Absolut Center For Nursing And Rehabilitation At T
Inspection history, citations, penalties and survey trends for this long-term care facility in Painted Post, New York.
- Location
- 101 Creekside Drive, Painted Post, New York 14870
- CMS Provider Number
- 335652
- Inspections on file
- 11
- Latest survey
- February 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Absolut Center For Nursing And Rehabilitation At T during CMS and state inspections, most recent first.
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies. A resident with Covid-19 was not placed on proper precautions, and staff were observed without appropriate PPE. Another resident with a pressure ulcer was not on enhanced barrier precautions, and staff did not wear gowns during care. The facility's infection control policies were not reviewed annually, contributing to these deficiencies.
The facility failed to comply with pneumococcal vaccine protocols for eight employees, lacking documentation of vaccine eligibility, education, and annual offering. Employees D, A, and B were last offered the vaccine in 2020 and 2022, while forms for Employees E, H, I, and J were incomplete. The Infection Preventionist and Administrator were unaware of the annual requirement, indicating a need for policy revision.
The facility did not conduct or document semi-annual visual inspections of its fire alarm system initiating devices, including smoke detectors, heat detectors, and pull stations, for the year 2024. The Environmental Services Director was unaware of the requirement, relying solely on the vendor for inspections. This resulted in non-compliance with NFPA 72 standards.
A Life Safety Code Survey found that the facility did not ensure proper illumination of egress pathways for four of seven exits. Observations revealed a lack of exterior lighting on several sections of the pathways. The Environmental Services Director was unaware of the deficiency but acknowledged the need for additional lighting.
A resident with dementia and impaired cognition fell out of bed during care provided by one CNA instead of the required two-person assistance. The incident, which resulted in a skin tear and bruising, was not reported to the Department of Health as required. Despite concerns about the CNA's conduct, the facility's DON and Administrator did not consider the incident reportable, citing the injury as not serious.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent nail care, as required by the facility's policy. Observations showed the resident with brown debris on their fingers and nails on multiple occasions, despite needing total assistance with personal hygiene. Staff interviews revealed a lack of communication and documentation regarding the resident's nail care.
A resident with edema did not receive prescribed ace wraps for their lower extremities, as observed during a survey. Despite physician's orders and a care plan directive, there was no documentation of the wraps being applied or any refusals recorded. Interviews revealed the resident occasionally refused care, but no refusals were documented. The DON stated refusals should be documented if care is refused after re-approach attempts.
A facility failed to provide appropriate dialysis care for a resident with end-stage renal disease, as they did not have physician orders or a care plan for the resident's tunneled catheter, nor did they monitor it for complications. The care plan and physician orders were inconsistent, and the facility did not follow the vascular physician's recommendations. Staff interviews revealed a lack of awareness regarding the resident's dialysis care needs, and there was no documented evidence of monitoring by the Infection Preventionist nurse.
The facility did not ensure proper maintenance of electric beds as per the manufacturer's guidelines. During a survey, it was found that electrically operated beds were not inspected at the required intervals, and there was no documentation of formal inspections or maintenance. The Environmental Services Director acknowledged the lack of unique identifiers for beds and stated that beds were checked annually using a room audit form, but specific beds were not identified. This failure to adhere to maintenance requirements constituted a deficiency in compliance with NFPA 99 standards.
The facility failed to conduct a fire drill for the second shift during the fourth quarter of 2024 and did not document staff participation in a November drill. The Environmental Services Director admitted to not using a schedule and acknowledged the oversight.
