Citations in New York
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New York.
Statistics for New York (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in New York
- Provided competency-based infection-control education to all in-house staff to reinforce proper precautions (K - F0880 - NY)
- Established a mandate for infection-control education of all oncoming staff before each shift to promote ongoing compliance (K - F0880 - NY)
- Planned continuous infection-control in-service education for staff not currently on the schedule to maintain workforce competency (K - F0880 - NY)
Widespread Failure to Administer Prescribed Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, as evidenced by multiple instances where residents did not receive prescribed medications over several days. For example, one resident with a history of kidney transplant and chronic kidney disease did not receive critical medications such as prednisone, nifedipine, and cyclosporine due to pharmacy delays and order entry errors. There was no documentation that the physician was notified of these missed doses, and in some cases, medications were administered at incorrect frequencies due to transcription errors from hospital discharge summaries. Staff interviews confirmed that nurses were responsible for entering and verifying orders, but lapses occurred, resulting in missed or incorrectly administered medications. Other residents with complex medical conditions, including end-stage renal disease, diabetes, bipolar disorder, and high blood pressure, also experienced missed doses of essential medications such as insulin, antihypertensives, antipsychotics, antidepressants, antibiotics, and antiplatelets. Medication Administration Records (MARs) showed blank entries for multiple medications on several days, with no documentation explaining the omissions or indicating that the medical team had been notified. Residents reported going extended periods without receiving their medications, and staff interviews revealed that staffing shortages contributed to the inability to administer medications as ordered. A facility-wide audit of medication administration revealed that a significant number of residents did not receive multiple medications on multiple days, affecting nearly the entire resident population. The Director of Nursing and Administrator acknowledged awareness of the issue, attributing it to staffing challenges and lapses in oversight. The Medical Director confirmed that all prescribed medications were significant and that missing doses, especially of antirejection medications, was unacceptable. The deficiency was determined to have resulted in the likelihood of serious injury, harm, or death for all residents in the facility.
Removal Plan
- The medical team was notified of all residents who had medication errors (missed medications), medical assessments were in process and daily vital signs were initiated and will be ongoing.
- 100% of all onsite day and evening shift licensed nursing staff education was completed and included the facility's policies Administering Medications and Adverse Consequences and Medication Errors, the missed medication daily review process and proper communication of staffing emergencies related to coverage.
- Interviews with licensed nurses onsite were completed to verify the above education including the evening nurse supervisor. An attestation that 100% of all facility licensed nurses including agency nurses would be educated prior to their next shift.
- A facility wide Medication Administration Audit Report for every shift for any missed or omitted medications will be conducted by the Nursing Supervisor or the Director of Nursing (or designee).
- Interviews with facility Administrator, Director of Nursing and Corporate Director of Nursing were completed regarding a root cause analysis of significant medication errors as related to staffing issues and plans initiated to prevent ongoing issues including closing one resident unit down and increased agency presence in the facility as needed.
Failure to Prevent Accident Hazards and Inadequate Supervision for Aspiration Precautions
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision or assistive devices to prevent accidents for residents on aspiration precautions. Multiple residents with diagnoses such as dysphagia, dementia, and cognitive impairment were observed eating meals without the required supervision or assistance, despite care plans and physician orders specifying the need for direct supervision, upright positioning, and thickened liquids. In several instances, residents were left alone in their rooms while eating, were not properly positioned, or were given liquids that were not thickened as ordered, resulting in coughing and increased risk of aspiration. Staff interviews revealed a lack of awareness regarding which residents required aspiration precautions and inconsistent practices in meal preparation and supervision. Additionally, the facility's dietary and nursing staff did not consistently ensure that meal trays matched the prescribed diet consistencies. For example, one resident received regular coffee instead of thickened liquids, and staff were unaware of the resident's dietary needs. Observations showed that staff often left residents unsupervised during meals, even when care plans required direct supervision or assistance. Staff interviews indicated that supervision was sometimes limited to walking by rooms or peeking in, rather than providing the direct oversight required for residents at high risk of aspiration. The facility also failed to address physical hazards related to heating surfaces in resident areas. Radiator covers and heating units in multiple rooms and common areas were found to have surface temperatures well above 125 degrees Fahrenheit, with some exceeding 150 degrees. These hot surfaces were accessible to residents, including those with wandering behaviors, and were located near beds, dining tables, and common areas. Maintenance staff did not keep records of temperature checks and were unaware of the potential hazard, despite the proximity of residents to these hot surfaces.
Removal Plan
- Review of residents identified to be on aspiration precautions, medical records, physician orders and care plans.
