Waterview Heights Rehabilitation And Nursing Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester, New York.
- Location
- 135 Meridan St., Rochester, New York 14612
- CMS Provider Number
- 335082
- Inspections on file
- 25
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 40 (2 serious)
Citation history
Health deficiencies cited at Waterview Heights Rehabilitation And Nursing Cente during CMS and state inspections, most recent first.
Surveyors found widespread failures including lack of supervision for residents on aspiration precautions, insufficient nursing staff to meet basic care needs, significant medication errors affecting many residents, and inadequate infection control measures such as failure to address Legionella in the water system. Additional issues included neglect of residents' personal care and delayed treatment for pressure ulcers, resulting in actual harm and Immediate Jeopardy.
A facility failed to maintain adequate nursing staff, resulting in residents not receiving essential care such as showers, toileting, and timely medication administration. Staff-to-resident ratios were critically low, with only one nurse and one CNA for up to 40 residents on some shifts. Multiple residents experienced prolonged waits for assistance, missed medications, and inadequate supervision, as confirmed by staff interviews, resident complaints, and audit reports.
Surveyors found that multiple residents with complex medical needs did not receive essential medications, including insulin, antihypertensives, antipsychotics, antibiotics, and antirejection drugs, over several days. MARs showed numerous missed doses without documentation or physician notification, and staff interviews revealed that pharmacy delays, order entry errors, and staffing shortages contributed to the failures. Facility-wide audits confirmed that a large number of residents were affected by missed or omitted medications.
The facility failed to implement effective infection control practices, including not testing residents with pneumonia for Legionnaires' disease after positive Legionella water results, not promptly disinfecting the water system, and not reporting high Legionella positivity to health authorities. Additionally, staff did not consistently use required PPE or perform hand hygiene during high-contact care for residents with indwelling devices or incontinence, and infection control signage and precautions were not properly maintained.
Multiple residents with swallowing difficulties and cognitive impairment were left unsupervised during meals, not properly positioned, or given incorrect liquid consistencies, despite care plans requiring direct supervision and specific dietary modifications. Staff were often unaware of which residents required aspiration precautions, and meal preparation did not consistently match prescribed diets. Additionally, radiator covers and heating units in resident areas were found to have dangerously high surface temperatures, accessible to residents, including those with wandering behaviors.
Surveyors found that insufficient staffing led to widespread neglect, with residents missing essential care such as showers, incontinence care, and medication administration. Some residents were left soiled for hours, developed pressure ulcers without timely intervention, or did not receive prescribed hand splints, resulting in actual harm. Staff reported being unable to meet residents' needs due to low staffing, and hundreds of residents missed significant medications over several days.
Two residents did not receive care in accordance with professional standards: one did not have recommended hand splints applied after therapy discharge, resulting in lost hand range of motion, and another did not have orders or documentation for nephrostomy tube care, leading to improper management and tube dislodgement. In both cases, there was a lack of documentation, communication, and follow-through among staff, resulting in harm.
A resident with severe cognitive impairment and incontinence was repeatedly left in wet clothing and bedding, leading to the development of pressure ulcers. Staff observed an open area on the resident's buttock but failed to promptly notify a medical provider or initiate treatment for several days. Documentation and communication lapses among CNAs, LPNs, and nursing management resulted in a delay in care, and the resident was later found to have two stage 2 pressure ulcers.
Surveyors found multiple food safety and sanitation deficiencies, including improper air drying and stacking of plates, soiled kitchen floors, undated and unlabeled food items, food stored on the floor, expired milk, perishable foods left at room temperature, dirty equipment, and staff not wearing required beard guards. These issues were confirmed by dietary staff and observed throughout the kitchen and food storage areas.
The facility failed to ensure effective administration, resulting in unsupervised meals for residents on aspiration precautions, significant medication errors affecting nearly all residents, insufficient nurse staffing, and repeated failures in providing timely ADL assistance and professional care. The infection control program was also inadequate, with unreported Legionella findings and lack of appropriate follow-up. These deficiencies led to Immediate Jeopardy and actual harm.
The facility did not ensure effective oversight and communication between the administrator and governing body, resulting in missed QAPI meetings by regional leadership, unawareness of critical issues, and lack of corporate infection control oversight. Residents on aspiration precautions were not properly supervised during meals, and all residents experienced missed medication administration due to inadequate nursing staff. Additional failures included improper use of hand splints, lack of nephrostomy tube care orders, and significant infection control lapses, including improper PPE use and failure to address Legionella in the water system.
The facility did not implement or maintain approved plans of correction for previously identified deficiencies in areas such as resident rights, environmental safety, ADL care, pressure ulcer management, staffing, drug storage, and kitchen sanitation. The QAPI committee was unaware of several ongoing issues, resulting in repeat citations for the same deficiencies.
The facility did not have a qualified or certified Infection Preventionist overseeing its infection prevention and control program, as required by policy. The DON, who lacked specialized infection control training and certification, was managing the program after the previous IP resigned, and there was no corporate IP available. Leadership confirmed the absence of a certified IP and stated that newly hired staff would be trained in the future.
Surveyors found that several residents were not treated with dignity or respect, including a resident left in a hallway with their incontinence brief exposed, another with an undignified sign above their bed, and two residents present while staff ate take-out food in a resident-only area. In a shared room, a resident's privacy was compromised during a mechanical lift transfer due to space limitations. Facility leadership confirmed these actions violated policy on resident dignity and privacy.
The facility did not promptly investigate or address care concerns raised by residents through grievances and Resident Council meetings, including issues with call light response times, medication administration, and personal care. There was no documented follow-up or evidence that these concerns were resolved, and leadership confirmed that no audits or systematic reviews were conducted to ensure grievances were addressed.
