Williamsville Suburban, L L C
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsville, New York.
- Location
- 193 South Union Road, Williamsville, New York 14221
- CMS Provider Number
- 335647
- Inspections on file
- 25
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Williamsville Suburban, L L C during CMS and state inspections, most recent first.
Multiple residents reported receiving cold, unappetizing, and sometimes inedible meals, with observations confirming that hot foods were served below required temperatures and meal delivery was delayed. Staff interviews revealed ongoing complaints about food quality, non-functioning kitchen equipment, and insufficient staffing, all contributing to the deficiency in providing safe and palatable meals.
Surveyors found extensive failures in food safety and sanitation, including improper food storage, undated and expired foods, soiled equipment and surfaces, lack of required hair and beard restraints, and malfunctioning refrigeration and dishwashing equipment. Multiple nourishment refrigerators were above safe temperatures and contained expired or unlabeled items, while staff were unclear about cleaning responsibilities and food labeling policies. The facility lacked a current kitchen cleaning schedule, and essential food safety practices were not consistently followed.
Surveyors found that the facility did not ensure a clean, sanitary, and homelike environment, with observations of torn and stained privacy curtains, soiled and discolored surfaces, broken fixtures, and soiled linens left on floors in both resident rooms and shower areas. Staff and residents reported ongoing issues with cleanliness, maintenance, and infection control, and documentation of daily cleaning could not be produced during the survey.
The facility did not properly contain and dispose of garbage and refuse outside both the South and North Buildings. Dumpsters were frequently left open and overfilled, with bagged garbage and loose debris observed on the ground, including food waste and other refuse. Staff interviews confirmed that dumpsters should be kept closed and the area clean, but these practices were not consistently followed.
Two residents with significant care needs did not receive timely assistance with personal hygiene and incontinent care. One resident was left without bathing or morning care for several days after admission, while another waited over an hour for requested incontinent care. Staff interviews confirmed that daily ADL support and prompt response to care requests were not consistently provided, contrary to facility policy.
Surveyors found that two residents did not receive treatment and care in accordance with physician orders and professional standards. One resident with pressure ulcers did not have consistent skin assessments or documentation of wound care, while another with a PICC line experienced delays in obtaining dressing change orders and incomplete documentation of required flushes and assessments. Staff interviews revealed confusion about care responsibilities and processes.
A resident with Alzheimer's disease and depression, who had a history of expressing sadness and making negative statements, did not receive a timely psychiatry consult as previously recommended. Despite family requests and staff awareness of the resident's mental health concerns, the facility failed to order or complete the consult due to lapses in provider coverage, communication breakdowns among staff, and lack of follow-up on provider recommendations.
Surveyors found that staff did not consistently follow enhanced barrier precautions and hand hygiene protocols during high-contact care activities for two residents with complex medical needs. Staff provided care without required gowns and failed to change gloves or perform hand hygiene between dirty and clean tasks, contrary to facility policy and posted instructions. Interviews revealed gaps in staff understanding of infection control requirements, contributing to the deficiency.
The facility did not consistently ensure that both incoming and outgoing nurses signed the controlled substance inventory sheets at each shift change, resulting in numerous missing signatures across multiple units. Despite clear policies requiring dual nurse verification and signatures for narcotic counts, staff interviews revealed that signatures were often omitted due to distractions, forgetfulness, or staff working double shifts. Supervisory staff confirmed that the records were incomplete and did not meet professional standards for accountability.
Surveyors found that the facility did not ensure a clean, safe, and homelike environment, with observations of dirty floors, stained ceiling tiles, damaged window blinds, soiled bathroom fixtures, and improper storage of personal care items. Staff and residents reported dissatisfaction with cleanliness, and interviews revealed that cleaning and maintenance standards were not consistently met, contributing to unsanitary and uncomfortable living conditions.
A resident with severe cognitive impairment and multiple diagnoses did not receive required assistance with shaving, resulting in unkempt appearance and facial hair longer than ¼ inch. Despite policies and staff acknowledgment that shaving should occur on shower days or as needed, documentation and interviews confirmed that the resident was not shaved as required, and no refusals were documented.
The facility failed to maintain sufficient staffing levels, leading to unmet resident care needs. Residents reported delays in personal care, and staff struggled to complete duties due to understaffing, particularly on weekends. The DON and Interim Administrator acknowledged the staffing issues and their impact on care.
The facility failed to maintain an effective antibiotic stewardship program, lacking documentation and tracking of antibiotic use from July to October 2024. A resident with multiple diagnoses, including a stage 4 pressure ulcer and osteomyelitis, was on several antibiotics, but there was no evidence of monitoring or tracking. Staff interviews revealed a lack of awareness and documentation, with the new DON still in training and the previous DON having left recently.