- Educate nursing, dietary and therapy staff, unit clerks, and resident assistants on aspiration precautions, checking meal tickets against tray contents, how to properly supervise and assist residents on aspiration precautions, and the correct procedure for feeding and recognizing signs of aspiration. Complete and review post-tests.
- Director of Dietary (or designee) to review meal tickets during tray preparation, and licensed staff to verify the meal tickets against meal trays for accuracy prior to passing.
- Review lunch trays on units to ensure correct food item consistencies, and interview staff to verify knowledge of the process.
- Review unit binders containing lists of residents on aspiration precautions and guidance on diet consistencies.
- Observe kitchen/dietary staff preparing thickened liquids before meal trays leave the kitchen.
- Review the facility's Aspiration policy.
- Ensure trays of residents on aspiration precautions arrive separate from other trays (per the facility's removal plan) and inform staff of the new process. Interview staff to verify knowledge of the new process.
- Observe staff supervising and assisting residents on aspiration precautions with meals.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in infection control practices for six of eight residents reviewed. Several residents who were on contact or droplet precautions for communicable diseases such as Clostridium difficile, COVID-19, and metapneumovirus did not have the appropriate isolation precaution signage posted on their doors. In some cases, precaution signs were missing, posted late, or incorrectly identified the resident on precautions. Staff frequently entered and exited rooms of residents on isolation precautions without donning the required personal protective equipment (PPE) or performing proper hand hygiene. For example, staff were observed entering rooms without PPE, removing PPE outside of rooms, and failing to wash hands after glove removal. In one instance, a physical therapist wore PPE but left the resident's room to take phone calls without changing PPE, and a nurse entered a room with only a surgical mask when an N95 was required but unavailable in the PPE caddy. Laundry and housekeeping practices also failed to meet infection control standards. Contaminated laundry from residents on contact precautions was not consistently separated from general population laundry, and laundry staff were not always informed when items required special handling. Housekeeping staff did not consistently use PPE when handling refuse from isolation rooms and did not follow enhanced cleaning protocols, such as using bleach for rooms of residents with Clostridium difficile. Some staff reported cleaning all rooms the same way, regardless of isolation status, and using plain water for mopping instead of disinfectant. Additionally, staff responsible for laundry and housekeeping were not always aware of which residents were on precautions and did not consistently wear appropriate PPE due to discomfort or lack of communication. The facility's own policies required the use of color-coded precaution signs, proper PPE usage, and specific cleaning and laundry protocols for residents on isolation precautions. However, observations and staff interviews revealed widespread non-compliance with these policies. Staff were often unaware of the correct precautions, did not follow signage, and failed to implement required infection control measures, increasing the likelihood of transmission of communicable diseases among residents and staff.
Removal Plan
- The facility ensured all residents on precautions were reviewed and had the appropriate isolation precaution signage in place.
- All in-house staff were educated on infection control with competency-based training.
- All oncoming staff would be educated prior to the start of their shift.
- The facility provided in-service education to staff, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Failure to Provide Preferred Communication Methods for Deaf Residents
Penalty
Summary
The facility failed to ensure the rights of two residents who were Deaf to choose activities and health care services consistent with their interests, assessments, and care plans, and to participate in social and community activities. Both residents were not provided with their preferred method of communication, which was American Sign Language (ASL), and instead were limited to using whiteboards and written communication. Staff interviews revealed a lack of knowledge and training on how to use available technology, such as tablets with video relay interpreting services, and there was no consistent provision of in-person or video ASL interpretation for daily communication, medical care, or participation in activities. One resident, who was cognitively intact but non-speaking and Deaf, reported feeling isolated and unable to communicate needs, socialize, or participate in meaningful activities. The resident's care plan and speech therapy recommendations specified the use of live ASL interpreting services via tablet, but this was not implemented. Staff relied on whiteboards, which the resident was not comfortable using due to limited English proficiency, and staff were unaware of or unable to use the tablet for interpretation. The resident experienced psychosocial harm, including feelings of isolation, inability to communicate about medication changes, and lack of participation in activities due to the absence of interpreters. The second resident, who was also Deaf with highly impaired vision and moderate cognitive impairment, was similarly not provided with their preferred communication method. Although care plans and therapy notes recommended live ASL interpretation and the use of tablets, these were not made available to the resident on a regular basis. Staff and family interviews confirmed that the resident could not effectively communicate needs or participate in care discussions, and staff often resorted to writing, which was ineffective due to the resident's vision and handwriting difficulties. The lack of appropriate communication support resulted in the residents' inability to express preferences, participate in activities, and communicate with staff and peers.
Removal Plan
- Facility provided Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident.