Surveyors found widespread deficiencies in housekeeping and maintenance, including persistent odors, dirty and damaged surfaces, malfunctioning equipment, cluttered and inaccessible resident rooms, inadequate privacy, and insufficient storage. A resident reported discomfort due to excessive heat, and several areas lacked proper sanitation and homelike features.
Surveyors found that several residents dependent on staff for ADLs did not receive regular showers, incontinence care, or grooming, resulting in poor hygiene such as unwashed hair, soiled clothing, and long, dirty nails. Staff interviews and documentation revealed missed care due to staffing shortages and lack of proper record-keeping.
Surveyors found that prescription medications, including blister packs and topical drugs, were left unsecured in multiple areas, such as unlocked cabinets, medication carts, and a medication room. An LPN and the DON confirmed that medications should have been locked, but overflow and lack of keys led to improper storage.
Surveyors identified that food and beverages were served at suboptimal temperatures, with hot items being cold and cold items being lukewarm, resulting in unpalatable meals for several residents. Staff interviews and direct observation confirmed that improper meal delivery practices and inadequate equipment contributed to the deficiency.
Surveyors found that beds in several units were placed less than three feet from radiators, windows, and other beds, and some rooms lacked required outside windows or had windowsills set too high. An LPN reported that these arrangements hindered EMS access and the use of mechanical lifts, and limited space for family visits.
The QAA Committee did not consistently include the Infection Preventionist or the Medical Director or their designee at required meetings, as shown by attendance records and staff interviews. The facility lacked a certified Infection Preventionist due to a recent resignation, and the Medical Director had not attended meetings, with only occasional attendance by a medical provider as designee.
A resident with multiple medical conditions and a history of behavioral issues was found unresponsive after an unwitnessed fall, with staff observing a mushy substance in the mouth and performing the Heimlich maneuver. Despite facility policy requiring immediate and comprehensive investigation, documentation was incomplete and did not include statements from all involved staff or address possible choking as a cause, resulting in a failure to rule out abuse, neglect, mistreatment, or care plan violation.
A resident with significant urinary and cognitive issues was admitted with an indwelling urinary catheter, but there were no orders for routine catheter care and the care plan did not address the catheter. After the resident removed the catheter and refused reinsertion, the medical team was not notified, and documentation failed to reflect the incident or provide follow-up, resulting in a deficiency in catheter management and communication.
A resident with chronic kidney disease and a permcath for dialysis did not have physician orders for post-dialysis care, and there was no documentation that nursing staff assessed the permcath site for complications after dialysis sessions. Observations and interviews confirmed that staff did not routinely monitor or document the site, despite facility policy and care plan requirements.
Two residents with dysphagia did not receive food and liquids in the prescribed consistencies, as one was served unthickened liquids despite orders for honey-thickened fluids, and another received shredded rather than pureed cabbage. Staff, including an agency LPN unfamiliar with the residents, failed to follow dietary orders and facility policy, resulting in inappropriate meal preparation and supervision.
A room designed for multiple residents was found to provide only 78.25 square feet of usable space per person, falling short of the required 80 square feet minimum. Four residents were observed occupying the room, and one resident reported that the room was originally intended for three people before a fourth was added.
Surveyors found that two resident rooms lacked adequate privacy curtains, resulting in residents being unable to achieve full visual privacy from others in the room or from the hallway. In both cases, curtains were either missing or too short, and residents reported having to use alternative means to maintain privacy.
A resident in a four-person room was required to share a wardrobe with another individual due to insufficient private closet space, after the room's occupancy was increased from three to four. Observations revealed that this issue affected multiple rooms on the unit, with inadequate storage provided for residents' personal clothing.
The facility failed to properly store and label medications, with expired drugs, incorrect resident identifiers, and unsecured narcotics found across multiple medication carts and rooms. Staff interviews confirmed non-compliance with storage protocols, and non-medical items were improperly stored with medications.
The facility failed to ensure quality care, with deficiencies in communication, dining supplies, and resident grievances. Residents reported delayed call light responses, untimely medication administration, and insufficient assistance with daily activities. Observations revealed a lack of linens, and staff reported inadequate supplies. The facility also failed to protect residents from abuse and neglect, with staffing shortages leading to missed medications and delayed care.
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving residents with cognitive impairments who were not provided with adequate interventions to prevent sexual abuse. A resident reported ongoing abuse from their roommate, but the facility did not investigate or resolve the situation. Additionally, a resident with a stage 4 pressure ulcer was left in soiled conditions due to a lack of available linens and understaffing, and another resident was observed sleeping on a bare mattress.
A resident with a stage 4 pressure ulcer did not receive timely and accurate wound care as ordered by the Wound Care Physician. The facility failed to transcribe and implement the physician's orders into the electronic medical record, resulting in incorrect treatments. The resident was also left without proper incontinence care, contributing to wound deterioration. Observations revealed lapses in infection control practices during wound care, highlighting communication and documentation issues within the facility.
A facility failed to ensure residents were free from significant medication errors, affecting 32 residents. Issues included missed doses of critical medications like insulin, anticoagulants, and anti-seizure drugs due to staffing shortages and medication unavailability. Interviews revealed systemic problems in medication administration and communication with medical providers.
The facility failed to maintain resident dignity and provide adequate care, as evidenced by residents being left in soiled linens, lacking proper clothing, and using disposable dining ware. A resident was observed in the dining room inappropriately dressed, while others were found without bed linens. Incontinence care was insufficient, with residents left in soiled conditions for extended periods. The use of paper plates and plastic utensils due to inadequate inventory further compromised resident dignity.
The facility experienced significant staffing shortages across multiple units, resulting in residents not receiving timely incontinence care and medications. Observations revealed residents left in soiled conditions and missed medication doses due to the absence of nurses. The facility's staffing plan was not effectively implemented, leading to inadequate care for residents.
