Citations in New York
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New York.
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Latest Citations in New York
A resident with dementia and recent hip fracture surgery was admitted on a PRN quetiapine order for agitation, which the facility continued and administered multiple times without a behavior care plan, without documented target behaviors, and without evidence that non-pharmacological interventions were attempted or that medication effectiveness was assessed. Facility policy required identification of underlying causes of behaviors, individualized non-drug interventions, and clear indications and documentation for PRN psychotropics, but the resident’s care plan addressed only potential adverse effects of antipsychotic use and did not include specific behavioral interventions. The MAR and progress notes lacked behavior descriptions and follow-up for most PRN doses, while the resident’s proxy reported excessive daytime sleepiness and difficulty obtaining information about the medication, and staff interviews revealed inconsistent practices and rationales for using PRN antipsychotics, including use for agitation and sleep without clearly documented medical necessity.
Surveyors found multiple instances where medication carts were left unlocked and unattended with computer screens visible and no privacy screens applied on two units. On one unit, carts were left in the hallway and near the nurse's station while an LPN was with a resident in the dining area, and staff later acknowledged they should have applied the privacy screens. On another unit, a cart was left in front of a room with the screen open to a resident's MAR while an LPN was inside the room, and in a separate instance an LPN was obtaining vitals with a resident while the nearby cart's computer remained exposed. Staff interviews confirmed that privacy screens were not used as required, despite an existing policy that residents are to be afforded privacy in treatment and care.
Surveyors found multiple instances where medication carts were left unlocked and unattended, with computer screens displaying medication administration records, on two nursing units. On one unit, a cart was left in a hallway and another near the nurse’s station while the assigned LPNs were away obtaining vitals and administering medications to a resident. On another unit, a cart was left unlocked outside a room with an open MAR while an LPN was inside with a resident, and a separate cart was left unlocked on one side of the nurse’s station while the LPN was on the other side with a resident. In interviews, involved LPNs and a unit manager acknowledged the carts should have been locked and that access to medications is supposed to be restricted to authorized staff under facility policy.
Surveyors found that the facility failed to provide and document needed grooming and shaving assistance for several residents who required help with ADLs. One resident with severe cognitive impairment and another with visual impairment, both care-planned for staff assistance with shaving, were repeatedly observed with overgrown facial hair and reported disliking facial hair or being unable to shave independently, while records lacked evidence that grooming was offered, provided, or refused. A third cognitively intact resident with Parkinson’s disease and other comorbidities, also care-planned for assistance with trimming facial hair, had a long beard and mustache for months despite requesting help, with no documentation of grooming or refusals. Staff and the DON stated that facial hair care was expected, usually on shower days, but acknowledged there was no consistent place or practice for documenting grooming services or refusals.
Surveyors identified that multiple resident rooms on two nursing units were stark, bare, and lacked personalization such as photos, decorations, or clocks, and many of these rooms did not contain chairs for resident or visitor use. One multi-occupancy room was also cluttered with a dirty floor and no seating. Staff interviews revealed that room personalization was largely dependent on family involvement, that some departments did not routinely address creating a homelike environment, and that managers were unaware of the extent of missing chairs. In addition, a tub room had windows with insulation coming out and a noticeable draft, and maintenance leadership reported being unaware of any issues or work orders related to that condition.
A resident with dementia, severe cognitive impairment, and a right hip replacement developed lethargy and right thigh tenderness, and an x-ray confirmed an acute posterior dislocation of the femoral head prosthesis. The resident was unable to explain what happened, staff reported no witnessed fall or incident, and the accident/incident report listed the date, time, and location of occurrence as unknown. Although the facility’s policy defined and required reporting of injuries of unknown source to the State Agency, there was no documentation that this event was reported, and the investigation form left the reporting section unchecked. The DON stated the event was not reported because there was no fracture and it was not considered an injury of unknown origin.
A resident with dementia, severe cognitive impairment, osteoarthritis, and a right hip replacement was found to have an acute posterior dislocation of the hip prosthesis after presenting with lethargy and right thigh tenderness. An X-ray confirmed the dislocation, and the injury was of unknown time, place, and cause, with the resident unable to explain the event. The facility’s investigation gathered multiple staff statements (from CNAs, LPNs, and therapy) that denied knowledge of any fall or incident but did not document what specific care was provided, when it was provided, or how many staff assisted with transfers, despite the resident requiring two-person assist. The investigative summary attributed the dislocation to the resident’s medical history and decline in ADLs and stated the care plan was followed, but there was no documented evidence detailing actual care activities to substantiate that conclusion or to fully rule out abuse, neglect, or mistreatment.