- Education was provided to the staff and residents on the use of the tablets.
- Tablets were to be kept in the resident's rooms.
- Facility provided in-service education to staff with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Latest Citations in New York
Surveyors identified that two residents received IV therapy that did not meet professional standards: one received expired IV fluids, and another had an undated IV site dressing and incomplete physician orders lacking infusion rate and site care instructions. Nursing staff failed to check expiration dates, properly document, and ensure complete orders, while oversight by the DON and medical providers was insufficient.
Dietary staff were observed handling food and utensils without properly covering facial hair, contrary to facility policy requiring beard guards for infection control. Staff interviews confirmed lapses in following the required uniform standards, and facility leadership acknowledged the expectation for all facial hair to be covered during food preparation.
An LPN failed to follow infection control protocols while administering medications to a resident with a gastrostomy tube, including not performing hand hygiene, not changing gloves after picking up a dropped medication, and not donning required PPE despite posted Enhanced Barrier Precautions. The LPN, who was newly hired and had received relevant training, did not notice the signage or available PPE supplies.
The facility did not post required notices about the availability of survey results in prominent and accessible areas, as confirmed by observations, staff interviews, and resident feedback. Residents were unaware of where to find survey results, and staff had not discussed or observed any postings regarding their availability.
A resident with dementia and recent facial trauma was not assessed by a qualified professional after family reported choking on liquids. Despite facility policy requiring RN assessment and possible therapy referral for changes in condition, only an LPN checked the resident's mouth, and no further action, care plan update, or therapy referral was documented. The resident later developed aspiration pneumonia and died, with the autopsy confirming aspiration pneumonia complicating facial trauma as the cause.
A resident with stroke-related hemiplegia and osteoporosis, requiring extensive assistance for transfers, sustained a left arm fracture after being transferred by family members who had not received training in safe transfer techniques. Facility staff were aware of family involvement in transfers, but there was no documentation of education or referral for training prior to the injury. The facility's policies and care plan did not address non-staff transfers or provide guidance for family participation.
The facility did not ensure immediate reporting of alleged abuse, neglect, or theft, nor did it submit required investigative conclusions to the Department of Health for three incidents involving residents with cognitive and physical impairments. These incidents included allegations of staff abuse, resident-to-resident sexual exposure, and concerns about a CNA's roughness and lack of empathy. Both the DON and Administrator were unaware that the required reports had not been submitted.
Care plans were not updated after incidents involving abuse allegations and inappropriate behavior between residents. Despite existing policies and the involvement of residents with complex medical and psychiatric conditions, the facility did not revise care plans to reflect new allegations or behaviors, as confirmed by staff interviews.
Two residents with significant physical and cognitive impairments did not consistently receive or have documented incontinence care as required by their care plans. CNA documentation showed multiple unsigned instances across several months, indicating lapses in care provision. Nursing leadership confirmed that documentation was expected to be reviewed daily, but issues such as short staffing and lack of consistent disciplinary action contributed to ongoing deficiencies.
The facility did not consistently provide the minimum number of certified nurse aides (CNAs) required by its own staffing assessment for the first floor, with multiple shifts in July and August showing CNA staffing below the established levels. Interviews and staffing records confirmed that actual staffing often fell short of the required ratios, despite the use of agency staff and scheduling tools.
Deficient IV Fluid Administration and Documentation
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids in accordance with professional standards of practice for two out of three residents reviewed for hydration. In one instance, a resident with severe cognitive impairment and a dislodged gastrostomy tube was observed receiving IV fluids from a bag that was past its expiration date. The LPN who administered the IV fluids admitted to not checking the expiration date before use, and the Unit Manager was unaware that expired fluids were being administered. The DON confirmed that nurses are required to verify both the match to the physician's order and the expiration date of IV solutions before administration. In another case, a resident with intact cognition and a need for IV hydration due to diarrhea was found with an undated peripheral IV catheter dressing. The physician's order for IV hydration lacked critical details, including the infusion rate and instructions for assessment and maintenance of the IV site. There was also no documented order for the insertion of the IV line or for dressing changes. The Medication Administration Record did not specify the infusion rate, and the Treatment Administration Record lacked documentation of site inspection, assessment, or dressing changes as required by facility policy. Interviews with nursing staff and the DON revealed lapses in following established protocols, such as failing to date IV dressings and not ensuring complete and accurate physician orders for IV therapy. The attending physician and medical director both acknowledged that the orders were incomplete and not properly reviewed or signed. These deficiencies were observed during the recertification survey and were not accompanied by any corrective or follow-up actions in the report.