Inadequate Infection Control Measures in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a recertification survey. Resident #45, who tested positive for Covid-19, was not placed on enhanced droplet/contact precautions, and staff were observed within six feet of the resident without wearing appropriate personal protective equipment (PPE). Additionally, Resident #100, who also tested positive for Covid-19, was placed on contact precautions instead of the required airborne precautions, and staff were observed handling the resident's environment without proper PPE. Resident #79, admitted with an open area on their leg and later developing a pressure ulcer, was not placed on enhanced barrier precautions. Staff were observed changing the dressing on the resident's heel ulcer without wearing a gown. Similarly, Resident #104, admitted with an unstageable pressure ulcer, was not placed on enhanced barrier precautions. Resident #16, who was on enhanced barrier precautions due to a multi-drug-resistant organism, was assisted by staff who only wore gloves during high-contact personal care, contrary to the requirement to wear gowns and gloves. The facility's Infection Prevention and Control Program policies and procedures were not reviewed annually as required. The Registered Nurse Educator/Infection Preventionist acknowledged the lapses in precaution signage and PPE usage, and the Director of Nursing confirmed that residents with certain conditions should have been on enhanced barrier precautions. The facility's failure to adhere to infection control protocols and ensure staff compliance with PPE requirements contributed to the deficiencies observed during the survey.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F880 Corrective Action - To assure the facility establishes and maintains an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. On 2/27/25 Resident #45 was placed on enhanced droplet/contact precautions for Covid-19 and the proper precaution sign was posted. CNA #4 was educated on proper PPE for enhanced droplet/contact precautions including wearing a mask/face shield. On 2/27/25 Resident #79 was placed on enhanced barrier precautions and the proper precaution sign was posted. The RN Educator and the Nurse practitioner were educated on proper PPE/gown use. On 2/27/25 Resident #100 was placed on enhanced droplet/contact precautions and CNA #3 was educated on proper PPE for precautions. Resident #104 was placed on enhanced barrier precautions. Additionally, the facility will ensure that Infection Prevention and Control Program policies are reviewed annually. Resident #16’s care plan was reviewed to assure the resident's enhanced barrier precautions remained appropriate and the proper precaution sign was posted. CNA #1 and #2 were educated on proper PPE precautions. 2. All residents who have respiratory symptoms and are being tested for COVID-19 have the potential to be affected by this deficient practice. A list of residents who have respiratory symptoms and are being tested for COVID-19 will be audited to ensure they are on enhanced droplet/contact precautions per policy, their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. All residents who have a wound with an expected healing time of greater than 4 weeks as per policy have the potential to be affected by this deficient practice. A list of residents with wounds will be generated and audited to determine if enhanced barrier precautions are necessary and their care plan will be updated as necessary, and that appropriate PPE is utilized by staff. 3. The facility policies for its Infection Control Program including: Infection Prevention and Control - General Statement, Policy on Use of Criteria for Infection Identification, Antibiotic Stewardship Program, Policy on Influenza Immunization (Seasonal/H1N1), Pneumococcal Vaccination Program - Residents, Policy on Surveillance, PPE Donning and Doffing, Enhanced Barrier Precautions and Coronavirus Policies will be reviewed and updated (if necessary), as well as annually. All facility staff will be educated on PPE Donning and Doffing. And all licensed nursing staff (RN/LPNs) will be educated on all our Infection Control Program policies listed above. The Director of Nursing/Designee will oversee the completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform 10 audits per month for 3 months, and then as needed based on findings. Audits will verify that residents on precautions (EBP, contact/droplet/airborne) have appropriate precaution signs on doors and that appropriate PPE is worn by staff during direct care. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed, the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F 880.
Inadequate Pneumococcal Vaccine Protocols for Employees
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the lack of compliance with pneumococcal vaccine protocols for eight out of ten employees reviewed. Specifically, the facility did not determine eligibility for the pneumococcal vaccine, provide education on its risks and benefits, or offer the vaccine annually to all employees who have direct care and/or close contact with residents. Documentation was missing for Employee F regarding vaccine eligibility and education. Employees D, A, and B were last offered the vaccine in 2020 and 2022, respectively, but declined it. Additionally, the consent/declination forms for Employees E, H, I, and J were not dated or signed by a facility representative, indicating a lack of proper documentation and attestation that the vaccine was offered and education provided. During interviews, the Infection Preventionist and the Administrator admitted to being unaware of the requirement to offer the pneumococcal vaccine annually to all employees. This oversight indicates a need for revision in the facility's policy and procedure to ensure compliance with New York State Department of Health regulations.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 I210 Corrective Action- To assure the facility determines eligibility for the pneumococcal vaccine, provides education on the risks/benefits of the pneumococcal vaccine, and offers the vaccine to all employees annually. 1. Employees (A-J) will have their eligibility for the Pneumococcal Vaccination determined, and if able, they will be offered, educated on, and have consent/declination forms signed. Those who are eligible and have consented, will have the vaccination administered. 2. All employees at the facility have the potential to be affected by this practice. The facility will complete a full house audit of staff. The audit will include eligibility, and if able, education, consent/declinations, and administration of the Pneumococcal vaccine (if appropriate). 3. The facility’s pneumococcal vaccination policy for employees will be reviewed and revised (if necessary). All Registered Nurses and HR staff in the facility will be reeducated on this policy. 4. To ensure prevention of future deficit in this practice, the Staff Educator/Designee will perform 10 audits per month for 3 months, then as needed based on the audit findings. Audits will verify that eligibility, and if able, education, consent/declinations, and administration of the Pneumococcal vaccine. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings. If continued improvement is needed, the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F I210.