A resident with an indwelling catheter and stage IV pressure ulcer was not provided care in accordance with enhanced barrier precautions. CNAs failed to wear gowns during high-contact activities, despite clear signage and available PPE. Interviews confirmed staff awareness of the requirements, yet they did not comply, indicating a deficiency in the infection control program.
A resident with severe cognitive impairment was found with a hematoma of unknown origin on their forehead. The injury was not reported to the facility's Administrator and the State Survey Agency within the required two-hour timeframe. Staff interviews revealed uncertainty about the incident and delayed notification to the Director of Nursing, highlighting a failure to adhere to reporting protocols for potential abuse cases.
Two residents with cognitive impairments and diabetes did not receive necessary grooming and personal hygiene care, including nail trimming and bathing, as required by their care plans. Observations showed unkempt nails and facial hair, while documentation inaccurately reflected care provision. Staff interviews revealed communication lapses and failure to follow through with scheduled care.
A resident with a foley catheter developed a urinary tract infection due to improper catheter care. The catheter drainage bag was left on the resident's lap instead of being positioned below the bladder, contrary to facility policy. The resident, who had a history of UTIs and a stage IV pressure ulcer, reported a burning sensation, and a urinalysis confirmed the infection. Staff interviews confirmed the improper positioning of the catheter bag, which should have been placed below the bladder to prevent infection.
The facility failed to properly store controlled substances, specifically Lorazepam, in a medication room. The medication refrigerator was not affixed, and the locked compartment inside was not used due to a missing key. Staff, including an LPN and the DON, were unaware of the unsecured state and the need for affixed storage, leading to improper storage of controlled substances.
A resident with a chipped tooth did not receive necessary dental services due to a breakdown in the facility's process for scheduling appointments. Despite a recommendation for a crown, the resident's care plan was not updated, and no follow-up appointment was made. Staff interviews revealed communication failures and a lack of responsibility in ensuring the resident's dental needs were met.
The facility failed to post contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline in an accessible manner for residents and their representatives. Observations and interviews revealed that the information was not posted in the North building, and staff were unaware of their responsibility to ensure its visibility.
The facility failed to implement care plans for three residents, which included the use of stop signs on room doors to prevent other residents from entering. Despite being documented in care profiles, the stop signs were not in place, and staff were unclear about the documentation and responsibility for this intervention. This oversight affected residents with conditions such as anxiety, depression, and dementia.
The facility failed to protect a resident from physical abuse when another resident with a history of aggression grabbed and threw them to the floor, resulting in significant injuries. Despite care plans in place for both residents, the incident occurred while an LPN was engaged in a medication pass, leading to the injured resident's hospitalization.
The facility failed to thoroughly investigate an incident of resident-to-resident abuse involving two residents. Despite video evidence of the altercation, no statements were collected from staff witnesses, and the facility did not follow its policy to evaluate the events leading up to the abuse. The investigation was deemed incomplete by multiple staff members, including the Administrator and Director of Nursing.
Failure to Provide Palatable and Safe-Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures for residents in both buildings, as well as on a test tray. Multiple residents reported that meals were consistently served cold, unappetizing, and sometimes inedible. Observations and interviews revealed that residents often received their meals late, with food items such as pork chops, mashed potatoes, and vegetables being served at temperatures well below the required hot holding threshold. Residents described the food as bland, tough, overcooked or undercooked, and lacking in flavor. Some residents reported missing meal components or receiving incorrect items on their trays, and several stated that they or their families had to supplement their diets due to the poor quality of the facility's food. Staff interviews confirmed ongoing issues with food temperature and palatability. Dietary and nursing staff acknowledged that residents frequently complained about cold and unappealing food, and that trays were often delivered late due to short staffing in the kitchen. Staff also reported that the plate warmer in the kitchen was not functioning and had not been replaced, and that the steam table was awaiting approval for replacement. The Food Service Director and Administrator were aware of the complaints and equipment issues, but there was no evidence that these problems had been resolved at the time of the survey. Staff also indicated that they were not always able to accommodate residents' requests for reheating food or providing missing items due to limited resources. Temperature checks conducted by surveyors during meal service confirmed that hot foods were not maintained at the required temperatures. For example, pork chops on the tray line were measured at 142.7 to 144.2 degrees Fahrenheit, but by the time they reached residents, the temperature had dropped to 99.2 degrees Fahrenheit. Other hot items, such as mashed potatoes and vegetables, were also served below the required temperature, while cold items were within acceptable ranges. The lack of functioning equipment, delayed meal delivery, and insufficient staffing contributed to the failure to provide meals that met regulatory standards for safety, palatability, and resident satisfaction.