Failure to Ensure Proper Facial Hair Restraint During Food Handling
Penalty
Summary
During a recertification survey, it was observed that dietary staff did not consistently follow professional standards for food service safety and infection control in the kitchen. Specifically, one dietary aide was seen handling utensils and scooping watermelon while having a visible mustache and goatee without a beard cover. Another dietary aide was observed on the tray line handling various food items with their beard guard positioned below their mustache, leaving facial hair uncovered. These actions were in direct violation of the facility's policy, which requires all facial hair to be covered by a beard guard when handling food. Interviews with the involved staff revealed that one aide forgot to wear the beard cover, while the other stated they were previously instructed to only cover the bottom part of their face. Both the Food Service Supervisor and Food Service Director confirmed that the facility's uniform policy mandates the use of hair restraints and beard guards for staff with facial hair to prevent hair from contaminating food. The failure to adhere to these standards resulted in a deficiency related to food safety and infection control practices.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to adhere to infection control protocols during medication administration to a resident with a gastrostomy tube. The LPN did not perform hand hygiene before donning gloves to prepare medications, picked up a medication that had fallen on the floor with the same gloved hands, and continued to administer medications without changing gloves or performing hand hygiene. Additionally, the LPN did not don the required personal protective equipment (PPE) before entering the resident's room, despite signage indicating the need for Enhanced Barrier Precautions. Interviews revealed that the LPN was newly hired and had received orientation and in-service education on infection prevention, including hand hygiene and Enhanced Barrier Precautions. The LPN stated they did not notice the signage or the availability of PPE supplies near the resident's room. Facility leadership confirmed that infection control education and signage were in place and that supplies were accessible, but the LPN did not follow established protocols during the observed medication administration.
Failure to Post Survey Results Notice in Prominent Areas
Penalty
Summary
The facility failed to ensure that notices regarding the availability of survey results were posted in prominent and accessible areas, as required by both facility policy and regulatory standards. Multiple observations throughout the facility, including the main lobby, revealed that there were no posted notices indicating where survey results could be reviewed. The facility's policy specifies that such notices must be visibly posted in designated areas, but this was not adhered to during the survey period. During a Resident Council meeting, all residents in attendance reported that they did not know where to find the survey results and had not seen any notices about their availability. Additionally, review of previous Resident Council meeting minutes showed no documentation that residents were informed about the location of survey results. Interviews with staff, including the Recreation Director, confirmed that the topic had not been discussed and that no signage was observed. The Administrator acknowledged that the signage had previously been present but was not currently posted.
Failure to Assess and Respond to Choking Incident Following Change in Condition
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of severe cognitive impairment was not assessed by a qualified professional after family reported the resident was choking on liquids. The facility's policy required staff to identify and report changes in a resident's condition, with licensed nurses responsible for initiating communication forms and registered nurses required to assess, notify providers, and document findings. Despite these protocols, there was no documented evidence that a registered nurse or other qualified professional assessed the resident following the family's report of choking, nor was there a referral to speech therapy or an update to the care plan addressing swallowing concerns. The resident had recently returned from the hospital with facial trauma, including multiple nasal fractures, and was experiencing decreased oral intake and difficulty breathing. Progress notes indicated ongoing issues with oral intake and complaints of sore throat, but when the family reported choking on liquids, the LPN checked the resident's mouth but did not document notifying a supervisor or initiating further assessment. No physician orders for diet modification or therapy screenings were completed during this period, and the comprehensive care plan was not updated to reflect the new swallowing concerns. Subsequent documentation showed the resident developed pneumonia and increased lethargy, ultimately leading to death. The autopsy report identified aspiration pneumonia complicating facial trauma as the cause of death. Interviews with staff confirmed that the expected protocol was not followed, as a registered nurse assessment and therapy referral should have occurred after the report of choking, regardless of the family's prior refusal of a modified diet.
Failure to Ensure Safe Transfers by Family Led to Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, left-sided hemiplegia, osteoporosis, and dementia sustained a left arm fracture of unknown origin. The resident required extensive assistance for transfers, as documented in their care plan and physical therapy assessments. Despite these needs, the facility's policy on transferring and ambulation did not address the involvement of non-staff, such as family members, in resident transfers. Family members were known to have transferred the resident between the bathroom, recliner, and bed without staff present or supervision. There was no evidence that the family received any training or education on safe transfer techniques prior to the injury. Multiple staff, including CNAs and LPNs, were aware that the family was assisting with transfers, but there was no documentation of this being communicated to therapy or administration, nor was there a referral for family education before the incident. The resident began complaining of left arm and shoulder pain, which was noted by nursing staff, but there was no documented assessment by a qualified professional on the day of the initial complaint. An x-ray later confirmed an acute fracture of the proximal humerus. The facility's investigation found that both staff and family had transferred the resident, and that the family had not been trained in safe transfer methods prior to the injury. The care plan and facility policies did not address or provide guidance for family involvement in transfers.
