Citations in New York h

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the facility’s average daily census exceeded 60 residents, as required by 10 NYCRR 415.13(b)(1). The DON job description stated that the DON was responsible for planning, directing, and coordinating nursing services, managing resident care 24 hours a day, seven days a week, and ensuring a sufficient number of qualified supervisory and supportive nursing personnel on each tour of duty. Census reports showed that during the review period the facility census ranged from 113 to 116 residents, and at survey entrance the census was 115 out of 135 beds. Despite this census level, daily staffing sheets from late January to mid-February documented that the DON was counted in the facility’s minimum staffing numbers for direct resident care. On specific evening shifts, the DON worked on a named unit from 6:00 PM to 10:00 PM as the second nurse, and on one of those dates, from 9:21 PM to 10:00 PM, the DON was the only nurse on the unit. The facility’s minimal staffing document required two nurses on that unit for the day and evening shifts, and the DON was used to meet those minimums. In interviews, the Facility Scheduler stated they were unaware that the DON was not supposed to act outside the DON role and acknowledged that the DON was used as staff when coverage could not be found, noting that the minimum staffing numbers were not ideal for completing work and providing good care. The DON reported not knowing the exact regulation, believing the practice was merely frowned upon, and stated they frequently acted as a CNA, housekeeper, or medication nurse while remaining available as DON. The Administrator confirmed that minimum staffing numbers were not the goal and that leadership was willing to help staff and residents when needed.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to report an injury of unknown origin for Resident #4 to the State Survey Agency within the required timeframe. Facility policy and federal regulation require that all alleged violations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source be reported immediately, but not later than two hours if abuse or serious bodily injury is involved, or within 24 hours if not. Despite this, when Resident #4 was found with a swollen, bruised left index finger that was later confirmed by x‑ray to be an oblique fracture of the second proximal phalanx, the Administrator did not report the incident to the Department of Health because they did not believe abuse, mistreatment, or neglect had occurred. Resident #4 had significant cognitive and behavioral issues, including vascular dementia with mood disturbances, a history of stroke, aphasia, severe cognitive impairment, confusion, agitation, and combative behaviors with care such as hitting and grabbing staff. Care plans and resident care profiles documented noncompliance, rejection of care, poor safety awareness, and resistance to activities of daily living, with interventions focused on behavior modification and de‑escalation. On the morning of 10/14/2025, a CNA discovered swelling and bruising of Resident #4’s left index finger and knuckles during morning care and immediately reported it to an LPN, who then reported it to the RN Manager. Staff interviews confirmed that Resident #4 was known to be combative during care and that no prior concerns about the hand had been noted the previous night. The injury was treated as an injury of unknown origin by nursing leadership, who completed an incident report, notified the medical provider and family, and initiated an internal review by collecting staff statements going back 72 hours. The ADON and DON both stated that injuries of unknown origin are supposed to be reported to the Department of Health within a two‑hour window and that the Administrator is responsible for making such reports. The Administrator acknowledged that injuries of unknown origin, abuse, mistreatment, and neglect are to be reported within two hours of notification but chose not to report Resident #4’s injury because they believed no abuse had occurred and later stated that, in retrospect, they should have reported it as required by regulation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow posted menus and provide meals that met residents’ nutritional needs and stated preferences, as required by facility policy and national guidelines. The facility’s Food and Nutrition Services policy required that each resident receive a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, with reasonable efforts to accommodate preferences, and that food trays be inspected to ensure the correct meal is provided. The Tray Identification policy required appropriate identification/coding for various diets and special considerations. The posted Fall/Winter Week 1 menu for the identified lunch specified stuffed shells (two each), Italian vegetables, a dinner roll, and pie, with an egg salad sandwich as the alternate, yet the kitchen did not prepare an adequate amount of the posted lunch meal to serve all residents. Surveyors identified ongoing concerns from Resident Council notes and staff and resident interviews about food quality, availability, and accuracy. Resident Council notes from two consecutive months documented that food was out of stock, supplies were low, items were missing, and there were complaints about food quality (such as steak being hard to cut). Multiple residents reported not receiving condiments, receiving small portions, and being served cold and unappealing food. Nursing staff and CNAs corroborated that there were many resident complaints about food being inedible, cold, unappealing, and poorly presented, with food “slopped” on trays, condiments rarely provided despite being listed on meal tickets, and no use of bases under plates to keep food warm. Staff also reported that residents’ meal tickets often did not match what was provided on trays due to menu changes or lack of supplies, and that condiments and juices were not readily available on the units. Direct meal observations and interviews on specific survey dates showed that residents did not receive items listed on their meal tickets and that the kitchen ran out of the main entrée. For breakfast, one resident’s meal ticket indicated jelly and apple juice, but their tray lacked both items, which the resident stated they would have liked. Another resident’s ticket indicated orange juice and jelly, but their tray lacked orange