies previously identified, indicating that the facility's QAPI processes were not effectively addressing or resolving these ongoing issues.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to designate a qualified individual as the Infection Preventionist (IP) responsible for the infection prevention and control program, as required by policy and regulation. According to the facility's policy, the IP is responsible for ongoing surveillance of healthcare-associated infections, determining the need for laboratory tests and special precautions, and gathering and interpreting surveillance data. During the survey, it was found that the Director of Nursing (DON) was serving as the IP but had not completed any specialized infection control training and was not certified. The previous IP had resigned a month prior, and since then, the DON, with assistance from nursing leadership, had been overseeing the infection control and antibiotic stewardship program without the required qualifications. Interviews with facility leadership confirmed that there was no certified IP in place at the time of the survey. The Administrator acknowledged the absence of a certified IP and stated that the DON was managing the program to the best of their ability. The Regional DON also confirmed that there was no corporate IP available and that two newly hired Assistant Directors of Nursing would be trained and certified in the future. No specific residents or patient conditions were mentioned in relation to this deficiency.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Multiple deficiencies were identified regarding the failure to honor residents' rights to dignity, respect, and privacy. In one instance, a resident with severe cognitive impairment and hemiparesis was observed in a public hallway wearing only a t-shirt and incontinence brief, with the brief visible to others, despite being dependent on staff for dressing and mobility. Another resident with dementia and severe cognitive impairment had a sign posted above their bed stating 'I AM A FEEDER,' which was placed by staff to indicate the need for eating assistance. The sign was not requested by the resident or their family and was considered undignified by both the family and facility management. Staff were also observed eating take-out food in a designated resident space (the sunroom) while two residents, both with severe cognitive impairment, were present and eating their lunch. This action was contrary to facility policy, which designated the sunroom as a resident-only area. Additionally, in a four-person room, a resident had to move out of their chair to allow staff to use a mechanical lift for their roommate, resulting in a lack of privacy for the resident being transferred. The limited space in the room prevented staff from maintaining appropriate privacy during the transfer. Interviews with facility leadership confirmed that these actions were inconsistent with facility policy, which requires residents to be treated with dignity and respect, prohibits undignified signage, and mandates the protection of resident privacy, including bodily privacy during care. The Director of Nursing acknowledged concerns about privacy in multi-occupancy rooms and confirmed that staff should not eat in resident spaces or post undignified signs.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that grievances and recommendations from the Resident Council regarding resident care and life in the facility were acted upon promptly. Multiple residents voiced concerns during a special Resident Council meeting about delayed call light responses, untimely medication administration, and insufficient assistance with activities of daily living such as bathing and showering. Review of meeting minutes and grievance records over several months revealed repeated reports of these issues, including lack of showers, not being assisted out of bed, and inadequate staffing. However, there was no documented evidence that these grievances were investigated or addressed in a timely manner, nor was there follow-up communication to residents regarding the status of their complaints. Facility policy required that grievances be investigated within three working days and that immediate action be taken to prevent further violations of resident rights. Despite this, interviews with facility leadership confirmed that grievances discussed in Resident Council meetings were written up and distributed to relevant departments, but there was no process in place to ensure that concerns were resolved or that old business was discussed in subsequent meetings. No audits were conducted to verify resolution of grievances, and meeting minutes lacked documentation of follow-up actions taken by staff.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple deficiencies in the facility's provision of a safe, clean, comfortable, and homelike environment across several resident units and both basements. Observations included persistent heavy urine and fecal odors in common areas, dirty and damaged floors and walls, jagged door frames, and malfunctioning or unclean equipment such as mechanical lifts, weight scales, and shower stretchers. Plumbing fixtures were found to be in disrepair or non-functional, and trash receptacles were missing lids or were cracked, with garbage bags left on the floor. Resident rooms and common areas were cluttered, with personal items stored in disarray, and lacked adequate space or fixtures for hanging personal belongings. Specific resident rooms were noted to have limited accessibility due to furniture placement, with pathways to bathrooms narrowed to less than the required width for wheelchair access. Privacy curtains were either soiled or did not provide full visual privacy, and some rooms lacked outside windows or direct access to natural light. In one instance, a resident reported discomfort due to excessive room temperature, which was confirmed by thermometer reading, and the room was described as bare and lacking decorations, with a bulletin board falling off the wall. Additional findings included damaged and rusted door frames, holes and cracks in walls, missing or damaged floor tiles, and accumulation of various items and debris in the basement. Shared closet space was insufficient for the number of residents in some rooms, and there was a lack of individual storage. The facility failed to maintain sanitary and orderly conditions, as evidenced by soiled equipment, non-functional sinks, and improper storage of medical and personal items.