A resident with diabetes, cellulitis of the left great toe, and prior sacral pressure ulcer history developed a new sacral pressure injury that was first noted by a CNA and assessed by an RN, who cleansed the area and applied a foam dressing but did not document the finding or notify a provider. On the following shift, a CNA again observed a reddened sacral area and a soiled, detached dressing, and an LPN applied a new foam dressing and notified an off-duty RN manager by text instead of the on-site supervisor, and did not contact a provider. Only later, when another LPN reported a change in condition including severe hyperglycemia, did an RN supervisor remove the dressing, find a foul-smelling sacral wound with gray-brown drainage, and notify the on-call provider, who ordered transfer to the ED, where the wound was identified as an unstageable/stage 3 sacral pressure ulcer requiring packing.
Two residents were not treated with respect and dignity when one cognitively intact resident with diabetes, cerebral palsy, and anxiety disorder repeatedly experienced significant delays in meal service, waiting up to 45 minutes or more while watching others eat despite having a completed meal ticket, and another resident with paraplegia, traumatic brain injury, severe cognitive impairment, and a feeding tube was repeatedly left unclothed or in only an incontinence brief with stool present, visible from the hallway due to an open door and lack of a privacy curtain, while staff attempted partial coverage and door positioning that did not fully prevent hallway visibility.
Surveyors found that MDS assessments did not accurately reflect the status of two residents. One resident with multiple comorbidities had repeated refusals of medications, IV therapy, and care, along with documented aggressive/combative behavior and behavior symptoms in nursing notes, MARs, and CNA ADL records, yet the MDS indicated no refusals or behaviors. Another resident with a chronic scalp infection and osteomyelitis had physician orders and documented treatments for a right temporal wound, but both the 5-day and quarterly MDS assessments recorded no ulcers, wounds, or skin problems. The Regional MDS Coordinator reported that errors occurred due to new staff completing MDS sections and a vacancy in the MDS Coordinator role, with corporate staff attempting to keep up with assessments.
PRN Antipsychotic Administered Without Indication, Behavior Care Plan, or Required Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs, specifically related to PRN antipsychotic use without adequate medical rationale or documentation. Facility policy on psychotropic medication required identification of underlying causes of behaviors, use of individualized non-pharmacological interventions, and clear indications for PRN antipsychotics, including specific target symptoms and documentation of post-medication effects. Despite this, the resident’s records did not contain a behavior care plan or personalized behavioral interventions, and the Resident Care Record lacked any information on behavioral symptoms or related interventions. The resident had diagnoses including unspecified dementia with behavioral disturbance and osteoporosis with a pathological hip fracture, and an MDS assessment documented severely impaired cognition, no behaviors, and a need for partial to moderate assistance with most ADLs. A comprehensive care plan addressed potential adverse effects from daily antipsychotic use but did not list an associated diagnosis and did not include a separate behavior care plan. The resident was admitted from the hospital with a PRN quetiapine order for agitation when unable to be redirected and with harm to self and others, and the facility’s admission orders continued quetiapine 12.5 mg PO in the evening as needed for 14 days. The NP’s history and physical documented dementia with behavior disturbances and other medical conditions and stated a plan to give PRN quetiapine for agitation, but there were no documented behaviors or related diagnosis specifically tied to the quetiapine in the record. The MAR showed the resident received PRN quetiapine on four occasions, yet there was no documentation of behaviors, non-pharmacological interventions attempted, or post-medication effectiveness for three of those administrations. A nursing progress note for one administration described restlessness, irritability, and reported aggression, with snacks, redirection, and incontinence care attempted, but did not specify the exact aggressive behaviors or the outcome after interventions and medication. The resident’s health care proxy reported difficulty keeping the resident awake, difficulty with eating coordination, and trouble obtaining information about medications, and stated that quetiapine had been given at night without notes explaining why, despite the resident not typically exhibiting agitation or aggression. Interviews with staff revealed inconsistent understanding and practice regarding documentation and indications for PRN antipsychotic use: one LPN described giving quetiapine for aggression and attempts to leave, but acknowledged missing documentation; another LPN could not recall the reason for administration; the RN Unit Manager confirmed there was no behavior care plan and that notes were missing for most PRN uses; the NP stated agitation alone was not an indication and that non-pharmacological interventions and their effectiveness should be documented; the Medical Director indicated the drug was used for agitation and sleep and that PRN antipsychotics were routinely used for sleep; and the DON stated that if an as needed antipsychotic was administered, a corresponding nurse’s note was expected. Collectively, these findings show the resident received PRN antipsychotic medication without documented medical necessity, without required behavioral assessments and care planning, and without consistent documentation of non-drug interventions or medication effects, contrary to facility policy and regulatory requirements.
