Waterview Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Flushing, New York.
- Location
- 119 15 27th Avenue, Flushing, New York 11354
- CMS Provider Number
- 335154
- Inspections on file
- 12
- Latest survey
- December 9, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Waterview Nursing Care Center during CMS and state inspections, most recent first.
The facility experienced significant staffing shortages on weekends, failing to meet the required levels of RNs, LPNs, and CNAs as outlined in their staffing plan. Staff interviews revealed that CNAs and LPNs were often overwhelmed, having to prioritize essential tasks and rush through their duties due to frequent call-outs and difficulty in finding replacements. Despite efforts to hire more staff, the facility struggled with retention, and the staffing levels listed in the Facility Assessment did not match the actual staffing on the units.
The facility failed to maintain a safe, sanitary, and comfortable environment, with deficiencies noted in multiple units, including mismatched paint, discolored blinds, worn window treatments, and damaged furniture. Maintenance and housekeeping staff reported delays in repairs and cleaning, contributing to the ongoing issues.
The facility was found to have several environmental deficiencies during a recertification survey, including damaged walls, dusty and dirty areas, and broken furniture in the Lobby, hallways, and nursing stations. The administrator acknowledged these issues but had not yet documented or implemented corrective actions.
The facility failed to report allegations of abuse and injuries of unknown origin in a timely manner. A resident's allegation of sexual abuse was not reported within the required two-hour timeframe. Another resident's elbow fracture was not reported when first observed, and a fall resulting in a hand fracture was not reported to the Department of Health. These incidents highlight deficiencies in the facility's adherence to reporting protocols.
The facility failed to involve two residents in their care plan meetings, violating their rights to participate in their person-centered care plans. One resident, who is cognitively intact, was not invited to any meetings since admission, and another resident with moderately impaired cognition was not documented as being invited or participating. The facility's policy requires invitations to these meetings, but this was not followed, as confirmed by staff interviews.
The facility failed to accurately document wandering behavior in the MDS assessments for two residents with dementia. Despite care plans and staff observations indicating wandering and elopement risks, the MDS assessments did not reflect these behaviors. The MDS Coordinator's approach of not documenting unobserved behaviors during the assessment period contributed to this deficiency.
A resident with dementia and depression was prescribed Seroquel and Valproic Acid without attempts at gradual dose reduction, despite no documented psychotic behaviors. The psychiatrist recommended dose reduction, but the resident's son refused, preventing its implementation. This led to a deficiency in managing psychotropic medications.
A facility failed to create and implement a comprehensive care plan for a resident with Prurigo Nodularis, despite ongoing skin issues and a dermatology diagnosis. The resident reported itchy skin since admission, and a dermatology consult confirmed the condition, but no care plan was developed. Interviews revealed a lack of coordination among staff, with the Medical Doctor not renewing Cortisone cream due to concerns about skin thinning and intermittent complaints, and the DON indicating that care plan responsibilities were not fulfilled.
A facility failed to review and revise a resident's oral/dental care plan quarterly, as required by policy. The resident, with conditions including Anxiety Disorder and Type 2 Diabetes Mellitus, had a care plan created in August 2023, but it was not updated following quarterly assessments. The DON acknowledged the oversight, attributing responsibility to the MDS Coordinator and RN supervisors.
The facility did not maintain the kitchen's automatic extinguishing system as required by 2009 NFPA 17A standards. The last inspection was overdue, and a report indicated issues with the cheese melter's protection. The Facilities Director stated that the equipment was replaced and a new vendor was contracted, but it was unclear if the new system was certified by the local fire department.
The facility was found deficient in providing continuous illumination for egress paths, as required by NFPA 101 standards. During a survey, it was noted that lights at the first-floor exit discharge and adjacent dining room exit were controlled by a timer, which did not comply with the requirement for continuous lighting. The Facilities Director acknowledged the issue.
A facility failed to report an alleged incident of sexual abuse involving a resident and a maintenance employee to law enforcement, as required by policy and federal regulations. The resident, with intact cognition, reported inappropriate touching by the employee. Despite the facility's policy mandating reporting to law enforcement, the facility did not proceed after the resident refused to contact law enforcement.
A medication error occurred when an LPN administered tube feeding to a resident without a medical order for it. The LPN failed to verify the resident's identity, leading to the administration of feeding formula through the Gastrostomy tube of a resident with a history of cerebral infarction and cognitive impairment. The error was discovered when the resident's spouse intervened, and no adverse effects were noted.
A resident with severe cognitive impairment eloped from the facility undetected due to inadequate supervision. Despite being last seen in their room, staff failed to verify the resident's whereabouts, leading to a delay in realizing the resident was missing. The resident was later found by police at a family member's house.