The facility failed to provide adequate care for residents unable to perform activities of daily living independently. Several residents were left in soiled conditions due to delayed incontinence care, with one resident experiencing feelings of neglect. Staffing issues and delayed linen delivery contributed to the inability to provide timely care, resulting in multiple residents experiencing neglect in personal hygiene and dignity.
The facility did not promptly address grievances from the Resident Council, affecting six residents. Issues such as delayed call bell responses, medication administration, and insufficient personal care were reported over six months without documented follow-up. Interviews revealed that while concerns were discussed, updates were not recorded, and the previous Administrator failed to follow up on grievances.
A facility failed to provide a safe and clean environment due to a linen shortage, affecting resident care across multiple units. Observations showed residents without proper bedding, lying on soiled or bare mattresses. Staff reported insufficient linen supplies, leading to improvised care methods. Additional issues included a dirty fan and damaged dining chairs. Interviews revealed a lack of awareness about the linen shortage's impact on care.
The facility did not provide Baseline Care Plan summaries to residents or their representatives within 48 hours of admission, as required by policy. Staff interviews revealed confusion about the process, with the Director of Social Work stating that reviews typically occur 14-21 days post-admission. The Assistant Director of Nursing was unsure about the review process, and the Director of Nursing acknowledged that reviews should occur before the admission care plan meeting.
An extended Recertification Survey identified deficiencies in the facility's kitchen operations, including improper air-drying of dishware, unclean floors with food debris, and maintenance issues in the walk-in freezer. The Director of Food Service acknowledged these challenges, citing inherited issues and the need for better organization and cleaning.
The facility failed to ensure safe and sanitary storage and handling of food brought in by family and visitors for residents. Observations revealed unlabeled and undated food items in nourishment refrigerators, and staff were not trained in reheating food. The Director of Food Service and nursing staff were unclear about their responsibilities, leading to improper food handling. Additionally, the Regional Registered Dietician and Diet Technician were not familiar with the relevant policy.
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet medical, nursing, and psychosocial needs. Residents with pressure ulcers were not consistently provided with protective boots, a resident with a urinary catheter lacked a care plan for catheter care, and residents with histories of sexual-related behaviors did not have these documented in their care plans. Additionally, a resident exhibiting inappropriate behaviors towards others did not have these behaviors addressed in their care plan.
Two residents in the facility did not receive appropriate grooming and hygiene care according to professional standards. One resident, with a history of stroke and anxiety, was observed with unwashed hair and long facial hair, despite not refusing care. The facility failed to schedule a requested haircut appointment, and staff were unaware of the resident's grooming needs. Another resident, with dementia and anxiety, had long, jagged fingernails with debris, indicating a lack of personal hygiene assistance. The facility's policy required documentation and adherence to care plans, which was not followed, leading to unmet care needs.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to enhanced barrier precautions for residents requiring such measures. A resident with a stage 4 pressure ulcer did not receive proper care as staff failed to wear appropriate PPE during wound care. Another resident's urine collection bag was observed on the floor, contrary to policy. Additionally, staff did not wear gowns while providing care to residents with feeding tubes and those requiring assistance with toileting, despite posted precautions.
A resident with a urinary catheter experienced inadequate care, as the catheter and drainage bag were repeatedly observed on the floor and above bladder level, contrary to facility policy. The facility failed to develop a care plan addressing the resident's urinary issues, despite the resident's history of urinary tract infections. Staff interviews revealed reliance on incomplete care instructions, leading to the resident's hospitalization for catheter-related complications.
A resident with dysphagia, malnutrition, and diabetes mellitus did not receive appropriate care for their feeding tube. The facility failed to label feeding bags with necessary information, leading to the administration of incorrect formulas. Observations showed unlabeled bags and unauthorized substitutions, which were not in line with physician orders. Staff interviews confirmed the lack of proper labeling and communication regarding formula changes.
The facility did not provide special eating equipment for two residents as recommended by their care plans and occupational therapy evaluations. One resident with moderately impaired cognition was observed eating from flat plates or plastic bowls instead of a divided plate, while another resident with severely impaired cognition was served meals on paper plates or bowls. Staff interviews revealed that the facility was waiting for a new order of divided plates due to previous supply issues.
Two residents with severe cognitive impairments did not receive requested pneumococcal vaccines despite signed consent forms. The facility's records lacked documentation of vaccine orders or administration, as confirmed by interviews with the Infection Preventionist and Assistant Director of Nursing.
Immediate Jeopardy Due to Pervasive Failures in Resident Care, Medication Administration, and Infection Control
Penalty
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.
Failure to Provide Sufficient Nursing Staff Resulting in Unmet Resident Care Needs and Medication Errors
Penalty
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.
Widespread Failure to Administer Prescribed Medications
Penalty
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.
Deficient Infection Control in Water Management and Resident Care
Penalty
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.
Failure to Prevent Accident Hazards and Inadequate Supervision for Aspiration Precautions
Penalty
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.
Widespread Neglect Due to Insufficient Staffing and Missed Care
Penalty
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.
Failure to Provide Care According to Professional Standards and Resident Needs
Penalty
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.
Delay in Pressure Ulcer Identification and Treatment
Penalty
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.
Widespread Food Safety and Sanitation Failures in Kitchen
Penalty
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.
Widespread Administrative Failures Result in Immediate Jeopardy and Substandard Care
Penalty
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.
Multiple Serious Deficiencies Due to Lack of Oversight and Communication
Penalty
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.
Failure to Implement and Maintain Effective QAPI Program
Penalty
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.
Lack of Qualified Infection Preventionist for Infection Control Program
Penalty
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.
Failure to Maintain Resident Dignity, Privacy, and Respect
Penalty
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.
Failure to Address and Document Resident Council Grievances
Penalty
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.
Failure to Maintain Sanitary, Safe, and Homelike Environment
Penalty
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.
Failure to Provide Necessary Assistance with Activities of Daily Living
Penalty
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.
Failure to Securely Store Medications Across Multiple Units
Penalty
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.
