Crown Heights Center For Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, New York.
- Location
- 810 20 St Marks Avenue, Brooklyn, New York 11213
- CMS Provider Number
- 335609
- Inspections on file
- 20
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Crown Heights Center For Nursing And Rehab during CMS and state inspections, most recent first.
A resident with a history of falls and moderately impaired cognition was observed by an OTA sliding from a wheelchair to the floor. Facility policy required immediate notification of the resident and/or representative and the physician for changes in condition, but there was no documentation that the resident’s representative or MD were notified. An RN supervisor confirmed that, although an assessment revealed no visible injury or trauma, neither the physician nor the resident’s representative was informed of the incident, and the DON stated that such notification was required.
A resident with a history of falls and moderately impaired cognition slid from a wheelchair to the floor on two occasions observed by an OTA, who reported the incident to an LPN and documented it on a facility form. The RN supervisor on duty stated they were notified and performed a full body assessment with no injuries or pain noted, but did not document the incident or update the resident’s fall-related care plan. There was no evidence that the interdisciplinary team reviewed or revised the care plan or held a team meeting to address the sliding event, despite facility policy requiring care plans to be revised when a resident’s condition changes.
A resident with a history of constipation and moderately impaired cognition requested a stool softener, and an LPN administered two tablets for constipation without a physician’s order and without proper medication documentation, contrary to facility policy requiring verification of orders before giving oral meds. The resident subsequently experienced abdominal pain and constipation symptoms, was transported to the ED after calling 911, and had large bowel movements there, with no bowel obstruction identified. Review of the medical record confirmed there was no active stool softener order at the time, and the attending physician reported receiving no request for such an order.
A resident with a history of falls, chronic pain, and moderately impaired cognition had an order to use a standard wheelchair with elevating leg rests and one-person assistance for transfers, but there were no documented nursing instructions on how staff should supervise the resident to prevent falls. An OTA observed the resident sliding from the wheelchair to the floor on more than one occasion and reported this to an LPN and wrote a statement, yet there was no documented body assessment, no notification to the MD or family, and no documented investigation. An RN supervisor later stated they assessed the resident but did not complete a fall assessment or notify the MD, and the DON reported being unaware of the incident.
A resident with chronic pain, a history of falls, and moderately impaired cognition slid from a wheelchair to the floor, as documented by an OTA. Despite facility policy requiring documentation of all incidents, accidents, and changes in condition, there was no nursing or MD documentation of any assessment following the event. An RN supervisor acknowledged being informed of the incident and not entering a progress note, and the DON confirmed that a nursing progress note should have been completed.
The facility failed to maintain proper records of monthly inspections for portable fire extinguishers. During a survey, it was found that the fire extinguisher in the 1st floor atrium had no recorded inspections, and further inspection revealed no records for extinguishers on all floors. The facility's inspection log was also incomplete, lacking a full inventory of extinguishers.
The facility failed to maintain a safe and homelike environment, with observations of damaged furniture, mismatched paint, and dirty medical equipment across various units. Staff interviews revealed inconsistent maintenance and cleaning protocols, with ongoing remodeling efforts but no specific timelines for completion. The facility's policies on cleaning and disinfecting were not adequately implemented, compromising residents' living conditions.
The facility failed to report several incidents of abuse and injuries of unknown origin to the New York State Department of Health. One resident with Alzheimer's was found with a hematoma, another incident involved a resident-resident altercation causing injuries, and a third involved a resident with a toe fracture. The facility did not report these incidents, believing they did not meet the criteria for reporting.
The facility failed to investigate allegations of abuse and injuries of unknown origin. A resident with Alzheimer's was found with a hematoma, and the cause was not determined. In another incident, two residents were injured in an altercation, but the investigation was incomplete, lacking a report for the aggressor. The facility did not adhere to its abuse prevention policy, compromising resident safety.
The facility failed to adhere to food safety standards, with staff observed not wearing proper hair and beard restraints in the kitchen. Additionally, improper storage of food thickening powder was noted, with an open box and torn plastic bag found in the dry storage room. The facility's policies lacked specific uniform requirements, contributing to these deficiencies.
The facility failed to post required signage reminding residents and staff of COVID-19 vaccination availability, as observed during a survey. The signage was removed during renovations, and staff were unaware of the ongoing requirement. Interviews with the Infection Preventionist, DON, and Administrator revealed a lack of awareness about the need to maintain the signage.
The facility was found non-compliant with NFPA 101: 19.1.6.1 due to its Type II (000) construction exceeding the allowed two stories, with four floors observed. A time-limited waiver is in place while the facility works on creating a rated ceiling system to address this issue.