Staffing Shortages on Weekends
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, particularly on weekends. The facility's policy on staffing guidelines, which was reviewed in September 2024, emphasized the importance of adequate and competent staffing levels based on the Facility Assessment. However, the Payroll Based Journal Staffing Data Report for the third quarter of 2024 indicated excessively low staffing levels on weekends, which was confirmed by a review of the actual weekend staffing schedules from April to June 2024. The facility's staffing plan outlined specific numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) required for each shift, but these numbers were not met, leading to significant staff shortages. Interviews with staff members, including CNAs and LPNs, revealed that the facility frequently operated with insufficient staff, resulting in increased workloads and stress for the remaining staff. CNAs reported having to prioritize essential tasks such as personal care and feeding residents, often having to rush to complete their duties. LPNs expressed feeling overwhelmed due to the responsibility of administering medications to all residents on their units, despite having another nurse present. The staff shortages were attributed to frequent call-outs and the difficulty in finding replacements, particularly on weekends. The facility's administration, including the Human Resources Director and the Director of Nursing, acknowledged the staffing challenges but believed that the current staffing levels were adequate based on the facility's acuity. However, the facility was flagged for not meeting the Centers for Medicare and Medicaid Services mandate of 3.5 hours of care per patient per day. Despite efforts to hire more staff, the facility struggled to retain them, and the staffing levels listed in the Facility Assessment did not reflect the actual staffing on the units. The ongoing staffing issues raised concerns about the facility's ability to provide safe and adequate care to its residents.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction 1) On 12/30/24, The Administrator, DON and HR Director furthered Facility recruitment efforts including: 2) On 12/30/24 contacted CNA School Training program 3) On 12/30/24 contacted 1199 SEIU Hiring division 4) On 12/30/24 contacted additional Staffing agencies like Meridian and Towne. 5) Reviewed the potential to add/hire HHA Hall Monitors to assist in responding to call bells and non-clinical needs informing Charge Nurse of resident needs as indicated. 6) The facility continues to post and promote ads for recruitment for all open positions in the facility with the Apploi platform on job sites like Indeed and Zip Recruiter. 7) On 12/31/24 The Administrator, DON and Staffing Coordinator met with the Resident Council to discuss Facility plan for improving staffing numbers and ensuring care needs are met. Residents expressed satisfaction. 8) Incentives to recruit staff, including the use of sign-on bonuses, job fairs, tuition coverage, shift pickup bonuses and staffing agencies, will continuously be used to increase the facility’s staffing levels. Identification of Others 1) Resident Safety Assessment: The Administrator will conduct a comprehensive review of all residents by 12/31/2024 to identify any who may have been negatively impacted by staffing shortages. This will include checking for delays in care, unmet needs, or changes in physical, mental, or psychosocial well-being. Any identified issues will be addressed by the interdisciplinary team. Systemic Changes 1) The interdisciplinary team revised the staffing policy and Facility Assessment to accurately reflect current staffing needs based on resident acuity, census, and care plans. 2) The DNS and Administrator will review and revise the Facility Assessment to document sufficient staffing needs for each unit based on: - Acuity level and Census including special care needs of residents on individual units, and any other pertinent information about the resident needs. - An evaluation of diseases, conditions, physical, functional, or cognitive limitations of the resident population - Specific skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. - The number of Nursing staff to provide services to residents and assist and monitor aides. 3) Implementing a weekend staffing strategy that includes a dedicated pool of on-call staff, incentives for weekend shifts, and pre-scheduled backup coverage. 4) Reviewing and revising licensed nurses and CNA Assignments for each Unit to ensure any staffing adjustments needed based on resident needs and acuity. 5) Developing an audit tool to identify the number of open positions based on par levels to ensure that safe sufficient staffing would be maintained. 6) The DNS will provide RN's, LPN's and CNA's with education on measures to be taken when staffing is below par levels. Highlights of the Inservice include: - The responsibility of the RNS to check staff at the beginning of each shift. - The need to have a contact list of available staff and agencies to be called in as needed. - The responsibility of the Charge Nurse on each unit to complete an assignment sheet and update as needed for any staffing changes. - The responsibility of all Nursing Staff to report to Charge Nurse/RNS when any care or services cannot be provided to residents during the shift. - The responsibility of the RNS is to ensure resident medications, treatments and care are provided in accordance with resident plan of care. - The need for ancillary staff to assist with responding to call bells and informing direct caregivers of resident needs/requests. - The responsibility of the DON/Designee to contact the NYSDOH Surge and Flex if the facility implements crisis staffing plan. Quality Assurance 1) The QAPI committee will conduct weekly audits of staffing patterns and compliance with the updated Facility Assessment. 2) Initiate resident and family satisfaction survey audit tools to identify concerns related to staffing or care delivery. 3) Review all incidents and complaints quarterly to identify any trends or correlations with staffing levels. 4) Include staffing as a standing agenda item during quarterly QAPI meetings to ensure continuous monitoring and improvement. 5) Audits will be completed by the Director of Human Resources weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 6) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, as observed during a recertification survey. Multiple deficiencies were noted across several units, including mismatched paint patches, discolored blinds, worn window treatments, torn wallpaper, damaged furniture, and dirty, dusty areas. These issues were evident in four out of five units, indicating a widespread problem with the facility's maintenance and housekeeping practices. On Unit 1 North, the baseboard and door corners in the shower room were in disrepair, and several rooms had large unpainted areas near the radiator. Unit 1 East had unpainted patches on hallway walls and ceilings, dirty windows, cracked plaster, missing privacy curtain hooks, and damaged walls. The 2nd Floor had mismatched paint, peeling paint, unpainted patches, tattered window treatments, and loose air conditioner units. Unit 1 West had stained and worn furniture, broken window blinds, dusty and dirty window sills, and broken plaster. Interviews with maintenance and housekeeping staff revealed that repairs and cleaning were not being completed in a timely manner. Maintenance workers acknowledged delays in painting and repairing damaged areas due to other priority assignments. Housekeepers reported challenges in cleaning certain areas due to resident presence and the inability to clean certain items effectively. The Director of Housekeeping and Maintenance and the Administrator acknowledged the issues and stated that efforts were being made to address them, but the deficiencies remained uncorrected at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Immediate Correction:** 1) As of 12/31/24, The Maintenance Department will prioritize the immediate repair of all areas identified in the survey, including the unpainted walls, mismatched paint patches, cracks, and damaged areas in Rooms 40, 38, 37 (Unit 1 North), Rooms 25, 28, 18, 16/17 (Unit 1 East), Rooms 206, 210, 203, 211, 215, 217 (2nd Floor), and Rooms W49, W65, W47b, W52 (Unit 1 West). 