Failure to Serve Food and Drink at Safe and Appetizing Temperatures
Penalty
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.
Non-Compliance with State Building Standards for Resident Room Layouts
Penalty
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.
QAA Committee Lacked Required Members and Attendance
Penalty
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.
Failure to Thoroughly Investigate Resident Incident Involving Unwitnessed Fall and Choking
Penalty
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.
Failure to Provide Appropriate Catheter Care and Notification
Penalty
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.
Failure to Document and Assess Post-Dialysis Care for Resident with Permcath
Penalty
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.
Failure to Provide Physician-Ordered Food and Liquid Consistencies
Penalty
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.
Insufficient Usable Space in Multi-Resident Room
Penalty
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.
Inadequate Privacy Curtains Compromise Resident Visual Privacy
Penalty
Summary
During the extended recertification survey, it was observed that two resident sleeping rooms did not provide adequate visual privacy for each resident as required. In both rooms, the privacy curtains were either missing or too short to fully shield residents from view by others in the room or from the hallway. Specifically, in one room, a resident's bed area lacked a sufficient section of privacy curtain parallel to the bed, resulting in no visual privacy from the other three residents in the room. When the curtain was extended, it still failed to provide privacy from the hallway due to its inadequate length. The resident reported having to close other residents' curtains or use the bathroom to change clothes, indicating the lack of proper privacy measures. In another room, a similar deficiency was noted where the privacy curtain did not extend far enough to provide full visual privacy from the hallway or from other residents in the room. When the curtain was pulled to shield the resident from the hallway, a significant section along the side of the bed remained exposed to view from other residents. These observations were made while the residents were in bed, and the findings were confirmed through interviews and direct observation during the survey period.
Lack of Private Closet Space for Residents
Penalty
Summary
During an extended recertification survey, it was observed that a four-person resident room on the North Two Unit lacked adequate private closet space for each resident. Specifically, there were only three freestanding wardrobes available for four residents, resulting in one wardrobe being shared between two individuals. One resident reported that the room was originally designed for three people, but an additional person was added after staff took measurements, leading to the need to share closet space. The survey further identified a total of six four-person occupancy rooms on the unit, raising concerns about the adequacy of private storage for residents' clothing. These findings indicate that the facility did not ensure each resident had private closet space to keep their clothing separate from that of their roommates, as required by regulations.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws across multiple medication carts and rooms. Observations revealed expired medications, medications without resident identifiers, and medications stored in inappropriate containers. For instance, an insulin pen was found in a toothpaste container labeled with a different resident's name, and eye drops were stored without any labeling. Additionally, some medications were found in containers with incorrect resident identifiers. Controlled substances were not adequately secured, as evidenced by a narcotic cupboard with an open outer door, leaving narcotic medications unsecured. Staff interviews confirmed that the narcotic cupboards should have both doors closed and locked, but this protocol was not followed. Furthermore, expired medications were found in several medication carts, and insulin vials lacked open or expiration dates, which is against the facility's policy. The facility also failed to maintain medication carts free from non-medical items, such as food and drinks, which were found stored alongside medications. Loose and unlabeled medications were discovered in the carts, and there were instances of medication spills within the drawers. Staff interviews indicated a lack of adherence to proper medication storage and labeling procedures, contributing to the deficiencies observed during the survey.
Removal Plan
- 100% of the licensed nursing staff received education on the proper labeling of all medications, discarding all medications with an expired medication date, improper labeling of medications manually, careful administration of medication using a blister pack, and the proper way to dispose of unused loose medications in both the medication cart and the medication rooms.
- Educate all staff (including licensed, certified, and non-medical staff) and agency staff, staff on vacation and/or leave prior to the start of their next shift and track by the administrative team to ensure 100% compliance.
Facility Deficiencies in Resident Care and Oversight
Penalty
Summary
The facility and its governing body failed to ensure appropriate quality of care for residents, as evidenced by multiple deficiencies identified during the extended Recertification Survey. There was inconsistent communication with the facility Administrator, leading to management and regulatory compliance issues. Observations revealed that residents were served meals on paper plates with plastic utensils due to insufficient dining supplies. Interviews with staff confirmed the lack of adequate stock, and the corporate controller's involvement in ordering decisions was noted. The Regional Administrator was unaware of ongoing concerns, indicating a lack of oversight and communication. Residents reported significant care concerns during a special Resident's Council meeting, including delayed call light responses, untimely medication administration, and insufficient assistance with activities of daily living. These issues were consistently reported in Resident Council meeting minutes over several months, with no documented follow-up or improvement. The Regional Administrator admitted to being unaware of the grievance follow-up issues, highlighting a failure in addressing resident complaints and grievances effectively. The facility also failed to maintain a safe, clean, and comfortable environment. Observations and interviews revealed a lack of linens, with residents found without sheets on their beds. Staff reported inadequate supplies to perform their duties, and the Regional Administrator was unaware of the linen shortages despite claims of a par system in place. Additionally, the facility did not ensure residents' rights to be free from abuse and neglect, with reports of ongoing abuse and neglect incidents not being addressed. Staffing shortages further exacerbated these issues, leading to missed medication administrations and delayed care for residents.
Removal Plan
- Review of weekly recruitment audits of all new incoming and outgoing staff and the hiring of a recruitment officer.
- Education of the Assistant Administrator and the Administrator regarding the role and duties of the Administration team, communication with governing body, involvement with QAPI team on an ongoing basis. Includes review of daily emails between Administrator and the Corporate Administrator involving current census, staffing issues, resident incidents requiring follow up, hospitalizations, discharges and/or deaths.
- Invoices for linen purchases and education to administration team regarding inventory controls.
- Two additional contracts with agencies for Registered and Licensed Nurses.
- Review of a revised Grievance process by the Administration team including the Grievance binder with all resident grievances, follow ups and outcomes.