juice, jelly, and sugar; the resident’s oatmeal remained uneaten, and an LPN reported being told by kitchen staff that there was no jelly or juice available. Another resident reported not receiving stuffed shells with red sauce, orange juice, or sugar as expected and stated they minded. A further resident stated they hardly ever received what was on their meal ticket, were frequently told items had run out and were substituted, and reported that juices such as orange, cranberry, and apple juice were never provided, with powdered fruit punch being used instead. During the observed lunch tray line, kitchen staff discussed that there were not enough stuffed shells and meat sauce to complete all resident trays, and the Dietary Supervisor acknowledged that not enough food had been pulled out. The kitchen ran out of stuffed shells before completing all carts, and the Clinical Dietician/Food Service Director stated that approximately twenty residents were unable to receive stuffed shells as posted on the menu. The alternate egg salad sandwich was also insufficient in quantity, leading staff to prepare breaded chicken patties on rolls without condiments or sauce as additional substitutions. Insulated plate bases were used as lids but did not fully cover plates. Dietary supervisors and the Food Service Director acknowledged that production sheets, which indicate required amounts and portions, were not properly used or understood, that counts of stuffed shells were not done, and that supplies such as orange juice, sugar packets, jelly packets, and Swiss cheese had run out or been used previously. The Administrator later stated that Food Service Directors should have recognized quantity changes when ordering and confirmed that residents should receive what is on the menu and all items listed on their meal tickets, and also noted issues with deliveries, wrong items, and misdirected shipments that were not communicated in time to prevent stockouts.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure residents were afforded their right to formulate advance directives, have corresponding physician orders for code status, and have those choices documented and communicated to staff. Facility policy required that advance directives be provided on admission, that residents’ wishes for code status be established before CPR through a code status identifier, and that the EMR contain a written MD order and a physical MOLST form. An additional policy required that upon admission and as needed thereafter, residents or their legal representatives be informed of their rights regarding advance directives, that the facility inquire about existing directives, and that the resident’s status be documented in the medical record. Despite these policies, surveyors found multiple residents without documented code status orders, without MOLST forms, and one resident with conflicting documentation of code status. One resident with a history including wedge compression fracture, ischemic heart disease, and hypertensive heart disease was cognitively intact and had no documented physician order for basic life support interventions or code status in the record. When this resident was found unresponsive with low oxygen saturation and no obtainable blood pressure, staff initiated CPR and called 911. Nursing notes and a provider note documented that there was no MOLST or advance directive limiting resuscitation on file at the time of the event, and the NP instructed staff to treat the resident as full code. Interviews with two LPNs revealed they could not identify the resident’s code status, found no MOLST in the binder or code status in the EMR, and followed an understood practice of treating residents as full code when no directive was found. The NP stated a MOLST had been completed at admission and verified, but it was missing from the binder and the code status had not been entered into the EMR because the nurse manager was responsible for that task. The NP also did not document the code status in the admission physical because it was not on the resident’s EMR profile. Additional residents were found without proper documentation of advance directives or code status. One resident with acute and chronic respiratory failure, COPD with acute respiratory infection, and interstitial pneumonitis was cognitively intact, had no MOLST form on the unit, no physician order for basic life support interventions, and no documented code status in the admission provider assessment; the resident and a family member reported that no admission paperwork or advance directive had been completed, though the resident stated a preference to be full code. Another cognitively intact resident with encephalopathy and acute respiratory failure had no physician order for basic life support interventions and no documented code status in the admission assessment; this resident reported not signing admission paperwork, did not know what advance directives were, and after explanation stated a preference for DNR. A further cognitively intact resident with acute respiratory failure, COVID-19 pneumonia, and acute pulmonary edema had no MOLST on the unit, no physician order for basic life support interventions, and no documented code status in the admission assessment, and did not recall signing admission paperwork or knowing about advance directives, later expressing a preference to be full code. Another resident with traumatic ischemia of muscle, dehydration, and muscle weakness, and mild cognitive impairment, had conflicting documentation regarding code status. A MOLST form dated in late January documented that this resident was to have CPR and was signed by the NP several days later. However, physician orders for the same resident included an order entered by an RN for DNR/DNI, which was signed by the NP on a subsequent date. This created a direct conflict between the MOLST form indicating CPR and the physician order indicating DNR/DNI. Interviews with facility leadership confirmed that the facility’s practice was to treat residents as full code when no advance directive was in place and that code status orders were supposed to be matched to the MOLST form when entered into the EMR. The survey identified that for multiple cognitively intact residents, there was either no documented physician order for code status, no MOLST form, or conflicting documentation, leading to an Immediate Jeopardy finding and substandard quality of care for the affected residents.