2) As of 12/31/24, All areas observed with visible dirt, dust, or staining (e.g., air conditioner units, windowsills, walls, and bathroom tiles) were thoroughly cleaned and sanitized by the Maintenance/Housekeeping team. 3) As of 12/31/24, the windows in room [ROOM NUMBER], the air conditioners in multiple rooms (e.g., W49b, W65), and the bathrooms with stained tiles were cleaned by the Maintenance/Housekeeping team. 4) As of 12/31/24, The Housekeeping staff performed a detailed cleaning of the affected areas and provided documentation of completion. 5) As of 12/31/24, In Room W49b, the stained and worn mattress, broken bed frame, and broken closet were repaired. 6) As of 12/31/24, The missing door handle in Room W49b was replaced by the Maintenance team. **Identification of Others:** 1) Units 1 North, 1 East, 2nd Floor, and 1 West will have their rooms assessed for cleanliness and safety, and corrective actions will be taken as needed. All affected rooms will be given priority for repairs and cleaning. 2) The Director of Housekeeping and Maintenance will oversee that the rooms are returned to a safe, clean, and comfortable environment. 3) A facility-wide audit will be conducted to identify any additional rooms or common areas that may require repair, cleaning, or redecoration. This includes assessing all floors, any unpainted walls, damaged window treatments, and necessary repairs to ensure that all areas meet the facility’s safety and comfort standards. **Systemic Changes:** 1) The facility’s Safe, Clean, Comfortable and Homelike Environment policy will be revised to include clearer guidelines on maintaining rooms, common areas, and the timely reporting of repairs or maintenance concerns. 2) The updated policy will also specify the roles and responsibilities of the Housekeeping and Maintenance departments in ensuring a safe and homelike environment. 3) The Director of Maintenance and Maintenance and housekeeping workers will undergo additional training to understand the updated standards and expectations for maintaining a safe, clean, and homelike environment. 4) A clear protocol will be implemented for housekeeping staff to immediately report issues to the Maintenance Director, including a system for tracking repairs and ensuring all issues are addressed in a timely manner. 5) The facility will implement daily environmental rounds with the Administrator, Assistant Administrator, Director of Housekeeping, and Maintenance Director to assess the cleanliness, safety, and comfort of resident rooms and common areas. 6) A formal audit checklist will be developed to ensure the environment meets the facility's standards for cleanliness, maintenance, and homelike qualities. 7) Any issues identified during the rounds will be documented, and corrective actions will be taken immediately. Any issues that cannot be resolved during the rounds will be logged and addressed within a defined timeframe (e.g., 24-72 hours). 8) A Maintenance Log will be implemented, where maintenance and housekeeping staff will be required to record and report any issues they notice during cleaning. This log will be reviewed daily by the Maintenance Director to ensure timely action is taken. 9) The facility will ensure all maintenance issues reported in the log are tracked through completion, with clear timelines for resolution and documentation. 10) Staff will be instructed to immediately report any areas of concern in resident rooms or common areas, ensuring that all repairs and cleanliness issues are promptly addressed. **Quality Assurance:** 1) The Director of Maintenance/Housekeeping will conduct weekly audits for the next 3 months to ensure that all repairs, cleaning, and updates have been completed as per the standards outlined in this plan. The audits will also assess whether the facility is maintaining a safe, clean, comfortable, and homelike environment for residents. 2) The facility administration will establish a feedback mechanism for residents and their families to provide input on the condition of the environment. A survey or comment box will be placed in common areas to allow for anonymous feedback on cleanliness, safety, and comfort. 3) Feedback will be reviewed by the Administrator and the QAPI team, and corrective actions will be taken based on the feedback received. 4) Weekly audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. **Person Responsible for this Ftag:** 1) The Administrator.
Environmental Deficiencies in Facility's Common Areas
Penalty
Summary
The facility failed to maintain a safe and functional environment for residents, staff, and the public, as observed during a recertification survey. Several deficiencies were noted in various areas of the facility, including the Lobby area, hallways, and nursing stations. Specifically, the bathroom near the Main Dining Room had holes in the wall, a rusty call bell panel, and broken molding. Additionally, cable wires at one nurse station were covered in dirt and dust, while the second-floor nurse station had torn vinyl armrests on chairs and a desk with broken Formica paneling. Further observations revealed that the third-floor nurse station had peeling wallpaper, a desk with rough edges, and a malfunctioning bottom drawer. The staff bathroom in this area also had a leaking faucet. The 1 North Nursing station was noted to have dusty areas and unpainted ceiling patches. The facility's policy emphasizes providing a clean, comfortable, and homelike environment, but the administrator acknowledged the environmental concerns and stated that corrective actions were not yet documented or implemented.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) As of 12/31/24, the facility repaired the holes in the wall of the bathroom near the Main Dining Room, repainted as needed and replaced the rusty call bell panel and broken molding. 2) As of 12/31/24, the West unit nurse station was thoroughly cleaned specifically all cable wires to remove accumulated dirt and dust. 3) As of 12/31/24, On the 2nd Floor nursing station, Maintenance/Housekeeping department replaced the two black swivel chairs with torn vinyl armrests and repaired the desk with broken and rough-edged Formica paneling. 4) As of 12/31/24, On the 3rd floor nursing station, Maintenance/Housekeeping department replaced the peeling and torn wallpaper underneath the desk area, repaired the desk with rough bottom edges and broken Formica panels, repaired the bottom desk drawer to ensure proper closure and fixed the leaking and loose faucet in the staff bathroom. 5) As of 12/31/24, On the North unit nursing station, the Maintenance/Housekeeping department cleaned the dusty areas thoroughly and patch/painted the unpainted ceiling areas. 6) The above Immediate repairs and replacements were documented in the maintenance log and overseen by the Maintenance Director to ensure timely completion. Identification of Others 1) The Director of Maintenance and Housekeeping will conduct a facility-wide environmental audit to identify other areas that may not meet the standards of a safe, functional, sanitary, and comfortable environment. 2) Include all common areas, resident rooms, nursing stations, and staff areas in the audit. 3) Document all findings and create a prioritized corrective action plan for each identified issue. Systemic Changes 1) Review and revision of the facility's Environmental Policy to include: - Detailed cleaning schedules for all areas, including nursing stations and common spaces. - Timelines for routine inspections of furniture, fixtures, and equipment to ensure functionality and safety. - Clear procedures for promptly addressing and documenting maintenance requests. 