Failure to Conduct Semi-Annual Fire Alarm Inspections
Penalty
Summary
The facility failed to properly maintain and inspect its fire alarm system initiating devices, as required by the 2010 edition of the National Fire Protection Association 72, National Fire Alarm and Signaling Code. During a Life Safety Code Survey, it was observed that the facility did not conduct or document semi-annual visual inspections for smoke detectors, heat detectors, and pull stations throughout the building for the calendar year 2024. Although annual functional testing was documented, the semi-annual visual inspections were not performed. The Environmental Services Director was unaware of the requirement for semi-annual visual inspections, relying solely on the vendor for inspection and testing. This oversight led to a deficiency in compliance with the NFPA 72 standards, which mandate that visual inspections occur twice per year, with a minimum of four months and a maximum of eight months between inspections.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K345 Corrective Action- The facility will ensure that it meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Alarm System Testing and Maintenance. 1. The facility’s contracted Fire Alarm Inspection company has been contacted to perform the semi-annual visual inspection for all fire alarm system initiating devices. 2. The semi-annual visual inspection for fire alarm system initiating devices will be added to the facility’s electronic work order system. 3. The Administrator will oversee in-services to all maintenance department staff in regards to the NFPA 101 Fire Alarm System Testing and Maintenance requirements including the importance of the visual inspection for initiating devices. 4. To prevent future deficit in this practice, the Maintenance director will perform 1 audit per month for 3 months to ensure the visual inspection requirements have been met and documentation is in place. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K345.
Inadequate Illumination of Egress Pathways
Penalty
Summary
During a Life Safety Code Survey conducted from February 24 to February 28, 2025, it was observed that the facility failed to ensure proper illumination of the means of egress for four of seven exits. Specifically, the outdoor exit discharge pathways lacked sufficient lighting to the public way. Observations made on February 24, 2025, between 1:11 PM and 1:24 PM revealed that there was no exterior lighting present to illuminate several sections of the exterior egress pathways. These included a 100-foot-long section between the exits from the A1 and D2 corridors, a 50-foot-long section between the exits from the D2 corridor and physical therapy, a 100-foot-long section between the exits from the D1 and C2 corridors, and a 50-foot-long section between the exits from the C2 corridor and the main entrance. During an interview conducted on the same day at 1:24 PM, the Environmental Services Director stated they were unaware of the lack of lighting between exits or the need for additional lighting. The director acknowledged the presence of lighting at the exits but indicated that additional lighting could be added for the pathways.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K281 Corrective Action - To ensure the facility meets the requirements of illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall either be continuously in operation or capable of automatic operation without manual intervention. 1) The facility will install lighting: in the 100 foot long section of exterior egress pathway between the exits from A1 and D2 corridors; the 50 foot long section of exterior egress pathway between the exits from D2 and D2 physical therapy; the 100 foot long section of exterior egress pathway between the exits from D1 and C2 corridors; and the 50 foot long section of exterior egress pathway between the exits from the C2 corridors and the main entrance so that the egress paths are illuminated in compliance with the Life Safety Code. 2) The Director of maintenance will conduct a complete inspection of all means of egress to identify any additional areas that may require increased lighting in compliance with the Life Safety Code. Annual inspection of egress path lighting will be added to the facility’s electronic work order system. 3) The Administrator will oversee in-services to all maintenance department staff in regard to the life safety requirements for means of egress lighting. 4) All means of egress will be audited monthly for 3 months and as needed based on the audits findings. Audits will verify all egress lighting meets the requirement of the Life Safety Code. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K281.