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to provide necessary care and assistance with activities of daily living (ADLs) for residents unable to perform these tasks independently. Multiple residents were observed over several weeks with poor personal hygiene, including unwashed hair, long and dirty fingernails, and unshaven faces. Documentation and staff interviews confirmed that showers and incontinence care were not consistently provided or recorded, and that some residents went extended periods without basic hygiene care. In several cases, staff cited insufficient staffing as a reason for missed care. One resident with severe cognitive impairment and incontinence was repeatedly observed with soiled clothing and linens, emitting a strong odor of urine, and with long, dirty fingernails. Staff could not recall when this resident last received incontinence care, and documentation was lacking. Another resident, cognitively intact but dependent on staff for bathing, reported not having a shower for three weeks, with no documentation of showers for the prior 30 days. Staff confirmed that showers were missed due to lack of available personnel. Additional residents dependent on staff for all ADLs were found with greasy, unwashed hair, soiled clothing, and long, uncut nails. Visitors and staff interviews corroborated that showers and hair care had not been provided for several weeks. Documentation of care was incomplete or missing, and staff were often unaware of when residents last received hygiene care. The facility's own policies required documentation of showers and interventions for refusals, but these were not consistently followed.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to ensure proper storage and security of drugs and biologicals on three of seven resident care units. Specifically, 218 blister packs of resident-specific prescription medications were found left on a counter and in unlocked cabinets behind the North One nurses' station. An LPN confirmed these were overflow medications that did not fit into the medication carts and acknowledged that the cabinets did not have a key, stating that medications should be stored in a locked area. Additionally, a five-drawer medication/treatment cart containing dozens of topical prescription medications was observed unlocked in the North Two hallway. Further observations revealed that the South One medication storage room was left unlocked with no staff present, and a resident was seen ambulating nearby. Inside the room, the medication refrigerator containing multiple medications was also unlocked, and several blister packs of prescription medications were left on the counter. Two medication/treatment carts in the South One hallway were also found unlocked and open, containing dozens of oral and topical prescription medications. The DON confirmed that all medications, including topicals, should be locked in a medication or treatment cart, cabinet, or medication room.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors found that the facility failed to ensure food and drink were served at safe and appetizing temperatures for residents on the South One Unit. Observations and interviews revealed that multiple residents received meals that were cold, unpalatable, and not in compliance with the facility's own food safety policy. During a test tray evaluation, hot food items such as corned beef, potatoes, and cabbage were served at temperatures well below the required 135 degrees Fahrenheit, while cold items like apple juice were above the recommended 41 degrees Fahrenheit. Residents reported that their meals were consistently cold, dry, and lacked flavor, with some refusing to eat the food provided. The deficiency was further substantiated by staff interviews and direct observation of the meal service process. The tray cart used for meal delivery lacked insulating doors and was only covered with a plastic bag, contributing to the temperature drop during the extended tray line process, which took about two hours. Staff acknowledged that both hot and cold foods were not maintained at appropriate temperatures, and that delays in tray delivery by nursing staff exacerbated the issue. The Registered Dietician was not available for comment during the survey.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During an extended recertification survey, it was observed that the facility failed to comply with state building construction standards for nursing homes, specifically Subpart 713-1, for units South One, South Three, and North Two. Beds in multiple resident rooms were found to be less than three feet from adjacent radiators and windows, with some beds as close as six inches to a radiator or one foot from a windowsill. In several rooms, beds were also placed less than three feet apart from each other. Additionally, one resident room lacked an outside window, instead having a cutout in the wall leading to a sunporch, with the connecting door padlocked. Windowsills in several rooms were measured at 3 feet 10 inches above the floor, exceeding the allowed height. These findings were based on direct observations of room layouts and measurements taken during the survey. Interviews with staff, including an LPN, confirmed that the arrangement of beds made it difficult for emergency medical services to access residents and for staff to use mechanical lifts in four-person rooms. The lack of space also limited the ability of families to visit comfortably. The deficiencies were identified in multiple rooms across the affected units, with specific measurements and room conditions documented by surveyors.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required membership and meeting attendance as specified by regulation. Record review showed that the QAA Committee did not consistently include the Infection Preventionist or the Medical Director or their designee at meetings from October 2024 to February 2025. Specifically, the Infection Preventionist was not present at any meetings during this period, and the Medical Director or designee was absent from the January and February 2025 meetings. Interviews revealed that the facility did not have a certified Infection Preventionist at the time of the survey due to a recent resignation, and the Medical Director had not attended meetings, with only occasional attendance by a medical provider serving as a designee. The facility's QAA and Performance Improvement Plan required these roles to be present, but documentation and staff statements confirmed that these requirements were not met during the review period.