2) Provide in-service training to Housekeepers, Maintenance Workers, RN's, LPN's and CNA's on the importance of maintaining a safe, clean, and homelike environment. 3) Emphasize protocols for reporting environmental concerns promptly to the Maintenance Director through in servicing and education. 4) Establish an annual budget and timeline for replacing worn or damaged furniture and equipment. 5) Maintain a vendor proposal log and receipts to ensure accountability for all purchases and replacements. Quality Assurance 1) The Maintenance Director or designee will develop and conduct a weekly environmental rounds audit tool focusing on areas cited in the deficiency and other high-traffic locations. 2) Conduct monthly audit of common areas, resident rooms, and nursing stations to ensure ongoing compliance. 3) Solicit feedback from residents, families, and staff through surveys and suggestion boxes to identify additional environmental concerns or improvements. 4) Audits will be completed by the Maintenance and Housekeeping weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin in a timely manner, as required by their policy and state regulations. Specifically, an allegation of sexual abuse involving a resident was not reported to the New York State Department of Health within the mandated two-hour timeframe. The incident occurred when a resident reported being inappropriately touched by another resident. The Registered Nurse on duty did not believe the allegation and delayed notifying the Director of Nursing, resulting in a late report to the authorities. Another deficiency involved a resident with a cognitive impairment who was found with a bluish discoloration and swelling on their elbow, which was later diagnosed as a fracture. The initial signs of injury were observed by a Certified Nursing Assistant, but the incident was not reported to the Department of Health when first noticed. The Director of Nursing was not informed until two days later, and the injury was only reported after the fracture was confirmed by an x-ray. Additionally, a resident experienced a fall resulting in a fracture of the right hand. The incident was unwitnessed, and although the resident was assessed and found to have no immediate visible injuries, an x-ray the following day revealed the fracture. The facility did not report this injury to the Department of Health, as the Assistant Director of Nursing believed it did not affect the resident's health condition or care. These failures to report incidents as required highlight deficiencies in the facility's adherence to reporting protocols.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction: 1) On 12/31/24, the facility implemented a 24-hour shift check to ensure that all staff are familiar with and adhere to reporting guidelines for abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. 2) On 12/31/24, training was provided to all staff on the importance of timely reporting of any alleged violations, specifically the 2-hour reporting requirement for abuse or serious bodily injury and the 24-hour reporting requirement for non-serious events that don’t result in major injury. 3) There were no adverse effects to Resident #139 as a result of reporting the incident late to the DOH. 4) There were no adverse effects to Resident #103 as a result of reporting the incident late to the DOH. 5) There were no adverse effects to Resident #71 as a result of not reporting the incident to the DOH. Identification of Others: 1) Conduct a facility-wide audit of all incidents reported over the past 6 months to identify if any other incidents were not timely reported. This will include any allegations of abuse, neglect, injuries of unknown origin, or accidents requiring reporting to the DOH. 2) The audit will be conducted by the Director of Nursing, Assistant Director of Nursing, and Administrator. Systemic Changes: 1) The facility’s Abuse Prevention Program and Incident Reporting policies will be reviewed and revised to: - Clarify the specific timeframes for reporting to the Department of Health and other relevant authorities. - Emphasize the need for immediate notification of the Administrator, Director of Nursing, and Department of Health within 2 hours of any abuse allegations or incidents involving serious bodily injury. - Include a clear statement that all incidents which don’t result in serious bodily injury must be reported to the Department of Health within 24 hours. 2) The reviewed policies will be distributed to all staff and reviewed in staff meetings. 3) Ensure that all nurses, nursing assistants, and supervisory staff are trained on the timely reporting of incidents, particularly those related to abuse, neglect, and injury of unknown origin. Training will emphasize: - Definition and identification of abuse, neglect, exploitation, mistreatment, and injuries of unknown origin. - The 2-hour and 24-hour reporting timeframes, as well as appropriate escalation procedures. - Use of the facility’s reporting forms, including how to promptly notify the Administrator, Director of Nursing, and Department of Health. 4) The facility will implement a tracking system audit tool for all reported incidents. This will allow for better tracking of timely reporting, including automated reminders and alerts for the 2-hour and 24-hour reporting requirements. 5) A daily log audit tool of incidents will be maintained, with a designated team to review and ensure compliance with reporting timeframes. 6) The Director of Nursing and Assistant Director of Nursing will implement a daily audit tool review of all reported incidents to ensure they are reported timely and accurately to the Department of Health. Any discrepancies in reporting will be addressed with immediate corrective action. Quality Assurance: 1) The Quality Assurance (QA) Committee will meet weekly to review the status of incident reporting and ensure that all allegations of abuse, neglect, and injury are reported in a timely manner. 2) The Director of Nursing (DON) and Assistant Director of Nursing (ADON) will review all current/future incidents and ensure all required reporting to the Department of Health (DOH) and State Survey Agency are submitted immediately where necessary. 3) A monthly audit of all incident reports will be conducted by the QA Committee to ensure that no incidents are missed and that all reporting requirements are followed. 4) The monthly audit will be completed by the Director of Nursing, Assistant Director of Nursing, and Administrator, weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 5) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The Administrator.
Failure to Involve Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents' rights to participate in the development and implementation of their person-centered care plans. This deficiency was identified during a recertification survey, where it was found that two residents were not invited to attend their scheduled Comprehensive Care Plan and quarterly meetings. Resident #111, who is cognitively intact, reported not being invited to any care plan meetings since admission a year ago, and there was no documented evidence of their participation or invitation. The facility's policy requires that residents receive written or verbal invitations to these meetings, but this was not adhered to, as confirmed by interviews with the Director of Social Work and Social Worker #1. Similarly, Resident #13, who has moderately impaired cognition, was not documented as being invited to or participating in care plan meetings. Although the resident's family was involved, there was no evidence that the resident was asked to participate or that their refusal was documented. The Director of Social Work acknowledged the lack of documentation regarding Resident #13's refusal to participate. The facility's failure to document invitations and participation in care plan meetings for these residents constitutes a violation of their rights under 10 NYCRR 415.3(f)(1)(v).