Failure to Report Resident Fall and Potential Neglect
Penalty
Summary
The facility failed to report an incident involving a resident, identified as Resident #66, who fell out of bed during incontinence care. The care was being provided by one Certified Nursing Assistant (CNA) instead of the two-person assistance required by the resident's Comprehensive Care Plan. This incident was not reported to the New York State Department of Health as required by state law, despite the resident sustaining a skin tear and bruising. The facility's policy mandates reporting any accident or incident where negligence is suspected, but the Director of Nursing and the Administrator did not consider the incident reportable, as they believed the injury was not serious. Resident #66 had a history of dementia, congestive heart failure, and atrial fibrillation, with severely impaired cognition as documented in their Minimum Data Set Resident Assessment. The incident occurred when the CNA instructed the resident to roll back, but the resident rolled the wrong way and fell. Statements from staff indicated that the CNA may have been rough with the resident, and another staff member expressed concerns about the CNA's conduct. Despite these concerns, the incident was not escalated to the Department of Health, highlighting a failure to adhere to reporting protocols for potential neglect or mistreatment.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F609 Corrective Action- To assure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator and to other officials in accordance with State law through established procedures. 1. As noted, the investigation regarding resident #66, dated 2/19/25, was made aware to the state DOH during survey 2/24/25 through 2/28/25. C.N.A. # 7, was educated/counseled on properly following the residents care plan. 2. All residents with alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source and misappropriation of resident property have the potential to be affected by this deficient practice. A retrospective review of all residents who have had such incidents in the past 30 days will be created and reviewed to assure that proper notification took place (if necessary). 3. The facility’s “Accident/Incident Investigation and Prevention” and “Facility Incident/abuse investigation and reporting” policies will be reviewed and revised if necessary to assure compliance. All staff will be in-serviced on these policies and the NYSDOH reporting guidelines. The Director of Nursing/Designee will oversee all education for staff. 4. To prevent further deficiency in this practice, the Director of Nursing / Administrator will perform audits of 10 resident accident and incident investigations each month for the next 3 months and then as needed based on the audit findings. Audits will verify that the facility is appropriately reporting all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are being reported immediately to the administrator of the facility and to other officials in accordance with State Law through established procedure. The administrator will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F609.
Inconsistent Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide consistent assistance with nail care for Resident #15, who was dependent on staff for personal hygiene due to severe cognitive impairment and other medical conditions. The facility's policy required routine nail care following baths or showers, but observations during the survey revealed that Resident #15 had brown debris on their fingers, nails, and cuticles on multiple occasions. Despite the resident's need for total assistance with personal hygiene, there was no documented evidence of nail care being refused or performed, as required by the facility's policy. Resident #15, diagnosed with vascular dementia, congestive heart failure, and traumatic brain injury, was observed with soiled hands and nails on several occasions, indicating a lack of proper hygiene care. The resident's care plan required total assistance with bathing and nail care, yet observations showed the resident with brown debris under their nails and on their hands, even while eating. Interviews with staff revealed a lack of communication and documentation regarding the resident's nail care, contributing to the deficiency in maintaining the resident's personal hygiene.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F677 Corrective Action- To assure all residents who were unable to carry out activities of daily living (ADLs) receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. On 3/17/2, Resident #15 had proper nail care performed. Resident #15’s Care plan was reviewed for level of assistance required for hygiene and remains appropriate. 2. All residents residing in the facility who require assistance for nail care have the potential to be affected by this practice. A list of all residents who are dependent on staff for nail care will be created. These listed residents will then be audited for appropriate nail care. 3. To ensure this practice does not reoccur, the facility policy on Nail Care will be reviewed and revised if necessary. Education will be provided to all nursing staff (RNs, LPNs, and CNAs). The Director of Nursing/Designee will oversee in-services for all nursing staff. 4. To prevent further deficiency in this practice, the Director of Nursing/Designee will perform 10 resident audits per month for 3 months, and then as needed based on the audit findings. Audits will verify that proper nail care has been completed. The DON will monitor this process and review results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of Nursing will assume overall responsibility for the correction of F677.