The facility failed to maintain electrical system safety, with unlocked circuit panels accessible to the public and non-GFCI outlets near sinks, violating safety codes.
The facility did not ensure proper enclosure of hazardous areas as per 2012 NFPA 101 standards. Observations included a non-fire-resistant plywood wall in the generator room, an open door, missing ceiling tiles, and improper sealing in the automatic transfer switch room. Additionally, doors to the trash compactor and boiler rooms lacked self-closing mechanisms and hardware, and the maintenance shop door was held open with a magnet not tied to the fire alarm system.
The facility failed to maintain clear egress routes, with obstructions noted in corridors and a locked exit gate. Combustible items and boxes reduced corridor widths, and a locked gate impeded egress from stair B. These issues were acknowledged by the Director of Maintenance.
The facility failed to maintain the sprinkler system as per 2011 NFPA 25 standards. Missing escutcheons were noted in several areas, and there was no record of the 5-year internal pipe inspection. The Director of Maintenance acknowledged these issues during the survey.
A survey found that the facility's egress stairs lacked required contrasting marking stripes on handrails and landings, violating NFPA 101 standards. Additionally, a door at the first-floor landing was missing a fire rating label, breaching NFPA 80 standards. The Director of Maintenance acknowledged these deficiencies.
The facility failed to ensure accurate MDS assessments for two residents. One resident's MDS inaccurately reflected their activity preferences, while another's did not document the use of a physician-ordered wander guard. Errors were attributed to oversight by the Activities Director and MDS Assessor.
Three residents in the facility were not provided with activities that met their preferences, specifically the ability to watch television in their rooms. Despite being aware of the residents' preferences, the facility failed to reinstall television sets after maintenance, leaving the residents without their preferred activities. The facility's staff acknowledged the issue but did not resolve it promptly, resulting in a deficiency in meeting the residents' physical, mental, and psychosocial well-being.
A resident with cognitive impairment and behavioral issues sustained a foot injury after placing their foot on a radiator with sharp edges. The facility failed to report the incident to the Department of Health, and staff interviews revealed inconsistencies in the facility's response and maintenance checks.
A resident with End Stage Renal Disease did not have documented physician orders for dialysis, despite attending regular sessions. The facility's policy required order reconciliation during admissions, but this was not followed during the resident's readmission. Staff were aware of the dialysis schedule, but the necessary orders were not documented, leading to a deficiency in care.
The facility failed to store medications according to professional standards, with expired Heparin flush syringes and intravenous fluids found in two units' medication rooms. Staff interviews revealed inconsistent monitoring and removal of expired items, despite monthly inspections by the Consultant Pharmacist. The lack of regular checks and communication breakdowns contributed to the oversight, posing a risk to resident safety.
The facility failed to follow its menu policy, resulting in food items being omitted or substituted without informing residents. Several residents with cognitive impairments were served meals missing items like milk and salad, which were crossed out on tray tickets without appropriate substitutions. Staff interviews revealed inconsistencies in handling menu changes, and the Director of Food Service and Registered Dietitian were not always consulted, leading to the deficiency.
A facility failed to maintain infection control practices, as a CNA did not perform hand hygiene between assisting residents, and an LPN did not follow proper wound care protocols, including hand washing and gown use, for a resident with a stage 4 pressure ulcer. Despite training, these lapses were observed during a survey.
The facility failed to maintain an effective pest control program, as evidenced by observations of a live rodent in the dining room and flies in various units. Staff and residents reported sightings of mice and flies, indicating a deficiency in the pest control program despite the facility's policy for weekly pest control services.
A refrigerator in the employee cafeteria was improperly plugged into a relocatable power strip, violating the facility's policy against connecting high amperage loads to power strips. Additionally, there were no records of periodic testing for power strips in the building.
The facility was found deficient in maintaining continuous illumination for egress as required by NFPA 101 standards. During a survey, it was noted that the 1st floor egress passageway had switches that could manually turn off all lights, compromising safety. The Director of Maintenance acknowledged the issue.
The facility did not ensure full sprinkler system coverage, with no protection under stair D and unclear coverage in the atrium. Additionally, electrical BX cable was improperly suspended from sprinkler piping in the fire pump room.
The facility did not have a policy in place to ensure occupant safety during a fire alarm system impairment lasting more than four hours. This deficiency was identified during a life safety survey, revealing the absence of procedures to protect occupants when the fire alarm system was out of service.
A facility was cited for not having a policy for actions when the sprinkler system is out of service. A surveyor found a covered sprinkler head in a construction area, rendering it inoperable, with no fire watch conducted. The facility lacked a policy for protecting occupants if the system was down for over 10 hours.