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction: 1) On 12/30/24, Immediate written and/or verbal invitations were sent to Resident #111 for all upcoming care plan meetings, including quarterly, significant change, and annual care plan meetings. 2) On 12/30/24, The Social Worker visited Resident #111 to explain the right to participate and assist in identifying a preferred time and manner for involvement in care planning meetings. 3) On 12/30/24, Documentation was completed by the Director of Social Services in the care plan and progress notes to indicate Resident #111's participation or refusal to attend each meeting. 4) On 12/30/24, Resident #13 was provided with written and/or verbal invitations for all upcoming care plan meetings, including quarterly, significant change, and annual meetings. 5) On 12/30/24, The Social Worker visited Resident #13 to assess their preference for participation and offer the option of attending the next care plan meeting. 6) If Resident #13 continues to refuse participation, the refusal will be documented in the progress notes, and the family will be invited to participate, with proper documentation of their involvement. Identification of Others: 1) The facility will review all other residents who have been cognitively assessed as capable of participating in care planning to ensure that all eligible residents and resident representatives have been appropriately invited and given the opportunity to engage in their care plan development. 2) A full audit by the DSW of residents who are cognitively intact and those with partial or full impairments will be conducted to ensure that invitations for care plan meetings are consistently extended, and participation is documented. Systemic Changes: 1) The facility's policy on Comprehensive Care Planning, revised 09/24, will be reviewed to clearly specify that residents must be invited to all care plan meetings, including quarterly, annual, and significant change meetings. Invitations must be extended in writing and/or verbally to all residents deemed cognitively intact. 2) The policy will include instructions for the Social Worker and interdisciplinary team on the documentation requirements, including invitations, attendance, refusals, and family involvement, to be included in the progress notes and sign-in sheets. 3) The Social Work department will receive additional training on the facility's policy regarding resident participation in the care planning process, including the requirement for documented invitations, participation, and refusals. 4) The Social Workers will be in serviced and training will focus on the importance of inviting all residents who are cognitively intact and resident representatives accurately documenting attendance, and ensuring all communications with residents and family members are clear and complete. 5) The care planning meeting schedule and process will be revised to include a checklist that confirms each resident's participation, the invitation status, and any family involvement. This checklist will be reviewed by the Director of Social Services before each meeting to ensure compliance. 6) The Director of Social Worker will ensure documentation is accurately recorded for future meetings, including whether the resident was invited and/or participated by documented efforts in progress notes and having the resident sign the care plan meeting sheets. Quality Assurance: 1) The Director of Social Services will implement a monthly audit of care plan meeting invitations, participation, and refusal documentation for the next three months to ensure compliance with the facility policy. 2) The facility administration will establish a process for residents and families to provide feedback regarding the care planning process and whether they felt adequately invited or involved by surveying residents and families on an ongoing basis. 3) The Care Plan Meeting Invitation Audits will be completed by the Director of Social Services weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Social Services.
Inaccurate MDS Assessments for Wandering Behavior
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the residents' status, specifically regarding wandering behavior. This deficiency was identified during a recertification survey for two residents. Resident #37, diagnosed with Non-Alzheimer's Dementia, Anxiety Disorder, and Mood Disorder, was documented in the MDS assessments as not exhibiting wandering behavior, despite evidence to the contrary. The resident's care plan included interventions for wandering, and observations noted the resident at the facility's entrance, indicating a risk for elopement. Interviews with staff confirmed that the resident occasionally attempted to leave the facility, contradicting the MDS assessment. Similarly, Resident #130, with diagnoses of Non-Alzheimer's Dementia, Malnutrition, and Depression, was also inaccurately documented in the MDS assessment as not exhibiting wandering behavior. The resident's care plan and evaluation notes indicated a history of wandering and the need for constant redirection. Observations during the survey showed the resident wandering off the unit and requiring staff intervention. Staff interviews corroborated these observations, highlighting the resident's frequent wandering and need for engagement in activities to prevent such behavior. The MDS Coordinator, responsible for completing the assessments, stated that wandering behavior was not documented if it was not observed during the assessment period. This approach led to inaccuracies in the MDS documentation for both residents, as their wandering behaviors were evident through care plans, staff observations, and interviews. The facility's policy on comprehensive assessments did not specifically address the accuracy of the assessments, contributing to the deficiency.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Correction 1) On 12/30/24, The Minimum Data Set (MDS) Coordinator reviewed and updated the Quarterly MDS assessment to accurately document Resident #37’s wandering behavior. 2) On 12/30/24, The Comprehensive Care Plan for Resident #37 was reviewed and revised by the MDS Coordinator to ensure interventions accurately reflect their current wandering status, including additional monitoring and activities to reduce wandering episodes. 3) On 12/30/24, The Quarterly MDS assessment for Resident #130 was reviewed and updated to reflect their wandering behavior accurately. 4) On 12/30/24, The Comprehensive Care Plan was updated by the MDS Coordinator to ensure alignment with observed behaviors, including enhanced monitoring and interventions to address wandering tendencies. 5) On 12/30/24, Education Counseling was conducted and completed on Accuracy of Assessments for the MDS Coordinator, DON, ADON, DSW, and DOR. Identification of Others 1) An audit of the last 30 days of MDS assessments will be conducted by the MDS Coordinator to identify any inaccuracies related to wandering or other behaviors. 2) Residents identified with discrepancies will have their MDS assessments updated, and care plans revised accordingly. Systemic Changes 1) The facility policy on Minimum Data Set Comprehensive Assessments has been revised by the Administrator to include explicit guidelines emphasizing the importance of accurate documentation of residents’ behaviors, including wandering. 2) All MDS Coordinators, Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) will be re-educated on: - A review of the regulatory requirement of F641. - The importance of accurate MDS documentation. - Observing, reporting, and documenting wandering and other behavioral patterns. - Utilizing interdisciplinary team input to ensure MDS accuracy. 