Failure to Apply Prescribed Ace Wraps for Edema Management
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema, as evidenced by the lack of application of ace wraps to the resident's lower extremities. The resident, who had diagnoses including congestive heart failure, atrial fibrillation, and edema, was observed multiple times without the prescribed ace wraps, despite having orders for their use to manage edema. The resident's care plan also included instructions to encourage the use of ace wraps and document any refusals, yet there was no documentation of the ace wraps being applied or any refusals recorded for the month of February. Interviews with facility staff revealed that the resident occasionally refused care, particularly from male caregivers, but there was no documented evidence of such refusals regarding the ace wraps. The Director of Nursing stated that refusals should be documented by nursing staff if a resident continues to refuse care after re-approach attempts. The lack of documentation and adherence to the care plan and physician's orders resulted in the resident not receiving the necessary treatment for their condition, as observed during the survey.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 F684 Corrective Action- To assure that Residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents’ choices. 1. On 2/27/25, the provider reviewed and revised resident #51’s order for ace wraps, requiring progress notes for all refusals. On 3/17/25, resident #51’s care plan was reviewed and remains appropriate in regards to ace wraps. 2. All residents who have orders for ace wraps have the potential to be affected by this practice. A list of all residents requiring ace wraps will be created and audited to ensure that ace wraps are applied as directed and documented appropriately. 3. To ensure this practice does not reoccur, the facility policy on “Medication/Treatment administration: Documentation” will be reviewed and revised if necessary. All licensed nursing staff (RN, LPN) will be re-educated on this policy. The Director of Nursing/designee will oversee in-services for all licensed nursing staff. 4. To prevent further deficiency in this practice, the Director of Nursing/designee will perform 10 audits per month for 3 months, and then as needed based on the audit findings. Audits will verify ace wraps are applied as ordered, and that all refusals are documented. The Director of Nursing will monitor this process and will review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Director of nursing will assume overall responsibility for correction of F684.
Deficient Dialysis Care and Monitoring in LTC Facility
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease, muscle weakness, and diabetes. The resident had a clotted dialysis fistula and a tunneled catheter was placed for dialysis treatments. However, the facility did not have physician orders or a care plan for the tunneled catheter, nor did they monitor the catheter and dressing for potential complications. The facility also did not follow the vascular physician's recommendations regarding blood draws and needle pokes in the resident's right arm. The resident's care plan and physician orders were inconsistent and incomplete. The care plan did not include the presence of the tunneled catheter or interventions for its care, and the physician orders did not address monitoring the catheter. Additionally, the facility's records showed inconsistent documentation of the resident's 24-hour fluid restriction, with daily fluid intake totals ranging from zero to 2160 milliliters, which did not align with the ordered 1500 milliliters per day. Interviews with facility staff revealed a lack of awareness and understanding of the resident's dialysis care needs. Licensed Practical Nurses were unsure about the resident's fluid restriction and tunneled catheter, and the Dialysis Clinical Coordinator confirmed that the tunneled catheter was used for dialysis treatments. The Director of Nursing and Quality Assurance Nurse acknowledged that all dialysis access sites should be monitored, and the care plan should include the tunneled catheter, but there was no documented evidence of monitoring by the Infection Preventionist nurse.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F698 Corrective Action- To assure that residents requiring [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. 1. Resident #36 orders were reviewed and updated for: 24-hour fluid restriction, and monitoring of the right chest tunneled catheter dressing. The left AV fistula orders were reviewed and discontinued and the interventions have been resolved. The care plan was reviewed and updated to include the right chest wall tunneled [MEDICAL TREATMENT] catheter, interventions for monitoring, and the 11/26/2024 vascular physician recommendations were reviewed by the provider and added to the care plan. The resident is scheduled to have a right arm fistula or graft completed on 4/7/2025. 2. All residents who receive [MEDICAL TREATMENT] treatment have potential to be affected by this practice. A list of all Residents on [MEDICAL TREATMENT] will be created and audited to assure fluid restrictions are monitored 24 hours a day, physician orders [REDACTED]. 3. To ensure this does not reoccur, the facility policy on [MEDICAL TREATMENT] will be reviewed and updated as needed. LPN and RN staff will be educated on said policy and written test to be provided to ensure competency. The Director of Nursing will oversee completion of these in-services. 4. To prevent future deficient practice, the Director of Nursing/Designee will perform audits of all [MEDICAL TREATMENT] residents each month for 3 months, and then as needed based on findings. Audits will include monitoring of any fluid restrictions, monitoring of physician orders [REDACTED]. The Director of Nursing will monitor this process and review the results monthly at QAPI meetings as needed. If continued improvement is needed the Committee may make further recommendations. The Director of Nursing will assume overall responsibility for correction of F698.