Failure to Protect Privacy of Electronic Medical Records on Medication Carts
Penalty
Summary
The deficiency involves failure to protect the privacy and confidentiality of residents' personal and medical information by leaving medication carts unlocked and computer screens visible without privacy screens. During an abbreviated survey on multiple units, surveyors observed on 3 North that medication carts were left unattended in the hallway and near the nurse's station with the computers open and no privacy screens applied. At one point, a unit manager walked past an unattended, unlocked cart and then locked the cart and computer screen, but the cart had already been left unsecured. One LPN on 3 North stated they were not aware that the privacy screen was not applied, and another LPN acknowledged they should have applied the privacy screen when walking away from the cart. On 2 South, surveyors observed a medication cart in front of a resident room with the screen open to a specific resident's medication administration record while the assigned LPN was inside the room. That LPN stated they were busy and forgot to apply the privacy screen, and acknowledged they should have locked the cart and applied the privacy screen, demonstrating they knew how to do so. In another observation on 2 South, an LPN was obtaining vitals with a resident on one side of the nurse's station while the medication cart on the other side had no privacy screen on the computer. That LPN confirmed the privacy screen was not applied, despite the facility's Resident Rights to Privacy Policy stating that residents are to be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and care for personal needs.
Unlocked and Unattended Medication Carts with Open MAR Screens
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure medications and biologicals were stored securely and accessible only to authorized personnel, as required by facility policy and 10 NYCRR 415.18(e)(1-4). During an abbreviated survey on 1/29/2026, multiple observations were made of unattended, unlocked medication carts with open computer screens displaying medication administration records. On Unit 3 North at 10:42 a.m., a medication cart was observed left in the hallway unlocked and unattended; a unit manager later walked past, noticed it was unlocked, and then locked the cart and computer screen. At 10:46 a.m. on the same unit, another medication cart near the nurse’s station was observed unlocked and unattended while the assigned nurse was in the dining area obtaining vitals and administering medications to a resident. On Unit 2 South, similar issues were observed. At 11:00 a.m., a medication cart was found in front of a resident’s room with the cart unlocked and the computer screen open to that resident’s medication administration record while the nurse was inside the room with the resident. At 11:03 a.m., another medication cart was observed unlocked on one side of the nurse’s station while the assigned nurse was on the opposite side of the station obtaining vitals from a resident. In subsequent interviews, the involved LPNs acknowledged that they had not locked the carts, stated they typically do lock them, and attributed the lapses to being busy or believing the carts were locked. These observations and statements occurred despite a written facility policy stating that medications and biologicals are to be stored safely and securely, with access limited to licensed nursing, pharmacy personnel, or other lawfully authorized staff.