3) A daily communication audit tool will be developed and implemented to ensure all wandering behaviors are documented and considered during MDS assessments. Quality Assurance (QA) 1) An interdisciplinary team meeting will be held bi-weekly to review residents with identified wandering behaviors and ensure care plans and interventions are appropriate and effective. 2) Monthly in-service training sessions on MDS accuracy and behavioral documentation will be conducted to ensure ongoing compliance x 6 months. 3) Audits will be completed by the MDS Coordinator weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI meeting quarterly for tracking of facility compliance. Person Responsible for this Ftag: 1) The MDS Coordinator.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic drugs underwent gradual dose reductions unless clinically contraindicated. This deficiency was identified during a recertification survey, where it was found that a resident with a diagnosis of Non-Alzheimer's Dementia and Major Depressive Disorder was receiving Seroquel and Valproic Acid for an unspecified mood disorder. Despite the absence of documented psychotic behaviors or mood symptoms that would justify the continued use of these medications, no attempts at gradual dose reduction were made. The resident's medical records and observations during the survey period showed no evidence of psychotic behavior, yet the resident continued to receive the prescribed antipsychotic medication. The psychiatric consultation notes indicated that the psychiatrist had recommended a gradual dose reduction of Seroquel, but the resident's son consistently refused this intervention. Interviews with the psychiatric nurse practitioner and the Director of Nursing confirmed that the resident's son opposed the dose reduction, preventing its implementation. The facility's failure to attempt a gradual dose reduction, despite the absence of clinical indications for continued use of the medication, constitutes a deficiency in adhering to regulatory requirements for the management of psychotropic medications.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Correction 1) On 12/24/24, A care conference was held with Resident #153’s son, the psychiatric nurse practitioner, and the attending physician to discuss the necessity of a gradual dose reduction (GDR) and behavioral interventions. 2) On 12/14/24, The psychiatrist/psychiatric nurse practitioner documented the clinical justification for attempting the GDR. 3) On 12/24/24, All [MEDICAL CONDITION] medications and CCP were updated by the IDT team for Resident #153 to ensure compliance with requirements, and any necessary changes were documented in the clinical record. Identification of Others 1) Develop an audit tool of all residents currently prescribed [MEDICAL CONDITION] medications to identify those who: - Have not undergone a GDR, if clinically appropriate. - Lack documentation of behavioral symptoms or a specific [DIAGNOSES REDACTED]. - Have PRN orders for [MEDICAL CONDITION] medications exceeding 14 days without proper evaluation and documentation. 2) Immediate corrective actions will be implemented for identified residents, including care plan updates, medication reviews, and staff education. Systemic Changes 1) Review and revise the facility's policy on [MEDICAL CONDITION] medication use to include: - Guidelines for initiating and documenting GDRs. - Processes for handling refusals by family or residents, including obtaining written refusal documentation. 2) Provide training to RN's, LPN's, Psychiatrist and Dr's on the following: - Regulatory requirements for [MEDICAL CONDITION] medications and PRN orders. - Documentation standards, including behavioral monitoring and physician rationales. - Effective communication strategies for engaging families in care decisions. 3) Develop standardized communication audit to educate families about the benefits of GDRs and the risks of long-term [MEDICAL CONDITION] medication use. 4) The facility’s medical director will review the case to ensure adherence to regulations and provide oversight for future interventions. Quality Assurance 1) The pharmacy consultant will conduct monthly reviews of [MEDICAL CONDITION] medication use for all residents, including compliance with GDRs and PRN order limits. 2) The interdisciplinary team (IDT) will review [MEDICAL CONDITION] medication cases during quarterly care plan meetings. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.
Failure to Develop Comprehensive Care Plan for Resident's Skin Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with ongoing skin issues, specifically Prurigo Nodularis, as identified during a recertification survey. The resident, who was admitted with diagnoses including Chronic Liver Disease and skin conditions, reported itchy skin since admission and noted that the facility was supposed to provide cream but did not. A dermatology consult confirmed the presence of erythematous papules and diagnosed the resident with Prurigo Nodularis, yet no care plan addressing these skin issues was created or implemented. Interviews with facility staff revealed a lack of coordination and responsibility in addressing the resident's skin condition. The Medical Doctor acknowledged the resident's chronic liver condition and its potential link to itchiness but did not renew the Cortisone cream due to concerns about skin thinning and the resident's intermittent complaints. The Director of Nursing indicated that the Minimum Data Set Coordinator and nurse supervisors were responsible for care plan initiation and revision, yet this was not done for the resident's skin condition, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) On 12/30/24, An MD assessment was completed on Resident #111 who addressed the itchy skin condition by giving the resident a cream. 2) On 12/10/24, A comprehensive care plan was developed and implemented to address Resident #111’s ongoing skin condition. 3) On 12/26/24, Education was completed for the staff responsible for initiating clinical care plans. Identification of Others 1) A facility-wide audit tool will be developed to identify all residents with skin conditions or similar complaints who may not have a comprehensive care plan in place. 2) All identified residents will have their care plans reviewed, developed, or updated to address their individual needs. Systemic Changes 1) The facility policy on Comprehensive Care Planning was reviewed and revised by Facility Administrator to include specific guidelines for the development and implementation of care plans addressing chronic conditions, including skin conditions. 2) Clear timelines for initiating care plans upon admission and updating them quarterly or as conditions change were added to the policy. 3) Minimum Data Set (MDS) Coordinator, RN's and LPN's were re-educated on: - The process of developing, implementing, and updating comprehensive care plans. - Identifying resident needs through assessments, observations, and interdisciplinary collaboration. - Incorporating physician recommendations, specialist input, and resident preferences into care plans. 4) A checklist audit tool was introduced to ensure care plans address all identified medical, nursing, psychosocial, and other resident needs. 5) The care plan includes measurable objectives and specific interventions, such as: - Monitoring the skin condition for changes or flare-ups. - Ensuring availability and application of prescribed topical creams or other dermatologic treatments as needed. - Coordinating with dermatology for follow-up consultations and recommendations. - Educating staff on proper skin care techniques and resident preferences. Quality Assurance (QA) 1) The Director of Nursing (DON) or designee will review care plans weekly to ensure all identified conditions are addressed in comprehensive care plans. 2) Random audits of care plans will continue quarterly for one year, ensuring compliance with federal regulations and timely updates to care plans as resident needs change. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.