- Updated Quality Assurance and Performance Improvement Plan Policy with goals and interventions.
- Updated Facility Assessment.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect several residents from abuse, mistreatment, or neglect, as evidenced by multiple incidents involving residents with cognitive impairments. Residents with dementia and other cognitive issues were not provided with adequate interventions to prevent sexual abuse. For instance, one resident with a history of sexual-related behaviors was not monitored appropriately, leading to incidents where they engaged in non-consensual sexual activities with other residents. The care plans for these residents did not include necessary interventions to address their behaviors, and staff failed to supervise them adequately, resulting in repeated incidents. Another resident reported ongoing abuse from their roommate, which included verbal abuse and disruptive behavior. Despite reporting these issues to multiple staff members, the facility did not investigate the allegations or take steps to resolve the situation. The resident's concerns were not communicated to the social work department or higher administration, and the abusive roommate had a history of similar behavior with previous roommates, indicating a pattern that was not addressed by the facility. Additionally, the facility neglected to provide timely incontinence care for a resident with a stage 4 pressure ulcer, leaving them in soiled conditions for extended periods. This neglect was exacerbated by a lack of available linens and understaffing, which hindered the staff's ability to provide necessary care. Another resident was observed sleeping on a bare mattress due to the unavailability of clean bed linens, further highlighting the facility's failure to meet basic care standards.
Removal Plan
- 100% of staff received education on abuse, neglect, mistreatment and proper reporting and notifications.
- Interviews with staff revealed appropriate knowledge of abuse, neglect, mistreatment, and proper reporting and notifications.
- 41% of all non-licensed staff were educated regarding abuse, neglect, mistreatment, and proper reporting and notifications.
- 61% of all licensed nursing staff were educated regarding abuse, neglect, mistreatment, and proper reporting and notifications.
- The corrective action included a plan to educate all staff (including licensed, certified, and non-medical staff), agency staff, and staff on vacation and/or leave and would be tracked by the administrative team to ensure 100% compliance.
Failure to Provide Timely and Accurate Wound Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with a stage 4 pressure ulcer, leading to a deficiency identified during a survey. The resident, who was cognitively intact and always incontinent of bladder and bowel, did not receive timely and accurate wound treatments as ordered by the Wound Care Physician. The facility did not ensure that the physician's orders were transcribed into the electronic medical record in a timely manner, resulting in the resident receiving incorrect treatments for extended periods. Additionally, the resident was observed on multiple occasions without proper incontinence care, which contributed to the deterioration of the wound. The Wound Care Physician's orders for wound treatment were not consistently implemented, as evidenced by the lack of transcription into the medical record and the continuation of outdated treatments. The resident's wound healing was negatively impacted by these failures, with the wound showing signs of critical contamination and maceration due to inadequate peri care. The facility's failure to provide timely incontinence care further exacerbated the resident's condition, as the resident was left in soiled incontinence pads for extended periods, leading to skin deterioration. Observations and interviews with staff revealed lapses in infection control practices during wound care, such as not wearing appropriate personal protective equipment and failing to perform hand hygiene. The Wound Care Physician and other staff members acknowledged the inconsistencies between the physician's orders and the treatments administered, highlighting a breakdown in communication and documentation processes within the facility. These deficiencies posed a potential risk of serious injury to the resident and other residents in the facility.
Removal Plan
- 100% of licensed staff received education on Appropriate Personal Protective Equipment and hand hygiene for wound care, Appropriate weekly, post admission/readmission skin assessments on all residents, Accurately transcribing and implementing Physician orders, including hospital discharge instructions and wound care medical consultants, for wound care treatments and ensuring treatment orders match Physician orders and consultant recommendations (unless otherwise indicated). Additionally notifying the medical team for unclear orders or no orders for existing skin issues, Accurate and timely documentation of wound care, Care Plan interventions for all existing skin issues.
- Interviews completed with licensed staff on all six facility resident units to verify content of education completed and understanding.
- Review of a facility wide audit conducted for all residents consisting of head-to-toe skin assessments to ensure all skin issues addressed with medical and orders were correctly transcribed and implemented.
- Medical record review of sample group of residents with current wounds/skin issues to ensure all Physician orders and consultant recommendations matched the treatment administration records to verify the correct treatments were being provided.
- The correction action included a plan to educate all licensed staff, agency staff and any staff on vacation/leave prior to next working shift and tracked by Administration team to ensure 100% compliance.
Significant Medication Errors Due to Staffing and Communication Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting 32 out of 46 residents reviewed during the survey. The deficiencies included residents not receiving critical medications such as anti-anxiety, respiratory, insulin, anticoagulants, anti-seizure, and anti-hypertensive medications. For instance, a resident with emphysema and chronic obstructive pulmonary disease did not receive their prescribed medications due to unavailability, leading to a hospital transfer the following day. Another resident with diabetes and atrial fibrillation did not receive their insulin and anticoagulant medications over a weekend due to nurse staffing issues, with no documented evidence of provider notification. The report highlights multiple instances where residents did not receive their medications as prescribed, often due to staffing shortages or medication unavailability. On one occasion, a resident with epilepsy and heart disease missed doses of their anti-seizure and anticoagulant medications over two days, with no follow-up or notification to medical providers. Additionally, on a specific date, residents on a particular unit did not receive any scheduled medications during the evening shift because there was no nurse available, affecting their treatment and care. Interviews with staff revealed systemic issues in medication administration, including delays in receiving medications from the pharmacy, lack of access to emergency medication supplies, and inadequate communication with medical providers regarding missed doses. The facility's leadership was reportedly unaware of the extent of the staffing and medication administration issues, which were not escalated appropriately, leading to significant lapses in resident care.
Removal Plan
- Immediate education regarding the medication administration policy and the medication error policy to include the medication error form, the medication error severity assessment tool, the missed medication daily review process to ensure compliance, and proper communication of staffing emergencies related to coverage was completed with all licensed nursing staff currently in the facility with an attestation that all of the facility's licensed nursing staff will be educated prior to their next shift.