Failure to Provide and Document Required Grooming and Shaving Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary grooming and personal hygiene services, specifically shaving and facial hair care, for multiple residents who required assistance with activities of daily living. Facility policies required shaving male residents daily and women as needed, and indicated that licensed nurses and CNAs were responsible for implementing shaving procedures to improve appearance and morale. The DON stated facial hair was expected to be groomed at least on shower days, yet also acknowledged there was no designated area in the record to document grooming assistance and that refusals were expected to be documented in progress notes. One resident with Alzheimer’s disease, dementia, and depression had severe cognitive impairment and required maximum assistance with personal hygiene, including shaving per the care plan and CNA Kardex. Over a review period of several months, the electronic medical record contained no documentation that staff offered, provided, or recorded refusals of shaving or grooming, despite observations on multiple days showing long, patchy facial stubble and an overgrown mustache curling into the mouth. The resident’s family member reported that staff were expected to assist with shaving and that the resident did not like facial hair. A CNA and an RN manager both stated residents were shaved on shower days and acknowledged the resident required assistance and could be resistive at times, but there were no documented refusals. Another resident with a history of stroke, diabetes, and hypertensive heart disease was cognitively intact, visually impaired, and required substantial assistance with personal hygiene, including hair combing and shaving. The care plan and Kardex directed staff to assist with grooming, and ADL sheets showed grooming after set-up assistance with no refusals documented. This resident was repeatedly observed with long chin hair and facial hair on the upper lip and reported disliking facial hair, being unable to remove it independently due to impaired vision, and not refusing grooming care; the resident also stated staff had not offered assistance. A nurse manager confirmed the resident did not refuse care and that staff were expected to offer grooming assistance. A third resident with Parkinson’s disease, diabetes, and anxiety, cognitively intact and requiring moderate assistance with personal hygiene, had a care plan and Kardex directing staff to assist with shaving and trimming facial hair. Over several months, there was no documentation of grooming assistance or refusals, while observations showed a beard several inches long and a mustache curling into the mouth. This resident stated they wanted help trimming facial hair and that it had been months since grooming was last completed, while staff interviews revealed grooming was usually tied to shower days, often undocumented, and dependent on resident requests, despite the resident’s stated preferences.
Failure to Maintain Homelike Resident Rooms and Safe Tub Room Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment on multiple nursing units and in a tub room. On the 3rd floor, several four-bed rooms (including rooms 302 a-b, 307 a-d, 315 a-d, and 316 a-d) were observed with bare walls and lacking personalized items such as photos, pictures, clocks, or decorations. One four-resident room was also described as cluttered with a dirty floor containing debris and had no chairs available for residents or visitors. On the 6th floor, numerous rooms (602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 614, 616, 617, 619, and 620) were observed to be stark and bare without visible personalization, and many of these rooms did not contain a chair for resident or visitor use. These observations showed that many residents’ rooms were not personalized or furnished in a way that supported a homelike environment. Staff interviews confirmed awareness of these conditions and clarified how room personalization was typically handled. A RN Supervisor acknowledged that many resident rooms were not homelike or personalized and noted that residents with family visitors were more likely to have personalized rooms, while many residents without visitors did not. The RN Supervisor also stated they were unaware that many rooms lacked chairs. A social worker reported that families and friends frequently assisted with decorating rooms and that the Social Work Department did not usually address creating a homelike environment, viewing it instead as a Recreation Department activity. The Administrator stated that holiday decorations were generally limited to common areas and that resident rooms were usually personalized by families, and also stated that every resident room should have a chair. The Director of Recreation reported that staff rounded daily and would assist with personalization upon request but had not received requests to personalize rooms on the 6th floor and had not discussed room personalization with managers or administration. Additionally, in the 4th floor tub room, two windows had insulation coming out with a noticeable draft, and the Director of Building Services stated they were unaware of any concerns with the window insulation and that no work orders had been submitted.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by regulation and by its own abuse reporting policy. A resident with dementia, severe cognitive impairment, and a right hip replacement was dependent on staff for activities of daily living. A physician progress note documented that the resident was seen for lethargy and right thigh tenderness, and an x-ray of the right femur confirmed an acute posterior dislocation of the femoral head prosthesis with inward rotation of the femur. The resident could not explain what had happened, and staff statements indicated that no one had witnessed any fall or incident involving the resident. The facility’s accident/incident report documented the date, location, and time of occurrence as unknown, and the investigative summary later concluded there was no reasonable cause to believe abuse, mistreatment, or neglect had occurred. Despite the unknown cause of the dislocated hip prosthesis and the resident’s inability to provide an account, there was no documented evidence that this injury of unknown origin was reported to the State Agency. The facility’s abuse policy defined injuries of unknown source as those not observed, not explainable by the resident, or suspicious due to extent or location, and required investigation and reporting per New York State Department of Health and CMS regulations. However, on the investigative summary, the section indicating whether the incident was reported to the Department of Health was left unchecked. In an interview, the DON stated that because the resident did not have a fracture, the incident was not reported and was not considered an injury of unknown origin, and asserted that the facility followed its protocols, even though the cause, time, and location of the injury remained unknown and the resident was not cognitively intact to explain the event.