Failure to Revise Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team after each assessment, as required by their policy. This deficiency was identified during a recertification and abbreviated survey, specifically affecting a resident who was reviewed for dental care. The resident, who had diagnoses including Anxiety Disorder, Dysphagia, and Type 2 Diabetes Mellitus, had a care plan for oral/dental care that was created on August 11, 2023. However, there was no documented evidence that this care plan had been reviewed or revised following the quarterly assessments conducted on April 18, 2024, July 10, 2024, and October 2, 2024. The facility's policy mandates that care plans be reviewed at intervals not exceeding 92 days after the last assessment reference date. Despite this requirement, the care plan for the resident's oral/dental care was not updated as necessary. During an interview, the Director of Nursing acknowledged the oversight, stating that while they strive to review and revise care plans, it sometimes does not get done. The responsibility for developing and updating care plans was attributed to the Minimum Data Set Coordinator and the Registered Nurse supervisors, but no interview with the MDS Coordinator was conducted to further explore the issue.
Plan Of Correction
Plan of Correction: Approved January 2, 2025 Immediate Correction 1) On 12/30/24, Resident #17 was assessed by MD. 2) Dental Consult was done on 12/19/24 at the hospital. 3) On 12/10/24, The comprehensive care plan for Resident #17 related to oral/dental care was reviewed and revised by the interdisciplinary team (IDT) to reflect the current assessment and oral health status. 4) The care plan now includes measurable goals, updated interventions, and a schedule for follow-up evaluations. 5) On 12/30/24, The Minimum Data Set (MDS) Coordinator and the registered nurse supervisor responsible for Resident #17’s care plan were counseled and re-educated on care plan timing and revision requirements. Identification of Others 1) A facility-wide audit in the last 30 days will be conducted to identify residents whose care plans had not been reviewed or revised within the required timeframes. 2) Care plans for all residents identified in the audit will be reviewed and revised as needed. Systemic Changes 1) The facility's policy on Comprehensive Care Planning was reviewed and revised by the Facility Administrator to explicitly include: - Care plan reviews and updates must occur after every comprehensive and quarterly assessment. - A checklist for MDS Coordinators and the IDT to ensure compliance with the 92-day review requirement. - Documentation requirements for resident and/or representative participation in care plan meetings or reasons for their absence. 2) MDS Coordinator, RN's and LPN's were re-educated on care plan timing and revision regulations by the Director of Nursing (DON). 3) Training emphasized the importance of timely care plan updates, interdisciplinary collaboration, and accurate documentation. 4) IDT meetings were restructured to include a dedicated review of residents due for care plan updates within the next 30 days. 5) The MDS Coordinator will send reminders to IDT members seven days prior to quarterly care plan review deadlines. 6) A care plan audit tool was developed and implemented to ensure that all care plans are reviewed, revised, and updated as required. 7) The tool will track care plan creation, review dates, and changes made during assessments. Quality Assurance (QA) 1) The DON or designee will complete random care plan audits quarterly for one year to monitor ongoing compliance. 2) Resident council meetings will include a discussion on care plan updates to ensure resident participation and satisfaction with their care plans. 3) Audits will be completed by the Director of Nursing weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 4) Findings will be brought to the QAPI quarterly meeting for tracking of facility compliance. Person Responsible for this Ftag: 1) The Director of Nursing.
Failure to Maintain Kitchen Fire Extinguishing System
Penalty
Summary
The facility failed to ensure that the kitchen's automatic extinguishing system was maintained according to the 2009 NFPA 17A standards. During a document review, it was discovered that the last inspection and maintenance report for the Ansul extinguishing system in the kitchen was dated January 24, 2024, which exceeded the required six-month interval for maintenance. The report from Fire Command Co. indicated that they were unable to perform the inspection due to a lack of protection for the cheese melter and noted that the system needed to be legalized following a change in equipment by the customer. Upon interviewing the Facilities Director, it was revealed that the Ansul equipment had been replaced and a new vendor was contracted for maintenance and inspections. However, it was unclear if the local fire department had inspected and certified the new equipment, and no recent vendor inspection report was available. At the exit conference, the Administrator mentioned that the vendor had recently visited the facility, but the report was not yet available.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Correction: 1) Upon discovering the missed 6-month maintenance interval for the Ansul automatic extinguishing system, the facility immediately contacted a licensed and certified vendor to perform a full inspection and servicing of the system. 2) The facility will ensure the new kitchen equipment (including the Cheese Melter) is properly integrated into the Ansul system. Following the inspection, a report and work quote from the Fire Command Co. vendor was obtained and approved. Identification of Others: 1) The facility will conduct a comprehensive review of all cooking equipment in the kitchen, including checking for proper installation, fire extinguishing system coverage, and compliance with NFPA 96 and NFPA 17A. 2) The Director of Maintenance will ensure that a list of all equipment and associated fire suppression systems is updated. Additionally, the facility will maintain regular communication with the vendor and the local fire department to ensure that all future inspections are performed in a timely manner and that the equipment is certified according to the latest standards. Systemic Changes: 1) The Director of Maintenance will implement a new automated maintenance tracking system audit tool to ensure that all fire suppression and extinguishing systems are inspected at the required intervals. 2) The Director of Maintenance and all relevant maintenance staff will undergo training on the NFPA 96 and NFPA 17A standards, specifically focusing on the requirements for maintaining automatic extinguishing systems in kitchens. Quality Assurance (QA): 1) The facility will implement monthly audits of all fire safety equipment in the kitchen, including automatic extinguishing systems, fire suppression systems, and related equipment. These audits will verify that all equipment is functional and maintained according to NFPA standards, and that service reports are up to date. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan.