- A facility wide audit to identify any residents with any missed or omitted medications and medical team notification of any missed medications.
- Interviews with licensed nursing staff on each resident unit to verify education completed and post test results related to medication errors, appropriate notifications (medical team, nursing supervisors) and documentation, missing medication reports, significant medication errors on severity and outcomes, and pharmacy process for missing medications.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by multiple observations of residents in undignified conditions. Resident #55 was seen in the dining room wearing only a t-shirt and an incontinence brief, without pants or shoes, which was inappropriate for a common area. Resident #92 was found asleep in a bed without sheets, and Resident #140 was observed lying on a mattress without sheets, wrapped in a personal blanket. These observations indicate a lack of proper attention to residents' personal dignity and comfort. Resident #457, who was cognitively intact and required assistance with toileting, reported inadequate care, stating they were often left in soiled linens for extended periods. Observations confirmed that Resident #457 was left in wet bed linens, and staff did not provide timely assistance. Similarly, Resident #106, who had a stage 4 pressure ulcer and required assistance with toileting, was found sitting in a urine-soiled incontinence pad, with no change in care provided from the previous night until after breakfast. These instances highlight a failure to provide necessary incontinence care and maintain residents' dignity. Additionally, the facility was observed using paper plates and plastic utensils for meals, which was against the facility's policy of using non-disposable dishware. Interviews with staff revealed that the facility lacked adequate dining supplies, leading to the use of disposable items. This practice was acknowledged by the facility's administration as a dignity issue, yet it persisted due to insufficient inventory control and ordering processes. The combination of these deficiencies reflects a broader issue of inadequate resource management and staffing, impacting the quality of care and residents' dignity.
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient staffing levels across multiple resident units, leading to inadequate care for residents. Observations and interviews revealed that residents were left in soiled conditions for extended periods, and there were instances where significant medications were not administered due to the absence of a nurse. For example, on the South 3 Unit, a resident was found incontinent and not assisted in a timely manner, and another resident had not been changed out of a wet incontinence brief since the previous night. These incidents highlight the facility's failure to provide adequate staffing to meet the residents' needs. On the North 2 Unit, residents reported not receiving assistance with incontinence care during the overnight shift, and one resident was found with a brown substance on their body and bed linens. Additionally, residents experienced delays in receiving medications due to staffing shortages. The facility's staffing plan was not effectively implemented, as evidenced by the lack of sufficient nursing staff to provide necessary care and medication administration. The facility's staffing issues were further compounded by the failure to notify leadership of the staffing concerns and missed medications. Interviews with staff and family members indicated that the facility was consistently short-staffed, particularly on weekends, resulting in residents not receiving timely care. The facility's emergency nurse staffing plan and daily staffing practices were not adequately followed, leading to significant lapses in resident care and medication administration.
Inadequate Care and Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living for residents who were unable to perform these tasks independently. Observations and interviews during the survey revealed that several residents were left in soiled conditions for extended periods, indicating a lack of timely incontinence care. For instance, Resident #106, who had a stage 4 pressure ulcer and required assistance with toileting, was found in a wet incontinence pad with an odor of urine, having not been changed since the previous night. Despite the resident's repeated requests for assistance, care was delayed, leading to feelings of neglect and worthlessness. Other residents, such as Resident #69 and Resident #116, were also observed in unsanitary conditions. Resident #69, who had severe cognitive impairment, was found lying in bed with a brown substance on their body and sheets, and their call bell was out of reach. Similarly, Resident #116 was found with a soiled incontinence pad and an odor of urine in the room. The facility's staffing issues were highlighted, with reports of understaffing and delayed delivery of linens, which further exacerbated the inability to provide timely care. Additional deficiencies were noted with residents not receiving proper nail care and assistance with toileting. Resident #182 had long, jagged fingernails with debris, and Resident #457 reported inadequate assistance with toileting, leading to urination in their brief. The facility's failure to ensure adequate staffing and timely care resulted in multiple residents experiencing neglect in their personal hygiene and dignity, as evidenced by the observations and interviews conducted during the survey.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances and recommendations from the Resident Council were addressed promptly, affecting six residents. During a special Resident Council meeting, residents reported issues such as long call bell wait times, delayed medication administration, a shortage of linens, and insufficient assistance with activities of daily living. These concerns were consistently raised in meeting minutes over a six-month period, yet there was no documented follow-up or resolution by the facility staff. The residents expressed that their complaints were not acted upon promptly, and there was no follow-up communication from the facility staff regarding their grievances. Interviews with facility staff, including the Director of Social Work and the Director of Nursing, revealed that while resident concerns were discussed in meetings and morning reports, updates were not documented in the meeting minutes. The Quality Assurance Committee was unaware that these grievances were not being addressed, and it was discovered that the previous Administrator had not been following up on resident grievances. The lack of documentation and follow-up on resident concerns led to the deficiency identified during the survey.
Linen Shortage and Unsanitary Conditions in LTC Facility
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents across multiple units, as evidenced by a lack of adequate clean bed and bath linens. Observations revealed that residents were left without proper bedding, such as Resident #106 who was given a bottom sheet for a top sheet and was found lying on a urine-soiled pad. Other residents, including Resident #92 and Resident #140, were observed lying on bare mattresses without sheets, and Resident #457 was found on wet linens for an extended period. The facility's linen shortage was a recurring issue, as noted in Resident Council meeting minutes, where concerns about linen shortages and improper use of linens were documented without improvement. Interviews with staff and residents highlighted the severity of the linen shortage. Certified Nursing Assistants and Licensed Practical Nurses reported insufficient linen supplies, with only a few towels and washcloths available for dozens of residents. Staff had to improvise by cutting bath sheets into washcloths or using disposable wipes, which were deemed inadequate for proper resident care. The laundry staff's limited availability and the absence of a par system for linen inventory exacerbated the issue, leading to delays in resident care and dissatisfaction among residents and their families. Additional observations noted unsanitary conditions, such as a dirty fan blowing dust and debris in a resident's room and dining room chairs in disrepair. Interviews with facility administrators revealed a lack of awareness about the extent of the linen shortage and its impact on resident care. Despite claims of significant spending on linen and an inventory control system, the facility failed to ensure the availability of necessary supplies, compromising the quality of care provided to residents.