Failure to Maintain Electric Beds as per Manufacturer's Guidelines
Penalty
Summary
The facility failed to ensure that patient care-related electrical equipment, specifically electric beds, was properly maintained according to the manufacturer's specifications. During the Life Safety Code Survey, it was observed that electrically operated beds were in use throughout the facility without documented formal inspections or maintenance. The facility's policy on medical equipment management required that all medical and electrical patient care equipment be evaluated prior to use and maintained according to specific criteria. However, there was no inventory or unique identification for the electrically operated beds, and no preventative maintenance forms were available to indicate that electrical safety checks were conducted routinely as required by the manufacturer. The survey revealed that the M.C. Rexx brand bed manual specified that each bed should be inspected at least once a year by qualified technicians, with a detailed checklist provided for the inspection. Despite this, the facility did not maintain records of such inspections. The Environmental Services Director confirmed that beds were checked annually using a room audit form, but there were no unique identifiers for the beds, and specific beds were not identified during these audits. This lack of documentation and adherence to the manufacturer's maintenance requirements constituted a deficiency in the facility's compliance with the 2012 edition of NFPA 99, Health Care Facilities Code, which mandates the establishment of policies and protocols for testing patient care-related electrical equipment.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K921 Corrective Action- To ensure the facility meets all the requirements for NFPA 101 Electrical Equipment Testing and Maintenance in regards to the testing of portable patient care related electrical equipment (PCREE), specifically patient electric beds. 1. The Maintenance Director has obtained manufacturers recommendations for each type of in-house electrical bed, and created an auditing system to monitor testing of each type of bed per manufacturer recommendations. 2. The Maintenance Director will complete a full house audit of resident beds to ensure all bed types are inspected per manufacturer recommendations, and documented as required by the NFPA 101. 3. The Administrator will oversee in-services to all maintenance department staff in regard to the NFPA 101 guidelines for patient care related electrical equipment testing and maintenance requirements. 4. To prevent future deficit in this practice, the Maintenance Director will perform 1 audit per month for 3 months to ensure bed inspections have been performed and documented according to the manufacturers recommendations. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K921.
Failure to Conduct and Document Fire Drills for Second Shift
Penalty
Summary
During a Life Safety Code Survey conducted from February 24 to February 28, 2025, it was found that the facility failed to ensure fire drills were properly performed for one of the three staff work shifts. Specifically, the facility did not conduct a fire drill for the second shift (2:00 PM to 10:00 PM) during the fourth quarter of 2024. The fire drill reports for the fourth quarter listed drills conducted on October 31 at 8:43 AM, November 1 at 9:30 AM, and December 27 at 4:00 AM, none of which covered the second shift. Additionally, the fire drill report dated November 1, 2024, lacked staff signatures or documentation of staff participation, with the attendance section left blank. The Environmental Services Director admitted to not using a schedule for fire drills and acknowledged the oversight in conducting the second shift drill and obtaining staff signatures.
Plan Of Correction
Plan of Correction: Approved March 19, 2025 K712 Corrective Action- To ensure that the facility meets all the application requirements of the Life Safety Code of the National Fire Protection Association in regards to Fire Drills. 1. On 3/6/25 a 2nd shift fire drill was performed to compensate for the missed second shift fire drill from the fourth quarter of Calendar Year 2024. 2. The Maintenance Director will complete an audit of fire drills for Calendar Year 2025, to ensure fire drills are properly documented (including sign in sheets) and performed on each shift as required by The Life Safety Code of the NFPA. 3. The Administrator will oversee in-services to all maintenance department staff in regards the importance maintaining compliance with the NFPA Fire Drill requirements. 4. To prevent future deficit in this practice, the Maintenance director / designee will perform 1 audit per month for 3 months to ensure fire drills have been performed and documented quarterly on each of 3 shifts. The Administrator will monitor this process and review the results monthly at QAPI meetings. If continued improvement is required, the committee may make further recommendations. The Administrator will assume overall responsibility for the correction of K712.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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