Egress Lighting Deficiency Due to Timer Control
Penalty
Summary
The facility failed to ensure continuous illumination of the means of egress, as required by the 2012 NFPA 101 standards. During a life safety survey conducted on December 3, 2024, it was observed that the lighting at the first-floor exit discharge at the West stair and the adjacent dining room exit was controlled by a timer. This setup did not comply with the requirement for continuous illumination, as the lights were not operable without the use of a timer. The deficiency was identified through both observation and interview, where the Facilities Director acknowledged the issue. The lighting arrangement at these egress points did not meet the standard that requires illumination to be continuous during occupancy and not compromised by energy-saving devices like timers. The failure to provide continuous lighting could potentially affect the safety of the egress paths, although the report does not specify any direct consequences or risks that occurred as a result of this deficiency.
Plan Of Correction
Plan of Correction: Approved December 19, 2024 Immediate Correction: 1) On 12/4/2024, the timers that controlled the lighting at the West stairs were immediately deactivated and replaced with photocell sensors. 2) The new photocell sensors now ensure that the lighting remains continuously operational, without the need for manual intervention, and fully meets the requirements. 3) The newly installed photocell sensors were tested on-site to confirm that the egress lighting now operates continuously during hours of occupancy, in compliance with the required illumination standards. The lighting was inspected to ensure that no failure of any single lighting unit resulted in an illumination level of less than 0.2 ft-candle in any designated area. 4) The Director of Maintenance documented the replacement of the timers and the installation of photocells, confirming that all lighting in the means of egress is now continuously illuminated. Identification of Others: 1) A comprehensive review of all lighting systems controlling means of egress throughout the facility was conducted to identify any additional instances where timers or other manual control systems might be in place. This included all exit access areas such as corridors, stairs, aisles, and exits. Systemic Changes: 1) As a systemic change, the facility will ensure that all areas requiring illumination of egress pathways are equipped with photocell sensors to guarantee that lighting will remain continuously on, even if power is lost or if there is a failure of an individual lighting unit. 2) The Facility Director will ensure that all maintenance and operations staff are trained in the requirements, specifically regarding continuous illumination for means of egress. This training will emphasize the proper installation and maintenance of lighting systems and photocell sensors. Quality Assurance (QA): 1) The Director of Maintenance will implement a monthly audit tool to verify that all means of egress lighting remain continuously operational and is in compliance. The audits will include checking that photocell sensors and lighting units function properly without any timers or manual switches. 2) Audits will be completed by the Director of Maintenance weekly x 4 weeks; monthly x 3 months; and quarterly for x 1 year. Any negative findings will be addressed immediately. 3) Findings will be brought to the QAPI meeting for tracking of facility compliance. Person Responsible for this Ktag: The Director of Maintenance will have direct oversight of the implementation and effectiveness of the corrective action plan.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving a resident and a maintenance employee to law enforcement, as required by their policy and federal regulations. The incident occurred when a resident, who had intact cognition as per their Minimum Data Set assessment, reported that a maintenance employee inappropriately touched them. The resident identified the employee by name to the Administrator. Despite the facility's policy mandating that suspicions of abuse be reported to local law enforcement and the New York State Department of Health, the facility did not report the alleged abuse to law enforcement. The resident involved had a medical history including Non-Alzheimer's Dementia, Depression, and Major Depressive Disorder. The facility's Potential for Victimization Comprehensive Care Plan for the resident included interventions such as providing emotional support and reality orientation. The Administrator, upon learning of the allegation, asked the resident if they wanted law enforcement to be contacted, and the resident refused. Consequently, the facility did not proceed with contacting law enforcement, which was a deviation from their established procedures and regulatory requirements.
Medication Error: Incorrect Tube Feeding Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving a Licensed Practical Nurse (LPN) who administered tube feeding to the wrong resident. On the specified date, the LPN did not verify the identity of the resident before starting the tube feeding process. This resulted in the administration of approximately 50 milliliters of feeding formula through the Gastrostomy tube of a resident who did not have a medical order for such feeding. The facility's policy on medication administration requires verification of the resident's identity, which was not adhered to in this case. The resident involved in the incident had a medical history that included cerebral infarction, aphasia, and hemiplegia, and was cognitively impaired with a low score on the Brief Interview on Mental Status. The resident's care plan and physician orders specified only the flushing of the Gastrostomy tube with water, not the administration of feeding formula. Despite the error, the resident was assessed and monitored for any adverse effects, and none were observed. Interviews with facility staff revealed that the LPN prepared the feeding for residents with medical orders and mistakenly connected the feeding pump to the wrong resident. The LPN did not check the identification bracelet of the resident before administering the feeding. The error was discovered when the resident's spouse alerted the Registered Nurse Supervisor, who then stopped the feeding. The incident was reported to the Assistant Director of Nursing and the Director of Nursing, who confirmed that the LPN did not follow the facility's medication administration policy.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident with severe cognitive impairment. On the morning of 09/12/2023, Resident #1, who was admitted with diagnoses including Metabolic Encephalopathy and Cerebral Infarction, left the facility undetected. The resident was last seen by the night nurse at approximately 7:00 AM in their room. However, by 7:15 AM, video surveillance captured the resident leaving their room and exiting towards the back door, eventually disappearing from camera view. The staff's inaction contributed to the deficiency. LPN #2, who arrived on the unit at 7:25 AM, was informed by the night shift nurse that the resident was in the bathroom. However, neither LPN #2 nor CNA #2 checked the bathroom or confirmed the resident's whereabouts. It wasn't until around 8:15 AM that staff realized the resident was missing, prompting a search and the activation of Code E for elopement. The resident was eventually located by police at a family member's house later that afternoon. Interviews with staff revealed a lack of adherence to the facility's policies on resident checks and elopement prevention. The Assistant Director of Nursing and the Director of Nursing both emphasized the responsibility of staff to visually monitor residents and ensure their safety. However, the failure to conduct routine checks and verify the resident's location led to the oversight that allowed the resident to leave the facility undetected.
Latest citations in New York
A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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