Widespread Food Safety and Sanitation Deficiencies in Food Service Operations
Penalty
Summary
Surveyors identified multiple failures in food storage, preparation, distribution, and service that did not meet professional standards for food safety. Observations in both the South and North Building kitchens revealed personal coats stored in food and single service item storage areas, soiled and dusty surfaces, broken wall tiles, and improper thawing of meats. Staff were seen in food preparation areas without required hairnets or beard nets, and there were numerous instances of undated, outdated, or unlabeled refrigerated foods. Food labeled as 'Keep Frozen' was found stored in refrigerators for unknown periods, and a bench style can opener was heavily soiled with food residue. Cases of food and single service items were stored directly on the floor, and raw meat was stored above ready-to-eat foods in the walk-in cooler. Equipment issues included a reach-in freezer with a broken door and unsafe temperatures, active water leaks from dishwashers, flies in dishwashing areas, missing or nonfunctional thermometers, and a missing floor drain grate. Nourishment refrigerators on multiple units were found to be soiled, contained expired or unlabeled foods, and lacked thermometers. Air and food temperatures in these refrigerators were frequently above safe ranges, with some measured as high as 62 degrees Fahrenheit. Trays of nourishments, including dairy products, were stored unrefrigerated for extended periods, and staff were unclear about the frequency of refrigerator cleaning and monitoring. Staff interviews confirmed that dietary and nursing staff were not consistently following policies for labeling, dating, and discarding perishable foods, and that there was confusion regarding responsibility for maintaining nourishment refrigerators. In several cases, expired or improperly stored foods were voluntarily discarded by staff during the survey. Additional deficiencies included the absence of chlorine test strips for low-temperature dishwashers, nonfunctional or unreadable thermometers on dishwashing machines, and the use of dry wiping cloths instead of storing them in sanitizing solution. Staff from other departments entered food preparation areas without appropriate hair restraints, and there was no current kitchen cleaning schedule in place. The Food Service Director and other staff acknowledged these issues during interviews, noting that some equipment problems had been reported but not resolved, and that cleaning schedules and food safety practices were not being consistently implemented.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a sanitary, orderly, and comfortable environment in both the North and South Buildings, as required by regulation. Observations revealed multiple deficiencies, including torn and stained privacy curtains in resident rooms, soiled and discolored walls, floors, and baseboards, and shower rooms with soiled furnishings, loose toilet seats, and unlabeled personal care items. Additional findings included broken blinds, wall board in disrepair, stained ceiling tiles, rusty ceiling tile grids, and soiled linens left on floors in both shower rooms and resident rooms. These conditions were directly observed by surveyors and corroborated by resident and staff interviews, which described the environment as unsanitary and lacking in ambiance. Interviews with residents and staff further confirmed the ongoing issues. One resident reported that their privacy curtain was stained with blood and had been unsanitary since admission, despite reporting it to staff. Staff members, including CNAs, RNs, and housekeeping aides, acknowledged the poor quality of the environment, noting dirty baseboards, grimy floors, and the presence of fecal matter on bathroom fixtures and furniture. Staff also indicated that maintenance and housekeeping were aware of some issues, such as broken floor tiles and soiled areas, but these problems persisted over time. Housekeeping staff reported challenges with cleaning certain areas due to wax buildup and damaged equipment, and maintenance staff were sometimes unaware of specific deficiencies until informed by surveyors or other staff. Documentation review showed that the facility had established housekeeping procedures and daily cleaning checklists, but completed checklists could not be produced during the survey. The Housekeeping Supervisor stated that audits of privacy curtains had been conducted and new curtains ordered, but many issues remained unresolved at the time of the survey. The Administrator and supervisors acknowledged problems with cleaning equipment and the need for further maintenance, but the observed deficiencies indicated a failure to ensure a safe, clean, and homelike environment for residents, as required by facility policy and regulation.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in both the South and North Buildings, as required by their policy and state regulations. Observations revealed that dumpsters outside both buildings were frequently left with open lids and sliding doors, and were often overfilled, with bagged garbage and debris extending above the top rim. Garbage and loose debris, including food waste, disposable gloves, milk cartons, and other refuse, were observed scattered on the ground around the dumpsters. In some instances, large items such as pieces of wood and broken ceiling tiles contributed to the dumpsters being overfilled and unable to be closed. Additionally, a bag of garbage was found left on the ground near a facility entrance. Interviews with the Maintenance Director and Housekeeping Director confirmed that the dumpsters should be kept closed and the surrounding areas clean, but these practices were not consistently followed. The Maintenance Director noted that cleaning around the dumpsters was a Maintenance department responsibility, but assistance had been requested from the Dietary department due to the nature of the waste. The Maintenance Director also indicated that the overflow was likely caused by large boxes occupying space in the dumpsters. Despite scheduled garbage pickups, the dumpsters remained overfilled and the surrounding areas were not maintained in accordance with facility policy.