Removal Plan

• The admission nurse was educated by the Administrator on their responsibilities to educate all residents/representatives on admission/re-admission of their right to formulate advance directives and to ensure a corresponding physician order for code status and/or a MOLST form are entered into the resident's medical record.
• The facility management team conducted a facility-wide audit of each current resident to ensure residents had physician orders for code status and/or a MOLST form.
• All residents without a MOLST had advance directives discussed with them or their representative by nursing staff.
• Corresponding MOLST forms and physician orders for advance directives were entered into the electronic medical record by the unit manager and approved by the Nurse Practitioner.
• The Administrator and Assistant Administrator reviewed the facility policy on advance directives and made no revisions.
• The facility initiated mandatory education for the Nurse Practitioner, all registered nurses, and a licensed practical nurse on the facility policy regarding educating all residents/representatives on admission of their right to formulate advance directives and ensuring a corresponding physician order for code status and/or a MOLST form are entered into the resident's medical record.
• Education was conducted verbally by the Nursing Supervisor and/or designee.
• Facility staff not reached by telephone would not be permitted to work until they received the education.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for two residents. One resident with recurrent moderate major depressive disorder, atrial fibrillation, seizures, and severe cognitive impairment was found asleep in bed with a clear plastic bag on the nightstand containing three prescription medication bottles: Sertraline 50 mg, Eliquis (Apixaban) 5 mg, and Levetiracetam 500 mg. These bottles were labeled with the resident’s name and contained medication. Facility policy on administering medications stated that medications were never to be left at the bedside and that medications brought in with a resident would be returned to the family or health care proxy, with medications to be reordered and filled by the facility or vendor pharmacy. Staff interviews revealed that a CNA stated they would remove medications found at the bedside and report them to a nurse, and an LPN stated that medications from home were to be locked in the medication cart and then either taken home by family or destroyed. When the surveyor showed the medications on the nightstand to the LPN, the LPN identified the fill dates on the bottles and removed them from the room. Another LPN stated they were not aware the resident had medications on the nightstand and that staff should have seen and removed them, noting that the resident was cognitively impaired and unable to self-administer medications. The Acting DON/Acting ADON stated that the medications at the bedside could have caused serious harm if taken by another resident and described all three as lethal medications that could cause serious harm depending on what and how much was taken. The family member reported that, at admission, a nurse told them the medications were not needed because they would be ordered at the facility and instructed them to put the medications in the bedside table. The second component of the deficiency involved an environmental hazard in another resident’s bathroom. This resident, who had ataxia, a history of falling, spinal stenosis, and used a wheelchair for mobility, was cognitively intact and able to make themselves understood and understand others. During observation, the bathroom door was open and a small electric baseboard heater was seen with its front cover removed and lying on the floor in front of the running heater. The heater was producing heat and a burning smell, and when the surveyor placed a hand close to the exposed heating elements, they were hot enough to cause injury if they came into direct contact with skin or clothing. A CNA reported having seen the heater cover on the floor the previous day and acknowledged they should have reported it to Maintenance but did not, and also did not report it on the day of the survey. The Director of Maintenance and an LPN confirmed that the heater was hot and that the cover had to be put back on, and the LPN stated staff should have reported the missing cover immediately.