Failure to Thoroughly Investigate Dislocated Hip Injury of Unknown Source
Penalty
Summary
Surveyors found that the facility failed to conduct a thorough and complete investigation to rule out abuse, neglect, or mistreatment after a resident with a right hip replacement was discovered to have an acute posterior dislocation of the femoral head prosthesis. The resident had severe cognitive impairment, dementia, osteoarthritis, and required extensive assistance with activities of daily living, including two-person assistance for transfers. A physician note documented the resident was seen for lethargy and right thigh tenderness, and an X-ray confirmed the acute dislocation. The incident report classified the injury as having an unknown date, time, and location, and noted the resident was unable to explain what happened. The facility’s abuse policy required classification of injuries of unknown source when not observed, not explainable by the resident, or suspicious by extent or location. The investigation conducted by the facility consisted primarily of obtaining written statements from CNAs, LPNs, and therapy staff, all of whom reported no knowledge of any fall or incident and did not document the specific care they provided, including transfers or other activities. The investigative summary concluded that the dislocation was most likely related to the resident’s history of hip arthroplasty, osteoarthritis, and decline in ADLs, and stated there was no deviation from the care plan and no abuse, mistreatment, or neglect. However, there was no documented evidence in the investigation identifying who provided what care, when it was provided, or how many staff were involved in transfers or other care around the time of the injury to verify that the care plan, including two-person assist for transfers, was followed. The resident’s representative reported being informed only that the resident had a dislocated hip and not how it occurred. The Assistant DON later stated they relied on CNA interviews to determine the care plan was followed but could not explain why this was not documented in the written interviews or statements.
Failure to Assess and Notify Provider for New Sacral Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and its own policies when a resident developed a new sacral pressure ulcer. The resident had multiple diagnoses including type 2 diabetes mellitus with complications, cellulitis of the left great toe, and a history of a stage 3 sacral pressure ulcer. Admission and subsequent assessments documented intact skin, and the care plan included weekly skin checks, incontinence management, pressure-reducing devices, and other skin integrity interventions. Prior to the incident, there were no physician orders for pressure ulcer treatment, and the resident was documented as not having unhealed pressure ulcers and not being at risk for pressure ulcers on the most recent MDS, despite other documentation indicating they were at risk. On the night shift of 12/26–12/27, a CNA observed a skin issue on the resident’s sacrum and notified an RN, who assessed the area as red and quarter-sized, cleansed it with normal saline, and applied a foam dressing. The RN did not document this assessment in the nursing progress notes and did not notify a medical provider, contrary to facility policy requiring assessment and physician notification for changes in condition. The RN reported the issue only to the oncoming nurse at shift change. The following day, a CNA on day shift again observed a reddened area on the sacrum and a soiled, detached dressing in the resident’s incontinence brief, and notified an LPN. The LPN applied a clean foam dressing and notified an off-duty RN unit manager by text, rather than the in-house nursing supervisor, and did not contact a medical provider. The RN unit manager, who was not in the building, instructed that a progress note not be written until an RN assessed the area, and no further direction was given. Later that same day on evening shift, another LPN reported to the RN supervisor that the resident had a change in condition, including a blood sugar of 504 and a pressure area on the sacrum. Upon removing the foam dressing, the RN supervisor found the sacral wound to be foul-smelling with gray and brown drainage and documented low oxygen saturation and an elevated temperature. The on-call medical provider was then notified and ordered the resident sent to the emergency department. Hospital documentation later identified the sacral wound as an unstageable pressure ulcer requiring packing and as a stage 3 decubitus ulcer. There was no documented RN assessment or provider notification at the time the sacral wound was first identified or during the subsequent day shift, and no Braden reassessment was completed when the ulcer was discovered, despite facility policy requiring such actions when a new pressure injury or change in condition occurs. Interviews confirmed that the physician assistant who last saw the resident before the ulcer was discovered had not been informed of any skin issues and had observed intact skin at that time. The assistant DON/wound nurse stated they were not notified of the sacral ulcer until the resident was readmitted from the hospital and that a Braden assessment should have been completed when the ulcer was first found. The DON stated that nurses who discover a skin issue are expected to notify the nursing supervisor and medical provider, obtain treatment orders, and, if the nurse is an LPN, ensure an RN assessment occurs or contact leadership if no RN is in the building. The facility’s own investigation concluded that the night-shift RN who first assessed the sacral area did not document the pressure area or notify a medical provider, and that both the night RN and the day-shift LPN failed to follow the required notification chain of command, resulting in a lack of timely assessment and provider notification for the new sacral pressure ulcer.