Failure to Provide Timely ADL and Incontinent Care
Penalty
Summary
Two residents were not provided with necessary assistance for activities of daily living (ADLs), specifically related to personal hygiene and timely incontinent care. One resident, who had diagnoses including macular degeneration, congestive heart failure, and diabetes, was admitted to the facility and did not receive any bathing or morning care for several days after admission. The resident reported feeling unclean and uncomfortable, and observations confirmed the absence of personal hygiene supplies in the room, as well as visible signs of poor hygiene such as dry, flaking skin on bedsheets. Staff interviews revealed that morning care was not provided daily as required, and that personal care items should have been present upon admission but were not. Another resident, with a history of hemiplegia, hemiparesis, and amputation, was dependent on staff for toileting and hygiene. This resident reported requesting incontinent care over an hour prior to being assisted, and repeated requests for care were not promptly addressed. Observations showed that the resident's call bell remained unanswered for an extended period, and staff acknowledged that care was delayed due to workload and the need for two staff members to assist. Staff interviews confirmed that timely incontinent care was not provided, despite the resident's dependency and the importance of preventing skin breakdown. Facility policies required daily assistance with ADLs, including bathing, grooming, and toileting, to maintain residents' dignity, skin integrity, and overall well-being. However, the documented actions and inactions of staff resulted in residents not receiving the necessary care as outlined in facility procedures and policies. Staff and supervisory interviews consistently indicated that the care provided did not meet the expected standards for daily hygiene and timely response to resident needs.
Failure to Provide and Document Ordered Wound and PICC Line Care
Penalty
Summary
Surveyors identified deficiencies in the facility's provision of treatment and care according to physician orders and professional standards for two residents. For one resident with a history of stroke, congestive heart failure, and diabetes, there was a lack of ongoing skin assessments and incomplete documentation and administration of ordered wound care. The resident was admitted with three stage 2 pressure ulcers, and although an initial treatment order was in place, weekly skin assessments were not consistently performed or documented between late November and mid-December. The Treatment Administration Record showed that wound care was only documented as completed on six out of twenty-two days, and there was minimal progress note documentation regarding the resident's wounds during this period. Interviews with nursing staff revealed uncertainty about wound care responsibilities and processes, and the wound care provider was not involved as expected. For another resident with macular degeneration, congestive heart failure, and diabetes, there was a delay in obtaining orders for PICC line dressing changes and incomplete documentation of required PICC line flushes. Upon admission, the resident had a double lumen PICC line, but no orders for dressing changes or monitoring were obtained until several days later. The Treatment Administration Record indicated that PICC line flushes were only documented as completed three out of eleven scheduled times over a four-day period. There was also no evidence that the PICC line dressing was changed or that required measurements and assessments were performed as ordered. Nursing staff interviews confirmed that initial assessments and ongoing care for the PICC line were not consistently performed or documented. The facility's policies required thorough documentation and adherence to physician orders for wound and PICC line care, including regular assessments, dressing changes, and completion of treatments as ordered. However, the survey found gaps in both the performance and documentation of these essential care activities. Staff interviews highlighted a lack of clarity regarding responsibilities and processes for wound and PICC line care, contributing to the deficiencies observed during the survey.
Failure to Provide Timely Psychiatric Consultation for Resident with Mental Health Needs
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, depression, and a history of expressing sadness and making negative statements did not receive a psychiatry consult as previously recommended by a psychiatric provider. The facility's policy required behavioral health services to be provided as needed, but there was no evidence that a psychiatry consult was ordered or completed for the resident, despite documented recommendations and family requests. The resident's care plan included interventions such as psychiatry/psychology consults and monitoring for mood changes, but these interventions were not fully implemented. Multiple staff interviews and record reviews revealed that the facility experienced a lapse in psychiatric provider coverage due to the previous provider discontinuing services and delays in securing a replacement. During this period, the resident's family expressed concerns about negative and potentially suicidal statements, requesting a psychiatric evaluation. Nursing staff implemented increased monitoring and communicated with the nurse practitioner, who evaluated the resident and recommended a psychiatry consult. However, no order for a psychiatry consult was placed, and the recommendation was not followed through. Further interviews indicated breakdowns in communication and follow-up among nursing, social work, and administrative staff. The social work department was unaware of the resident's negative statements and did not complete an assessment or facilitate a psychiatric referral. The nurse practitioner did not place an order for a psychiatry consult, citing the absence of an in-house provider at the time. The administrator and director of nursing acknowledged gaps in the process, including lack of documentation, missed follow-up, and unclear protocols for handling provider recommendations and psychiatric referrals.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for two of five residents reviewed. For one resident with multiple medical conditions, including a PICC line, Foley catheter, and a wound requiring a wound vac, staff did not adhere to enhanced barrier precautions as required. Certified Nurse Aides provided hands-on care, such as bathing, turning, and catheter care, while wearing gloves but not gowns, despite signage and facility policy mandating both gown and glove use for high-contact activities. Interviews with staff revealed a lack of understanding regarding the specific requirements of enhanced barrier precautions and the appropriate use of personal protective equipment (PPE) based on the type of precaution indicated. In another instance, a resident dependent on staff for toileting and hygiene care received fecal incontinence care from a Certified Nurse Aide who failed to remove gloves and perform hand hygiene before handling clean briefs, applying barrier cream, and touching clean linens and the bed remote. This action was contrary to the facility's hand hygiene policy, which requires glove removal and hand hygiene after contact with bodily fluids and before handling clean items. The staff member acknowledged during interview that they should not have touched clean items with contaminated gloves, recognizing the risk of cross-contamination. Further interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that the expectation was for staff to follow enhanced barrier precautions and proper hand hygiene protocols to prevent the spread of infection. The deficiency was attributed to staff not consistently following established infection control policies, including the use of PPE and hand hygiene practices during resident care activities involving high risk for transmission of communicable diseases.