Removal Plan

• Resident #2's home medications observed at the bedside were removed from the room and secured.
• Nurse Practitioner #1 was notified regarding the medications found in Resident #2's room.
• The family was to be notified according to facility process.
• Education was provided to all staff on medication administration and continued until all staff were educated.
• Staff rounds occurred during care delivery, activities, therapy, and routine safety checks multiple times a day.
• A full-house in-service was conducted to reinforce medication safety, admission procedures, and environmental monitoring.
• Administrator #1 was notified regarding the prescription medications left at Resident #2's bedside.
• A facility-wide audit of each resident room (including drawers and cabinets) was conducted to ensure no other residents had medications in their rooms.
• A second facility-wide audit of each resident room (including drawers and cabinets) was conducted to ensure no other residents had medications in their rooms.
• Administrator #1 and Assistant Administrator #1 reviewed the facility policy 'Administering Medications' and made no revisions.
• Medications from Resident #2's room were returned to Family Member #3 to take home and destroy.
• Mandatory education/re-education was initiated for all staff that residents were not to have medications in their room and any medications found must immediately be given to a nurse.
• Education was to be conducted verbally (in person or by telephone) by the Nursing Supervisor and/or designee.
• Staff not reached by telephone would not be permitted to work until they received the education.
• Director of Maintenance #1 replaced the cover on the baseboard heater in Resident #3's bathroom.
• Director of Maintenance #1 conducted an audit of the electric baseboard heaters in the facility to ensure covers were in place.
• Assistant Administrator #1 and Director of Maintenance #1 reviewed the facility Work Request Policy and made no revisions.
• Mandatory education was initiated for all staff regarding the process for reporting damaged, broken and/or malfunctioning equipment.
• Education on reporting damaged/broken/malfunctioning equipment was to be conducted verbally (in person or by telephone) by the Nursing Supervisor and/or designee.
• Staff not reached by telephone would not be permitted to work until they received the education on reporting damaged/broken/malfunctioning equipment.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and person-centered care plans for multiple residents, particularly in bowel management, infection assessment, and post-fall evaluation. One resident with chronic idiopathic and slow-transit constipation, a history of large bowel obstruction, and recent hospitalizations for severe constipation returned from the ED with instructions from a nurse practitioner to continue bowel regimen, closely monitor bowel movements, abdominal distention, nausea, vomiting, and overall comfort, and to update the plan of care. Despite this, the resident’s constipation care plan was not revised after mid-October, and there was no documented evidence that the nurse practitioner’s instructions were incorporated into the care plan or physician orders. Review of bowel movement records, MARs, and nursing notes for December and January showed no routine abdominal assessments when bowel movements were absent, no administration of PRN bowel medications per orders and facility policy, and no timely provider notification when the resident went more than 24 hours without a bowel movement, even on multiple multi-day stretches without documented bowel movements. The resident ultimately required repeated hospitalizations, including treatment for severe sepsis and proctocolitis and later fecal impaction requiring disimpaction under general anesthesia. The facility also failed to ensure timely assessment and intervention for suspected urinary tract infection in another resident with severe dementia, diabetes, and chronic kidney disease. A nurse practitioner note documented that the family was concerned about a possible UTI and that a urinalysis would be considered, and a subsequent note documented decreased oral intake with a plan to provide extra fluids and obtain a urine sample for urinalysis. However, there was no documented evidence of an order for a urinalysis on the date specified, and progress notes lacked documentation of the resident’s condition around the time of the planned testing. The resident was later diagnosed with septic shock secondary to UTI, indicating that the infection progressed without documented timely diagnostic follow-up as initially planned. Additional deficiencies involved failure to assess and document a reported fall and failure to administer PRN bowel medications or notify providers for other residents. One newly admitted resident reported a fall on an evening shift, but there was no nursing assessment documented at the time of the fall, no incident report initiated, and no documentation of family notification by the nurse on that shift. The resident later complained to a family member about the fall and was sent back to the hospital within 24 hours of admission. For two other residents with bowel management needs, the facility did not ensure administration of ordered PRN bowel medications during specified months and did not notify the provider when these medications were not given. Interviews with CNAs, LPNs, an RN, the nurse practitioner, the medical director, the DON, and the administrator revealed inconsistent understanding and implementation of the bowel protocol (including differing beliefs about when bowel alerts should trigger interventions and provider notification), lack of awareness of specific monitoring expectations, and acknowledged issues with documentation and processes for adverse event reporting and follow-through.