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to thoroughly investigate an incident involving a resident who was found unresponsive after an unwitnessed fall in front of the nurse's station. The resident, who had diagnoses including diabetes, depression, and hypertension, was cognitively intact and required supervision with eating and ambulation. The resident was on a pureed diet with thin liquids and had a history of putting foreign objects in their mouth. On the day of the incident, the resident was found lying on the floor, unresponsive but breathing, with a mushy substance coming from their mouth. Staff performed the Heimlich maneuver and initiated a code blue, but the resident was later pronounced deceased after unsuccessful resuscitation efforts. The facility's documentation of the incident was incomplete, lacking statements from all involved staff or potential witnesses and failing to provide evidence of a thorough investigation to rule out abuse, neglect, mistreatment, or care plan violation. The facility's policies required immediate and comprehensive investigation of such incidents, but the investigation did not address possible choking as a factor, despite staff performing the Heimlich maneuver. The Director of Nursing acknowledged that the investigation did not consider choking as a possible cause, and the available reports were insufficiently detailed to determine the circumstances surrounding the incident.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of acute kidney injury, obstructive uropathy, urogenital implants, urinary retention, and dementia was admitted with an indwelling urinary catheter. Upon admission, there were no physician orders for routine catheter care, and the comprehensive care plan did not address the presence of the catheter or include related goals and interventions. The hospital discharge summary indicated the need for a voiding trial and scheduled catheter change, but only an order for monthly catheter change and urology follow-up was documented, with no specific instructions for ongoing catheter care. Shortly after admission, the resident was found attempting to remove the catheter and was later discovered to have pulled it out. Attempts to reinsert the catheter were unsuccessful due to the resident's resistance, and the supervisor was notified. Documentation in the 24-hour report sheet reflected the removal and refusal of replacement, but the medical team was not notified of the incident at the time. Subsequent nursing and medical progress notes did not mention the catheter or its removal, and the resident was later transferred to another unit without a catheter. Interviews with nursing staff and providers revealed that catheter care should have been ordered and included in the care plan upon admission. The physician was unaware of the catheter removal and stated they should have been notified. The DON confirmed that the care plan and orders were incomplete and that the provider should have been informed when the catheter was pulled out and could not be reinserted. The lack of appropriate orders, care planning, and timely provider notification led to the deficiency.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate dialysis care for a resident with chronic kidney disease, diabetes mellitus, and morbid obesity who was dependent on dialysis. There were no physician orders in place regarding post-dialysis care or monitoring of the resident's permcath site. Additionally, there was no documented evidence in the electronic health record or 24-hour nursing reports that the permcath site was assessed for complications such as bleeding or infection upon the resident's return from dialysis treatments, as required by facility policy and the resident's care plan. Observations confirmed that the resident's permcath was visible, with the dressing dry and intact, and the resident reported that staff did not assess or monitor the site after dialysis. Interviews with nursing staff and the Director of Nursing revealed a lack of clarity regarding post-dialysis care orders and confirmed that vital signs and site assessments should be performed and documented, but this was not being done. The physician interviewed also expected post-dialysis assessments and documentation, which were not present in the resident's records.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Two residents with dysphagia did not receive food and liquids prepared in the appropriate consistency as ordered by their physicians and recommended by speech-language pathologists. One resident, with a history of dysphagia and moderate cognitive impairment, was on a pureed diet with honey-thickened liquids and aspiration precautions. During a meal observation, the resident was found drinking unthickened hot water and milk, resulting in coughing episodes, while the thickener packet remained unopened. The LPN present was an agency nurse unfamiliar with the residents and did not ensure the liquids were thickened as required. Another resident, also with dysphagia and moderate cognitive impairment, was ordered a dysphagia Level Two (ground solids) diet with thin liquids and aspiration precautions. The resident's meal ticket specified pureed braised cabbage, but the lunch tray contained shredded cabbage that was not pureed. Staff initially misidentified the food consistency, and the speech-language pathologist later confirmed it was not pureed as required. Facility policies specified the need to adhere to prescribed food and liquid consistencies, but these were not followed for the two residents.

Penalty

Inspection fine: $185,840

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A multiple resident bedroom was found to have insufficient usable space per resident during an extended recertification survey. Specifically, a room housing four residents measured 340 square feet, excluding the bathroom, but after subtracting the space occupied by wardrobes and nightstands, only 313 square feet of usable space remained. This resulted in each resident having 78.25 square feet, which is below the required minimum of 80 square feet per resident for multiple occupancy rooms. Observations confirmed four residents occupying the room, and an interview with one resident revealed that the room was originally intended for three people, but a fourth resident was added after staff measured the space.