Failure to Ensure Timely Meal Service and Privacy, Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity and that their quality of life was maintained or enhanced. One resident with diabetes, cerebral palsy, anxiety disorder, and intact cognition, who required set-up assistance with meals, experienced repeated and significant delays in meal service compared to other residents. During a dining observation, this resident remained the only person in the dining room without a meal for more than 45 minutes after trays began being passed, watching others eat while being told by an LPN that the meal would arrive shortly. The resident eventually left the dining room without having been served and later received the meal in their room, after the LPN acknowledged the meal ticket had been completed that morning and that the meal should have arrived with the others. Interviews and record review showed that this resident routinely received meals later than others, with delays sometimes lasting 30 minutes to an hour, and that the resident reported feeling bad and frustrated while waiting and watching others eat. A CNA stated they frequently contacted the kitchen about this resident’s meal and were often told it would take additional time, even when other residents had already been served. The RN Manager confirmed it was problematic that the resident did not receive their meal for more than 45 minutes after others and that the meal ticket had been reviewed by the dining services supervisor, who could not explain why the meal was not placed on the cart. The dining services supervisor acknowledged that residents seated together were not always served together and attributed this to lack of attentiveness to seating sheets, while the DON confirmed awareness of dining concerns and that other residents had reported long wait times. A second deficiency involved another resident with paraplegia, traumatic brain injury, severe cognitive impairment, and a feeding tube, whose care plan and CNA Kardex documented a preference not to wear clothing in bed and a requirement that the privacy curtain remain drawn at least halfway. Observations showed this resident lying in bed unclothed with the room door open and genitals exposed, visible from the hallway, and on another occasion lying in bed wearing only an incontinence brief with stool present between the legs, again visible from the hallway. Staff interviews revealed that the room lacked a privacy curtain, and staff sometimes left the bathroom door open or covered the resident with a top sheet in an attempt to conceal the resident while honoring the preference to be unclothed. The RN Manager stated staff attempted to preserve the resident’s dignity by covering them but was unaware the resident was frequently visible from the hallway, and the DON acknowledged it was not dignified for the resident to be visible from the hallway while unclothed.
Inaccurate MDS Coding for Refusals and Chronic Scalp Wound
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status for two residents reviewed for skin issues. For one resident with diagnoses including diabetes mellitus, heart failure, and morbid obesity, the quarterly MDS dated 09/29/2024 documented intact cognition and no behaviors, including no refusals of care, medications, or activities of daily living. However, nursing notes showed that this resident refused an IV catheter for IV infuvite on 09/23/2024 and refused milk of magnesia on 09/27/2024, stating they had not eaten in days. Additional documentation on 09/27/2024 described the resident as aggressive/combative and resisting/refusing care. The September Medication Administration Record showed refusals of Eliquis on 09/22/2024, 09/24/2024, and 09/25/2024, and CNA ADL documentation for September 2024 recorded behavior symptoms on multiple dates. Despite these documented refusals and behaviors, they were not captured on the MDS, and the Regional MDS Coordinator later acknowledged that these behaviors should have been included and that information may have been entered incorrectly by new staff. For a second resident with diagnoses including urinary abscess of the head/scalp, unspecified open wound of the head, and chronic osteomyelitis of the skull, the MDS assessments also failed to accurately reflect the resident’s condition. A physician’s note dated 11/26/2025 documented a chronic right scalp infection with greenish-brown exudate, and physician orders on 11/26/2025 and 11/27/2025 directed cleansing of the right temporal area with normal saline, application of a clean dry dressing, and topical Gentamicin Sulfate for osteomyelitis of the scalp. The Treatment Administration Record showed that the ordered scalp treatment was administered on 12/30/2025 and 12/31/2025. Despite this, both the Five-Day and Quarterly MDS assessments documented that the resident did not have other ulcers, wounds, or skin problems. The Regional MDS Coordinator stated that staff entering the MDS information made mistakes, that the MDS Coordinator position had been vacant, and that corporate staff were attempting to complete assessments while the Regional Coordinator was overseeing them but having difficulty keeping up.
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