Penalty

No penalty information released

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

Summary

The governing body failed to establish and implement effective policies for managing and operating the facility and did not maintain a consistent, properly functioning Administrator responsible for regulatory compliance. Surveyors identified multiple deficiencies across numerous regulatory areas, including repeat deficiencies related to providing a safe, clean, comfortable, homelike environment (F584), developing and implementing comprehensive care plans (F656), revising care plans in a timely manner (F657), and ensuring influenza and pneumococcal immunizations (F883). Additional cited deficiencies included failures in resident dignity (F550), notification of providers and resident representatives about changes in condition (F580), protection from abuse and neglect (F600), reporting injuries of unknown origin to the State Survey Agency (F609), and thoroughly investigating all allegations of abuse, neglect, exploitation, or mistreatment (F610). The scope of deficiencies also extended to discharge/transfer documentation and notification (F628), activities programming (F679), and ensuring that services, including respiratory care, met professional standards (F684, F695). The facility’s Quality Assurance and Performance Improvement (QAPI) program, as documented in an undated policy, described a structure for feedback, data systems, monitoring, and Performance Improvement Projects (PIPs) based on high-volume, high-risk, or problem-prone activities, and input from various data sources such as incident reports, infection control reports, consultant reports, and department head meetings. The policy listed objectives to establish and maintain an ongoing QAPI program, assist departments with performance improvement projects, evaluate results of actions taken, and centralize quality improvement activities. However, the document provided to surveyors was incomplete, ending abruptly after the word “All,” and the last two pages consisted of a QAPI test. Administrator #1 reported not recalling ever doing a Performance Improvement Project or Plan with any individuals in the facility, despite the written QAPI policy describing such activities as part of the facility’s quality program. Interviews further demonstrated instability and inconsistency in facility leadership and administration. Ombudsman #1 reported being in the facility weekly and not seeing the Administrator for extended periods, sometimes a month or more, and stated that the Assistant Administrator was effectively administering the building and was viewed by residents as the actual Administrator. Assistant Administrator #1 stated that Administrator #1 was only periodically in the facility but was accessible by phone and in frequent contact. Administrator #1 stated they became Administrator in August 2025 after the prior Administrator abruptly left, that they owned 9% of the facility, and that they had previously been in the building every other week when the prior Administrator was in charge. Administrator #1 acknowledged that residents might not know they were the Administrator and stated they were unaware of some issues identified during the survey and had not conducted PIPs. The DON, who had been in the building for about a week at the time of interview, stated that the facility “needed revamping” and that they were actively interviewing for a local administrator. Collectively, these observations and statements supported the finding that the governing body did not ensure stable, effective administrative leadership or fully implemented policies and systems necessary to manage operations and maintain regulatory compliance. The deficiencies extended into multiple operational domains, including staffing, pharmacy, dietary, maintenance, and training. Surveyors cited failures to ensure sufficient and competent nursing staff (F725, F726), to provide pharmaceutical services that met residents’ needs (F755), and to ensure physician notes were accurately entered and maintained (F711). Dietary-related deficiencies included failure to provide palatable, attractive food at safe and appetizing temperatures (F804) and to store, prepare, distribute, and serve food in accordance with professional food safety standards (F812). The facility also failed to maintain mechanical, electrical, and patient care equipment in safe operating condition (F908). Training-related deficiencies included failure to develop, implement, and maintain an effective training program for all new and existing staff (F940), failure to include mandatory QAPI training as part of the QAPI program (F944), and failure to provide at least 12 hours per year of in-service training to ensure nurse aide competence (F947). The facility was also cited for failing to submit accurate staffing information based on payroll data to CMS (F851) and for failing to ensure effective QAPI feedback, data systems, and monitoring (F867), as well as for failures related to providing and/or documenting required influenza and pneumococcal immunizations (F883). These findings collectively demonstrated that the governing body had not effectively implemented the policies and oversight necessary to ensure compliance with regulatory requirements across multiple areas of facility operation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff, including licensed nurses and CNAs, to meet residents’ needs as outlined in its own facility assessment. The assessment dated January 2026 