Failure to Timely Report and Submit Abuse Investigation Conclusions
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately, and that the results of investigations were submitted to the New York State Department of Health within the required timeframe. Specifically, the facility did not report the investigative conclusions for three separate incidents involving three different residents, as required by state law and facility policy. The incidents included allegations of staff abuse, resident-to-resident sexual exposure, and concerns about a certified nurse aide's roughness and lack of empathy. In one case, a resident with chronic obstructive pulmonary disease, schizophrenia, and major depressive disorder reported to their representative that staff had physically abused them in the dining room. The administrator was not informed of the allegation until several days after the incident, and there was no documented evidence that the investigative conclusion was submitted to the Department of Health. In another case, a resident with dementia and schizoaffective disorder exposed themselves to another resident, causing distress, but again, the investigative conclusion was not reported to the Department of Health. A third incident involved a resident with muscle weakness, major depressive disorder, and anxiety, who complained that a certified nurse aide was rough and showed no empathy. The facility investigated and found no evidence of abuse, but did not submit the investigative conclusion to the Department of Health. Interviews with the Director of Nursing and the Administrator revealed a lack of awareness regarding the failure to submit the required reports, despite both being responsible for reporting and documentation.
Failure to Update Care Plans Following Abuse and Behavioral Incidents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised in response to significant events for three residents reviewed. Specifically, one resident reported being beaten by staff, but their abuse care plan was not updated to reflect this allegation. Another resident was exposed to inappropriate behavior by a peer, yet neither the abuse care plan for the affected resident nor the behavior care plan for the resident exhibiting the behavior was updated to document the incident. These omissions occurred despite facility policy requiring care plans to be revised as residents' conditions or circumstances change. Record reviews showed that the residents involved had complex medical and psychiatric histories, including diagnoses such as COPD, schizophrenia, dementia, and major depressive disorder. The care plans in place prior to the incidents included interventions for abuse risk and behavioral concerns, but these were not revised to address the new allegations or behaviors. Interviews with nursing staff and administration confirmed that care plans should have been updated following these events, but this did not occur.
Failure to Provide and Document Required Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary care and assistance, specifically in the area of incontinence care. Two residents with significant physical and cognitive impairments, including diagnoses such as Parkinson's disease, dementia, hemiplegia, and hemiparesis, were identified as being dependent on staff for toileting and incontinence care. Both residents had care plans in place that required staff to check and provide toileting care every two to four hours as tolerated. Record reviews revealed multiple instances where Certified Nurse Assistant (CNA) documentation for incontinence care was not signed, indicating that care may not have been provided as required. For one resident, there were five unsigned instances in June and seven in July. For the second resident, there were four unsigned instances in July and fourteen in August. These lapses occurred across various shifts, including day, evening, and night shifts, and were documented in the facility's electronic medical record system. Interviews with nursing leadership confirmed that CNA documentation is expected to be reviewed daily by supervisors and that missing documentation is followed up with staff. However, it was acknowledged that issues such as short staffing and assignment splitting sometimes contributed to incomplete documentation. Despite reminders and monitoring at multiple levels, including from the DON and corporate oversight, the problem of incomplete documentation persisted, and at the time of the survey, there was no consistent disciplinary action for failure to complete documentation.
Failure to Maintain Minimum CNA Staffing Levels on Multiple Shifts
Penalty
Summary
The facility failed to consistently provide sufficient certified nurse aide (CNA) staffing to meet the needs of residents on the first floor, as determined by its own facility assessment and staffing grid. Review of daily staffing schedules for July and August 2024 revealed multiple shifts where CNA staffing fell below the minimum levels established by the facility, including instances where only two or three CNAs were present during day and evening shifts, and occasions with only one or no CNAs on night shifts. These staffing levels did not align with the provider average ratio levels required for the unit, which called for five CNAs on day shift, four on evening shift, and two on night shift. The facility's policy states that adequate staffing must be maintained to meet resident care needs as outlined in their comprehensive care plans. Interviews with the Administrator and Human Resources Director confirmed that staffing had been an issue in the past, with reliance on agency staff to cover callouts and a history of insufficient CNA numbers. The Human Resources Director acknowledged the use of a staffing application and a weekly scheduling process, but records showed that actual staffing often did not meet the established minimums. The Administrator provided documentation confirming the required staffing ratios, which were not consistently met during the reviewed period.
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