Incomplete Documentation of Controlled Substance Counts
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards, specifically regarding the documentation of controlled substance inventory counts. Review of the Controlled Substance Inventory Sheets for several units revealed 149 blank signature spaces between 12/1/2025 and 12/19/2025, indicating that the required shift-to-shift counts were not consistently signed off by both the incoming and outgoing nurses. Facility policy and the inventory record form both require that two nurses perform and sign off on the count at each shift change. Multiple staff interviews confirmed that the process was not always followed, with some nurses attributing the missing signatures to distractions, forgetfulness, or staff floating between units. In some cases, nurses working double shifts did not sign between shifts, despite having counted and verified the medications. The Director of Nursing and other supervisory staff acknowledged that the expectation was for both nurses to count and sign for controlled substances at every shift change, regardless of staffing patterns or shift length. The incomplete records were confirmed by several nurses and supervisors during interviews, who emphasized the importance of signatures for accountability and tracking access to narcotics. There was no indication of a staffing shortage contributing to the issue, and the missing signatures were attributed to lapses in following established procedures.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on the second floor of the South Campus and the C Wing of the North Campus. Observations revealed dirty and sticky floors, stained ceiling tiles, window blinds with missing or damaged slats, and residue on shared bathroom sinks. In several resident rooms, there was food debris, sugar packets, tissues, paper, and other debris on the floors and under furniture. Unlabeled bedpans and wash basins were found on the floors of shared bathrooms, and some rooms labeled as 'detailed-full clean' still contained debris, soiled surfaces, and unclean bathroom fixtures. Stained and bowing ceiling tiles were also noted, and some rooms lacked proper window coverings, impacting privacy and the homelike atmosphere. Interviews with staff, including housekeeping aides, supervisors, CNAs, LPNs, and the Director of Housekeeping, confirmed that daily cleaning and maintenance expectations were not consistently met. Housekeeping staff acknowledged that rooms were not cleaned to standard, with some admitting that the conditions would not be acceptable for their own family members. Nursing staff and supervisors expressed concerns about infection control due to unclean floors, soiled bathroom fixtures, and improper storage of personal care items. Maintenance staff reported issues with replacing damaged blinds and ceiling tiles due to supply shortages, and acknowledged that these deficiencies detracted from the environment's cleanliness and safety. Residents also reported dissatisfaction with the cleanliness and comfort of their living spaces, describing their rooms as dirty, unhomelike, and lacking privacy due to damaged or missing blinds. Staff interviews further revealed that environmental concerns were sometimes reported but not always addressed promptly, and that staff shortages and supply delays contributed to the ongoing issues. The facility's own policies required regular cleaning and maintenance of resident rooms and environmental surfaces, but these standards were not upheld, resulting in unsanitary and unsafe conditions for residents.