Failure to Provide Baseline Care Plan Summaries Within 48 Hours
Penalty
Summary
The facility failed to ensure that a written Baseline Care Plan summary was provided to residents and/or their representatives within 48 hours of admission. This deficiency was identified during an extended Recertification Survey, which reviewed eight residents. The facility's policy, reviewed in January 2024, mandates that a baseline care plan be developed within 48 hours to address the immediate needs of residents and that a summary be provided to them or their representatives. However, the facility could not provide evidence that such plans were completed or shared with the residents or their representatives within the required timeframe. Interviews with facility staff revealed a lack of clarity and adherence to the policy. The Director of Social Work indicated that the Baseline Care Plan is typically reviewed during the admission care plan meeting, which occurs 14-21 days post-admission, rather than within the first 48 hours. The Assistant Director of Nursing was unsure about who was responsible for reviewing the plan with residents or their representatives and how this review was documented. The Director of Nursing confirmed that the Baseline Care Plans and reviews should be completed before the admission care plan meeting, highlighting a gap between policy and practice.
Food Service Safety Deficiencies in Kitchen Operations
Penalty
Summary
During an extended Recertification Survey, it was observed that the facility's main kitchen did not adhere to professional standards for food service safety. Specifically, dishware was not properly air-dried before storage, as evidenced by moisture and water droplets found on stacked stainless steel pans. The kitchen floors were unclean, with food debris present in various areas, including the dish wash area and under cooking equipment. Additionally, there was a liquid egg spillage on a shelving unit in the walk-in cooler, and ice buildup was noted on the floor and around the door of the walk-in freezer. The Director of Food Service acknowledged these issues, citing challenges inherited from previous directors and the need for better organization and cleaning. Further observations in the basement kitchen revealed significant cleanliness issues, including black residue resembling tar on the floor, grimy residue under a stove, and grease buildup on cooking equipment. Frozen water droplets were found on food items in the walk-in freezer, indicating potential issues with the freezer's maintenance. Additionally, plate covers and utensils were not properly air-dried before being set for service, with water droplets observed on their surfaces. The Director of Food Service admitted to repeatedly instructing staff on proper drying procedures, highlighting ongoing compliance challenges within the kitchen operations.
Deficiencies in Food Handling and Storage for Resident Meals Brought from Outside
Penalty
Summary
The facility was found to have deficiencies in the handling and storage of food brought in by family members and visitors for residents. The policy, dated January 2024, required that such food be labeled, dated, and stored separately from facility-prepared food. However, observations revealed that food items in the nourishment refrigerators were not labeled with resident names or dates, and there was no probe thermometer available to measure the temperature of reheated food. Staff interviews indicated a lack of awareness and training regarding the policy, with some staff unaware of the time frame for discarding food and others stating that they were not trained to reheat food. Further interviews with staff, including the Director of Food Service, revealed that there was confusion about responsibilities for labeling and discarding food. The Director of Food Service stated that food service staff did not handle resident food brought from outside, citing cross-contamination concerns, and that it was the nursing staff's responsibility. However, nursing staff were not trained in reheating food, and there were no microwaves available on the units due to a previous incident. This lack of coordination and training led to improper handling and storage of food, as evidenced by unlabeled and undated food items found in the refrigerators. The report also highlighted that the Regional Registered Dietician and Diet Technician were not familiar with the policy for food brought in from outside. Observations on a later date showed continued issues with unlabeled and undated food items in the nourishment refrigerator, including takeout food in plastic bags and containers. Staff interviews confirmed that food was not consistently labeled or discarded within the required time frame, and there was no clear process for reheating food for residents, with some staff taking food to the staff cafeteria to use a microwave.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. For Resident #559, who had severe cognitive impairment and a Stage 3 pressure ulcer, the care plan included the use of protective boots to prevent further skin breakdown. However, observations revealed that the resident was often found in bed without the boots, and there was no documented evidence of refusal by the resident. Similarly, Resident #139, who was at risk for pressure ulcers, was observed without protective boots or elevated extremities, contrary to the care plan and physician orders. Resident #45, who had a urinary catheter and a history of urinary tract infections, did not have a care plan addressing catheter care. Despite physician orders for catheter care every shift, the care plan lacked specific interventions, which could have contributed to repeated infections. Additionally, Residents #92 and #177, both with severely impaired cognition, had histories of sexual-related behaviors that were not included in their care plans. An incident involving these residents engaging in sexual behaviors highlighted the need for such information to be documented and addressed in their care plans. Furthermore, Resident #134, who exhibited behaviors such as touching and kissing other residents, did not have these behaviors documented in their care plan. Observations and staff interviews confirmed these interactions, yet the care plan lacked interventions to manage them. The facility's failure to include and implement comprehensive care plans for these residents resulted in unmet needs and potential risks, as evidenced by the survey findings.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents during the extended Recertification Survey. Resident #122, who had diagnoses including cerebral infarction, malnutrition, and anxiety, was observed with unwashed hair and long unshaven facial hair on multiple occasions. Despite being cognitively intact and not refusing care, Resident #122 reported that their hair had not been washed for weeks and they were waiting for a haircut appointment, which had not been scheduled. The facility's records showed no evidence of hair washing or shaving being offered, received, or refused, and staff interviews revealed a lack of awareness and action regarding the resident's grooming needs. Resident #182, diagnosed with dementia, anxiety, and depression, was observed with long, jagged fingernails that had brown debris underneath. The resident required assistance with personal hygiene and had not refused care, yet their nails remained uncut over several days. A Certified Nursing Assistant acknowledged the need for nail care but had not addressed it, as the resident was not on their assignment. The facility's failure to provide necessary nail care was evident through observations and staff interviews. The facility's policy on Resident Care with Activities of Daily Living required staff to review care plans for special needs, follow guidelines, and document care provided or refused. However, the facility did not adhere to these standards, resulting in unmet grooming and hygiene needs for the residents. Interviews with staff and administrators highlighted awareness of ongoing concerns related to assistance with activities of daily living, but no corrective actions were documented in the report.