specified required nursing administration and direct-care staffing per unit and per shift, including RN/LPN supervisory coverage and minimum CNA numbers on days, evenings, and nights. Review of staffing sheets from late November 2025 through late February 2026 showed repeated and sometimes severe understaffing compared to these minimums, including multiple shifts with fewer nurses and CNAs than required and numerous night shifts with no scheduled nurses or no CNAs. On several dates, there were zero nurses scheduled for the night shift aside from a nurse supervisor, and on some nights there were no CNAs scheduled at all. Residents reported that this staffing pattern affected their care. One resident stated staffing was an issue, turnover was very high, and they were sometimes scared to ask for pain medication because staff were so busy; this resident reported receiving only one shower per week and feeling that staff became upset if they asked for more assistance. Another resident described being suspicious of staff and believed the facility was short staffed, reporting that getting help to clean up was inconsistent and that they sometimes had to wait a long time for pain medication. A different resident reported that staffing was too often short, especially at night, and described waking up in the morning with the bed soaked from overnight because no one had been available to change them; this resident stated they would ring the call bell when needing the bathroom or incontinence care, but no one would come, and that call bells often took 30 minutes or more to be answered, particularly on nights. Additional residents and staff corroborated ongoing staffing shortages. Several residents stated there were not enough staff, particularly on the overnight shift, and that medications were not always given on time and they had to wait a long time for help. A CNA reported that it was difficult to get to all residents on their assignment, especially on the 3 PM–11 PM shift when some residents became more confused, and that they often had to complete documentation an hour after their shift ended due to workload. The staffing coordinator, who assumed responsibility for staffing in mid-February 2026, acknowledged that staffing levels were based on the facility assessment and that call-outs and no-call/no-shows disrupted staffing. An LPN described typical patterns of having fewer aides than expected on days and evenings and only one aide per floor and one LPN for both floors at night, with situations where the supervisor was the only LPN and had to perform both medication passes and supervisory duties. Dietary staff and the ombudsman also reported inconsistent staffing, including an instance when breakfast was delayed until late morning and prepared by maintenance because kitchen staff had called out.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that licensed nurses and certified nurse aides possessed and maintained the specific competencies and skills required to meet residents’ needs, as outlined in the facility assessment. The facility assessment dated 1/2026 listed numerous required staff training and competency areas, including communication, resident rights and facility responsibilities, emergency planning, person-centered care, dementia and behavioral management, substance abuse identification, trauma-informed care/PTSD, proper body mechanics, abuse/neglect/exploitation, infection control, culture change, required in-service training for nurse aides, identification of resident changes in condition, and cultural competency. It also specified that nurse aides must receive at least 12 hours of annual in-service training, including dementia management and resident abuse prevention, and that training should address areas of weakness and special resident needs. Additional competencies such as ADLs, disaster planning, infection control, medication administration, measurements, resident assessment/observation, Alzheimer’s/dementia care, and specialized mental/psychosocial care were also identified as necessary. Record review showed that multiple staff did not have complete or verifiable education records consistent with these requirements. One CNA’s education file lacked evidence of completion of all annual education after 1/09/2022, and the electronic record showed less than 12 hours of annual education completed by the time of survey. Another CNA’s file contained multiple in-service sign-in sheets and some posttests, but it could not be determined from the documentation whether all required annual education had been completed; this CNA’s electronic record also showed less than 12 hours of annual education. A third CNA’s file contained no evidence of annual education other than a written statement of verbal education related to a specific incident in 2/2026, and the electronic records contained no education topics for this aide. For LPNs, one nurse’s file had no documented evidence of annual education since 2022 except for a single 2024 posttest and part of an untitled answer sheet, and the electronic record showed only 2 of 10 required topics completed for 2025. Another LPN’s file lacked documented annual education since 2024, and the electronic record showed only 1 of 6 required topics completed for 2025. Interviews further demonstrated a lack of clear oversight and consistent implementation of the education program. The assistant administrator stated that the nurse educator role was typically filled by the assistant DON, and that an RN had been filling in, but also