Failure to Provide Necessary Assistance with Personal Hygiene and Grooming
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dementia, cerebral infarction, and seizure disorder did not receive necessary assistance with personal hygiene, specifically shaving. The resident required partial to moderate assistance with personal hygiene and had no documented refusals of care. Despite facility policies requiring support for activities of daily living and maintaining dignity, the resident was observed on multiple occasions to have facial hair longer than ¼ inch and appeared unkempt. Documentation showed the resident received showers, but there was no indication that shaving was performed, nor was there evidence of refusal. Interviews with staff revealed that shaving was expected to occur on shower days or as needed, and that maintaining grooming was important for dignity. Multiple staff members acknowledged that the resident should have been shaved during their scheduled shower, but this was not done. The assigned CNA admitted to forgetting to shave the resident, and other staff confirmed that shaving was part of the grooming routine. The lack of documentation and follow-through resulted in the resident not receiving the necessary services to maintain personal hygiene and grooming, as required by facility policy and state regulation.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of all residents, as evidenced by multiple instances of understaffing on specific dates. The facility did not meet its assessed minimum staffing levels for Certified Nurse Aides (CNAs) on several occasions, including 8/24/2024, 9/8/2024, 9/16/2024, 9/22/2024, 10/5/2024, 10/6/2024, and 10/20/2024. The facility's policy stated that adequate staffing should be provided to meet the care and services needed by the resident population, but this was not adhered to, leading to unmet care needs. Residents expressed concerns about the impact of low staffing levels on their care during resident council meetings. They reported issues such as delays in getting out of bed, missed personal hygiene care, and inadequate attention to activities of daily living. Interviews with residents revealed specific instances where they experienced delays in receiving care, such as not being able to get out of bed until late in the day or not having their nails and facial hair groomed. Staff interviews corroborated these concerns, with CNAs and nurses reporting difficulties in completing their duties due to insufficient staffing. The staffing issues were particularly pronounced on weekends, as noted by the staffing coordinator and several staff members. The lack of adequate CNAs led to challenges in providing essential care, such as showers and nail care, and affected the ability of nurses to complete their charting and supervisory duties. The Director of Nursing and the Interim Administrator acknowledged the staffing shortages and the resulting impact on resident care, highlighting ongoing efforts to recruit more staff to address these deficiencies.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of documentation and tracking of antibiotic use from July 2024 to October 2024. The policy titled 'Antibiotic Stewardship - Review & Surveillance of Antibiotic Use & Outcomes' required that antibiotic usage and outcomes be documented and reviewed by the Infection Preventionist. However, there was no evidence that this process was followed. Interviews revealed that the Licensed Practical Nurse was unaware of any current tracking process, and the Corporate Infection Preventionist could not provide documentation to support the tracking of antibiotic use. The Director of Nursing, who was responsible for the program, had recently left, and the new Director of Nursing was still in training. Resident #84, who had diagnoses including chronic pain syndrome, a stage 4 pressure ulcer, and osteomyelitis, was on multiple antibiotics. Despite the comprehensive care plan's requirement to monitor for side effects and report them, there was no documentation of antibiotic tracking for this resident. The Pharmacy Consultant's role was limited to checking the accuracy of the order's duration and diagnosis, and they were not directly involved in the stewardship process. The Interim Administrator acknowledged the importance of an effective antibiotic stewardship program and admitted that the current system was inconsistent and ineffective.
Inadequate PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aides (CNAs) #2, 4, 5, and 6, who did not adhere to the required personal protective equipment (PPE) protocols during care activities for a resident on enhanced barrier precautions. This resident, identified as Resident #84, had an indwelling catheter and a stage IV pressure ulcer, conditions that necessitate strict adherence to infection control measures. Despite the presence of an orange sign outside the resident's room indicating the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities, the CNAs failed to comply. Observations revealed that during a mechanical lift transfer and subsequent care activities, CNAs #5 and #6 only donned gloves, neglecting to wear gowns as required. They handled the resident's foley catheter and performed incontinence care without the appropriate PPE. Additional CNAs, #2 and #4, also entered the room and participated in care activities without wearing gowns, despite the clear signage and available PPE supplies outside the resident's room. Interviews with the CNAs confirmed their awareness of the enhanced barrier precautions and the necessity of wearing gowns, gloves, and masks, yet they did not follow these protocols during the observed care activities. Interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), further highlighted the expectation for staff to adhere to the enhanced barrier precautions to prevent infection transmission. The Corporate Quality Assurance/Infection Preventionist and the Interim Administrator also acknowledged the requirement for staff to follow the established infection control policies. Despite the training and resources provided, the CNAs' failure to wear the appropriate PPE during high-contact care activities for Resident #84 represents a significant deficiency in the facility's infection prevention and control program.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged violation involving abuse, specifically an injury of unknown source, within the required timeframe for a resident with severe cognitive impairment and multiple health conditions. The resident, who was dependent on staff for transfers and care, was found with a hematoma on their forehead, the origin of which was unknown. The incident was not reported to the facility's Administrator and the State Survey Agency within the mandated two-hour window, as required by the facility's policy and state regulations. The incident occurred when two Certified Nurse Aides were caring for the resident, and the injury was noticed during care. Despite the initiation of neurological checks and documentation by nursing staff, the injury was not reported to the appropriate authorities until several days later. Interviews with staff revealed a lack of immediate recall of the incident and uncertainty about the timing of notifications to supervisors and the Director of Nursing. The delay in reporting was acknowledged by the facility's Interim Administrator and the Director of Nursing at the time, who emphasized the importance of timely reporting of injuries of unknown origin due to their potential link to abuse.