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to enhanced barrier precautions for residents requiring such measures. Resident #106, who had a stage 4 pressure ulcer and was on enhanced barrier precautions, did not receive proper care as staff failed to wear appropriate personal protective equipment (PPE) during wound care. The Licensed Practical Nurse (LPN) did not wear a gown, failed to change gloves, and did not perform hand hygiene during the procedure, despite the presence of a sign indicating the need for enhanced barrier precautions. Resident #83, who had a urinary catheter, was observed with their urine collection bag lying directly on the floor on multiple occasions. This was contrary to the facility's policy, which required the catheter tubing and drainage bag to be kept off the floor. Staff interviews revealed that some staff did not consistently hook the bag to the bed frame, leading to the bag being placed on the floor, which was not in compliance with the facility's infection control policies. Additionally, Resident #66, who had a feeding tube, was not provided with care in accordance with enhanced barrier precautions. An LPN was observed flushing the feeding tube and changing the dressing without wearing a gown, despite the requirement for PPE during high-contact activities. Similarly, Resident #607, who required assistance with toileting, was assisted by a Certified Nursing Assistant (CNA) who wore gloves but not a gown, failing to adhere to the enhanced barrier precautions posted on the resident's door. These lapses in infection control practices were noted across multiple units within the facility.
Deficiency in Urinary Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections. Resident #45, who was cognitively intact and had a history of urinary tract infections, was observed multiple times with their urinary catheter and drainage bag improperly managed. The catheter and drainage bag were seen on the floor without a protective barrier and above the level of the bladder, contrary to the facility's policy. Additionally, the facility did not develop a care plan to address the resident's urinary issues and catheter care, which was a critical oversight given the resident's medical history and current condition. Interviews with staff revealed a lack of adherence to the facility's catheter care policy. Certified Nursing Assistant #6 acknowledged responsibility for ensuring the drainage bag was off the floor and below the bladder level but relied on the Kardex for guidance, which lacked specific instructions for Resident #45. Licensed Practical Nurse #5 and the Assistant Director of Nursing #2 confirmed that the care plan and Kardex should include specific interventions for residents with urinary catheters, which was not the case for Resident #45. The resident was eventually sent to the hospital for further evaluation due to complications related to the catheter, highlighting the facility's failure to provide necessary care and prevent infections.
Failure to Properly Label and Administer Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a feeding tube was provided with appropriate care and services to prevent complications. Specifically, the facility did not consistently label the tube feeding bags with necessary information such as the contents, the resident's name, the start time, or the initials of the staff who initiated the feeding. This lack of labeling made it impossible to verify that the correct formula was being administered according to the physician's orders. Observations revealed that the resident's feeding bags contained unlabeled fluids, and the formula present in the resident's room did not match the physician's orders. The resident in question had a medical history of dysphagia, malnutrition, and diabetes mellitus, requiring a feeding tube for nutrition. The physician's orders specified the use of Diabetisource AC or Glucerna 1.2, but observations found bottles of Glucerna 1.5 and Jevity 1.5, which were not ordered. Interviews with staff, including an LPN and the Regional Dietitian, confirmed that the formula was not labeled correctly, and substitutions were made without proper authorization. The Corporate Administrator was unaware of these issues until they were brought to attention by surveyors.
Failure to Provide Special Eating Equipment for Residents
Penalty
Summary
The facility failed to provide special eating equipment for two residents, as recommended by their care plans and occupational therapy evaluations. Resident #18, who has moderately impaired cognition and requires supervision for meals, was observed eating from flat plates or plastic bowls instead of a divided plate, which was specified in their care plan and meal ticket. Similarly, Resident #134, with severely impaired cognition and requiring supervision or assistance for eating, was observed consuming meals from paper plates or bowls rather than the divided plate indicated in their care plan and meal ticket. Interviews with staff revealed that the facility had previously provided divided plates, but the supply had been depleted due to issues with the quality of the plates, which broke after initial use. The Dietary Technician and Assistant Director of Food Service indicated that the facility was waiting for a new order of divided plates, as the corporate office controlled the ordering process. The Assistant Director of Rehabilitation was unaware of the shortage of divided plates, and the Assistant Administrator confirmed that a par level count had been conducted, and an order for more plates had been placed.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that two residents received the pneumococcal immunizations as per their requests, leading to a deficiency identified during the extended Recertification Survey. Resident #22, who had diagnoses including dementia with psychotic disturbance, adult failure to thrive, and atrial fibrillation, was found to have severely impaired cognition and an outdated pneumococcal vaccination status. Despite a verbal request from the resident's representative for the pneumococcal vaccine, there was no documented evidence in the resident's medical records that the vaccine was ordered or administered. Similarly, Resident #177, with diagnoses of dementia, diabetes, and adult failure to thrive, also had severely impaired cognition and an outdated pneumococcal vaccination status. The resident's representative had signed a consent form requesting the vaccine, but again, there was no documentation in the medical records indicating that the vaccine was ordered or administered. Interviews with the Infection Preventionist and the Assistant Director of Nursing revealed a lack of awareness and documentation regarding the administration of the vaccines.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