acknowledged that with staff changes, education had stopped for a period and that a binder of education information maintained by the prior assistant DON could not be located. The assistant administrator and other leaders described reliance on an electronic education system and on-the-spot or group in-services, but staff interviews revealed confusion about how to access online education, awareness of overdue modules, and reports of not having enough time to complete them. Several CNAs and an LPN reported not receiving education in the last year or not having training on key topics such as abuse, neglect, infection control, dementia/behavioral health, or QAPI. The acting DON stated they did not conduct education, and a unit manager LPN was unsure who was responsible for assigning education. A laundry attendant reported receiving only task-specific training and no house-wide education such as abuse and neglect. Overall, the documentation and interviews showed incomplete education records, insufficient annual hours for CNAs, missing required topics, and no clearly designated person overseeing education, contrary to the facility’s own assessment and regulatory requirements.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to timely report and investigate multiple allegations and incidents of abuse, neglect, and injuries of unknown source, and to notify the administrator and the State Survey Agency within required timeframes. Facility policy required that all alleged violations and injuries of unknown source be reported immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not involve abuse and did not result in serious bodily injury. The policy also required immediate notification of the nursing supervisor, DON, or administrator, initiation of an investigation, and reporting to the New York State Department of Health (NYSDOH). Surveyors found that these requirements were not followed for several residents. For two residents involved in a resident-to-resident altercation, the facility did not ensure timely reporting or investigation. One resident with moderate cognitive impairment reported that another resident entered their room during the night, yelled at them, and dumped water from a refillable water bottle on them, leading the resident to call 911 when staff did not respond to their calls for help. The family later learned of the incident directly from the resident and filed a grievance. The grievance form lacked documentation of who received it, whether further investigation was required, and any investigation or follow-up details, although it noted the complainant was notified of actions taken. Nursing progress notes for the month did not document the altercation or any post-incident assessment, and the comprehensive care plans for both residents did not include interventions related to abuse or neglect. The facility could not provide an incident report or investigation, and there was no evidence the incident was reported to NYSDOH or that the administrator was notified at the time of occurrence. For another resident, the facility failed to meet reporting requirements after an allegation of staff-to-resident abuse. This resident reported an allegation of abuse by a CNA on a specific evening. The allegation was not reported to the administrator within two hours as required for abuse allegations, and it was not reported to NYSDOH until approximately 24 hours after the allegation was made. Additionally, a resident who sustained an unwitnessed fall and was later found to have a hip fracture was not reported to NYSDOH, despite the serious injury. Another resident with dementia and severe cognitive impairment experienced two unwitnessed falls with head lacerations, was sent to the hospital, and later was found to have an acute left hip fracture of unknown source after returning to the facility and developing acute hip pain and functional decline. Staff interviews indicated that this resident had been ambulatory and independent with a walker before the fracture and experienced a significant decline afterward. The acting DON and administrator stated that injuries of unknown origin should be reported to NYSDOH, but there was no evidence that this fracture of unknown source was reported or that an investigation consistent with policy and regulatory requirements was completed. Interviews with facility leadership and clinical staff confirmed that required notifications and investigations did not occur as expected. The assistant administrator reported they were not notified of the resident-to-resident incident and could not locate an incident report or investigation, and acknowledged the event was reportable and should have triggered a full investigation and assessments of both residents. The DON and administrator, who were not in their roles at the time of some incidents, stated their expectations that resident-to-resident altercations, abuse allegations, and injuries of unknown origin be immediately reported to them and to NYSDOH, and that thorough investigations be conducted. The medical director stated they were not always notified of reportable incidents and expected investigations for injuries of unknown origin. Overall, surveyors determined that for multiple residents, the facility did not ensure immediate reporting of alleged violations and injuries of unknown source to the administrator and appropriate authorities, and did not ensure that required investigations and documentation were completed in accordance with facility policy and 10 NYCRR 415.4(b)(2).