Deficiency in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene. Specifically, two residents, one with hemiplegia, dysphagia, and diabetes mellitus, and another with diabetes mellitus type 2 and dementia, were observed with unkempt, dirty, and jagged fingernails. The first resident also had unwanted facial hair and reported not having received a bath or shower in two weeks. Documentation discrepancies were noted, as the Bath & Shower Sheets inaccurately recorded that care had been provided. The first resident, who was moderately cognitively impaired and required substantial assistance for personal hygiene, had a physician's order for weekly nail trimming. However, observations revealed that their nails were not maintained, and they had not been shaved. Interviews with staff indicated a lack of communication and follow-through, as the Certified Nurse Aide responsible did not notify the nurse of the missed shower or nail care, and the Licensed Practical Nurse was unaware of the resident's care status. The second resident, severely cognitively impaired and dependent on staff for personal hygiene, also had long, yellow fingernails with debris. Their care plan did not include instructions for nail care, and observations confirmed that nail care was not adequately performed. Interviews revealed that the Certified Nurse Aide only cleaned under the nails, and the Licensed Practical Nurse, who was responsible for nail trimming due to the resident's diabetes, was not informed of any refusals or issues. The Assistant Director of Nurses acknowledged the oversight and the need for licensed nurses to trim diabetic residents' nails.
Improper Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling foley catheter, leading to a urinary tract infection. The resident, who had a history of urinary tract infections and a stage IV pressure ulcer, was observed with the catheter drainage bag improperly placed on their lap instead of below the bladder. This improper positioning was noted during an observation and interview, where the resident reported a burning sensation, a symptom of a urinary tract infection. The facility's policy required the drainage bag to be positioned lower than the bladder to prevent backflow and infection, but this was not adhered to by the staff. The resident's care profile did not document the presence of the foley catheter, and the comprehensive care plan indicated a need to monitor for infection signs. Despite the resident's complaints of burning and the collection of a urine sample for analysis, the catheter bag was left on the resident's lap by a Certified Nursing Assistant, contrary to the facility's procedures. Interviews with various staff, including a Nurse Practitioner and the Director of Nursing, confirmed that the drainage bag should have been placed below the bladder to prevent infection. The failure to follow proper catheter care procedures resulted in a confirmed urinary tract infection, as indicated by the bacteriology report.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs in one of the medication rooms observed. Specifically, three bottles of liquid Lorazepam, a Schedule IV controlled substance, were stored in a removable locked box inside a small refrigerator that was not permanently affixed. This refrigerator was located in a room with an unlockable door, involving Resident #32. The facility's policy required that refrigerated controlled substances be stored in a refrigerator with a locked, affixed narcotic box, and the refrigerator itself must be affixed to the floor or wall. During the survey, it was observed that the medication refrigerator was not affixed, and the locked compartment inside the refrigerator was not being used due to the absence of a key. Interviews with staff, including an LPN, the President of Clinical Services, the LPN Unit Manager, the Director of Nursing, and the Interim Administrator, revealed a lack of awareness regarding the unsecured state of the refrigerator and the availability of a key for the affixed locked compartment. The staff expressed that they were unaware of the need for the refrigerator and narcotic box to be affixed and secured, which led to the improper storage of controlled substances.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident, leading to a deficiency. The resident, who had a chipped front tooth, did not receive follow-up care for a recommended crown. The facility's policy required the Director of Nursing or designee to notify Social Services of dental needs and coordinate appointments, but this process was not effectively executed. The resident, who had moderate cognitive impairment and was dependent on staff for oral hygiene, expressed self-consciousness about the chipped tooth and had not seen a dentist for the issue. The facility dentist had noted the need for a crown during an initial visit, but the recommendation was not followed up with an outside appointment. The care plan did not reflect the chipped tooth, which was necessary for monitoring potential issues such as weight loss, pain, or difficulty chewing. Interviews with staff revealed a breakdown in communication and responsibility. The dental consults were placed in the medical records mailbox and distributed to unit managers, who were supposed to address recommendations and schedule appointments. However, the process failed, as the unit manager and unit clerk did not ensure the appointment was made. The Interim Administrator acknowledged the need for an additional step to verify appointment scheduling.
Failure to Post Ombudsman and Complaint Hotline Information
Penalty
Summary
The facility failed to post contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline in a manner accessible and understandable to residents and their representatives. This deficiency was identified during a Standard Survey completed on 10/28/24, specifically in the North building of the facility. The policy titled Resident Rights, dated 3/1/17, guarantees residents the right to communicate with outside agencies, but the survey found that this was not being upheld. During a Resident Council meeting, residents expressed that they were unaware of where these contact numbers were posted, indicating a lack of communication and visibility of this important information. Observations throughout the North building confirmed the absence of postings for the Ombudsman and State Agency Complaint Hotline numbers in key areas such as the reception area, bulletin boards, nursing stations, elevators, and hallways. Interviews with facility staff, including the Assistant Director of Activities, Director of Nursing, Director of Social Work, and the Interim Administrator, revealed a general lack of awareness and responsibility regarding the posting of these contact numbers. Staff acknowledged that the information should be accessible to residents and family members, but it was not clear who was responsible for ensuring this was done, leading to the deficiency.
Failure to Implement Care Plans for Resident Safety
Penalty
Summary
The facility failed to implement person-centered care plans for three residents, leading to a deficiency in meeting their medical and nursing needs. Specifically, the care plans for these residents included the use of a stop sign across their room doors to deter other residents from entering, but this intervention was not provided. Observations and interviews revealed that the stop signs were missing, and staff were unsure of the documentation and implementation process for these interventions. Resident #1, who was cognitively intact and had diagnoses including anxiety, depression, and diabetes, expressed concerns about other residents entering their room. Despite a care profile indicating the need for a stop sign, the comprehensive care plan did not document this intervention, and the stop sign was not in place. Similarly, Resident #2, with moderate cognitive impairment and diagnoses including anxiety and bipolar disorder, also lacked a documented stop sign in their care plan, despite previous issues with other residents entering their room and taking belongings. Resident #3, with moderate cognitive impairment and diagnoses including dementia and depression, also did not have a stop sign documented in their care plan, although it was noted in their care profile. Interviews with staff, including a CNA, RN Unit Manager, and the Director of Nursing, revealed a lack of clarity and communication regarding the documentation and responsibility for ensuring the stop signs were in place. This oversight resulted in the failure to meet the residents' expressed wishes and care needs as outlined in their care plans.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility did not ensure residents had the right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #2, who had a history of aggressive behavior, grabbed Resident #1's arm and threw them to the floor, resulting in significant injuries including a compression fracture of the T2 vertebra, and fractures of the left elbow and hip. This incident occurred while Resident #1 was wandering in the hallway and was witnessed by an LPN who was engaged in a medication pass at the time. Resident #1 had severe cognitive impairment, advanced dementia, and was known to wander daily. Their care plan included interventions to keep them away from other residents exhibiting aggressive behavior. Resident #2, who also had severe cognitive impairment and a history of psychosis and mood disorder, had a care plan that included measures to manage their aggressive behavior, such as encouraging participation in activities and providing psychological services. Despite these measures, the altercation occurred, leading to Resident #1's hospitalization and subsequent palliative care. The incident was captured on video surveillance, which showed Resident #2 approaching Resident #1 and forcefully grabbing and throwing them to the floor. Interviews with staff confirmed that Resident #2's actions were intentional and constituted physical abuse. The facility's policies and procedures on abuse, neglect, and exploitation were not effectively implemented to prevent this incident, resulting in harm to Resident #1.
Incomplete Investigation into Resident-to-Resident Abuse
Penalty
Summary
The facility did not ensure that all alleged allegations of abuse were thoroughly investigated for two residents. Specifically, the facility failed to complete a thorough and accurate investigation into resident-to-resident abuse, including conducting interviews with witnesses and other pertinent staff. The policy and procedure titled 'Abuse, Neglect and Exploitation of Residents' required the Administrator/DON or designee to conduct an investigation, gather written and signed witness reports, and follow the procedure for reporting and investigating incidents of resident abuse. However, this was not adhered to in the case of the altercation between Resident #1 and Resident #2. Resident #1, who had advanced dementia, depression, and anxiety, was identified as being at risk for resident altercations due to wandering into peers' rooms. Resident #2, diagnosed with psychosis, aphasia, and mood disorder, had a history of impaired social interactions and resident-to-resident altercations. On the day of the incident, video surveillance footage revealed that Resident #2 forcefully grabbed Resident #1's right arm and threw them to the floor. Despite this, there was no documented evidence of statements or interviews conducted with witnesses, and the facility did not implement their policy to evaluate the events leading up to the abuse. Interviews with various staff members, including the Administrator, Certified Nurse Aide #3, Licensed Practical Nurse #1, Licensed Practical Nurse Unit Manager #2, Assistant Director of Nursing #1, Director of Nursing, and Regional Director of Nursing, confirmed that no statements were collected from staff who witnessed the incident. The Assistant Director of Nursing admitted to not gathering statements, focusing instead on the immediate care of Resident #1. The Director of Nursing and Regional Director of Nursing acknowledged that the investigation was incomplete without these statements, which would have provided perspective on the root cause of the abuse. The Administrator also confirmed that the investigation was not thorough due to the lack of collected statements.
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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