Failure to Notify Resident Representative of Change in Condition After Wheelchair Incident
Penalty
Summary
The facility failed to notify a resident’s representative of a change in condition after the resident was observed sliding from a wheelchair to the floor. Facility policy dated 12/2024 required that changes in a resident’s condition or treatment be immediately shared with the resident and/or resident representative and reported to the attending physician, and that staff be educated to identify and report such changes. Resident #1, who had diagnoses including constipation, chronic pain syndrome, history of falling, and moderately impaired cognition per the 11/22/2025 MDS, was seen on 12/06/2025 at 5:00 PM by Occupational Therapist Assistant #1 sliding from the wheelchair to the floor. Record review showed no documented evidence that Resident #1’s representative was notified of this event. During interview, Registered Nurse Supervisor #2 stated that upon body assessment there were no visible injury, trauma, or skin changes, and acknowledged that neither the medical doctor nor the resident’s representative was informed of the incident. In a separate interview, the Director of Nursing stated that Registered Nurse Supervisor #2 was required to notify the medical doctor and the resident’s family representative when the resident slid from the wheelchair to the floor. This failure to notify the representative of a change in condition was cited under 10 NYCRR 415.3(e)(2)(ii)(b).
Failure to Review and Revise Care Plan After Wheelchair Sliding Incident
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan by the interdisciplinary team after a change in condition, as required by facility policy and regulation. The resident had diagnoses including constipation, chronic pain syndrome, a history of falling, and a Minimum Data Set showing moderately impaired cognition. The existing care plan for an actual fall, initiated months earlier, included interventions such as keeping personal items within reach, neuro checks, physical therapy, and routine rounding. On a specific date and time, an occupational therapist assistant (OTA) observed the resident sliding from a wheelchair to the floor, reported the incident to an LPN, and documented the event on a facility statement form. The RN supervisor on duty acknowledged being notified that the resident had slid from the wheelchair to the floor and stated that a full body assessment was performed, with no injuries, trauma, or pain reported by the resident. However, the RN supervisor also stated they did not document the sliding incident and did not update the resident’s care plan. There was no documented evidence that the care plan was reviewed or revised with new interventions following this event, and no documentation of a team meeting to discuss the incident. The DON reported being unaware of the sliding incident and stated that the RN supervisor should have completed an incident report and updated the care plan. This lack of documented care plan review and revision after the resident slid from the wheelchair to the floor formed the basis of the cited deficiency under 10 NYCRR 415.11.
Unauthorized Administration of Stool Softener Without Physician Order
Penalty
Summary
The deficiency involves the failure to provide treatment and care in accordance with professional standards and physician orders when a nurse administered a stool softener without a valid order and failed to document it. Facility policy on administering oral medications, dated 12/2024, required verification of a physician’s medication order prior to administration. Resident #1, admitted with diagnoses including constipation, chronic pain syndrome, and a history of falling, had a care plan addressing bowel incontinence with interventions such as checking the resident every two hours, assisting with toileting, observing incontinence patterns, and initiating a toileting schedule if indicated. The Minimum Data Set dated 11/22/2025 documented moderately impaired cognition for Resident #1. Review of physician orders from 12/01/2025 to 12/29/2025 showed no active order for any stool softener. On 12/19/2025 at 11:11 AM, a nursing progress note by Licensed Practical Nurse (LPN) #1 documented that Resident #1 requested a stool softener and that the medication was given and tolerated well. Resident #1 later reported they informed LPN #2 of constipation and received medication for it, but continued to have pain and subsequently called 911. LPN #2 confirmed in interview that, at the resident’s request, they administered two tablets for constipation despite there being no physician’s order for the medication. The administration was not documented as a medication entry in the record. The Emergency Department note for that same date recorded that Resident #1 presented with constipation, intermittent cramping, and abdominal pain, reported no bowel movement for three days, had received medication at the facility and had a bowel movement just before arrival, and then had a large bowel movement in the ED with resolution of pain and no bowel obstruction found. The attending physician (Medical Doctor #1) stated that after an initial 30‑day bowel regimen at admission, there were no further constipation complaints and no call requesting a stool softener order on the date in question. The Administrator acknowledged that LPN #2 administered a stool softener without a physician’s order.
Failure to Supervise High Fall-Risk Resident and Document Wheelchair Fall Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as high risk for falls. The resident had diagnoses including constipation, chronic pain syndrome, a history of falling, and a Minimum Data Set showing moderately impaired cognition. A physician’s order dated 11/11/2025 allowed the resident to be out of bed to a standard wheelchair with bilateral elevating leg rests and required partial to moderate assistance during manual transfer by one person. Despite a facility fall risk assessment policy requiring identification and documentation of fall risk factors and evaluation of conditions that may predispose residents to falls, there was no documented evidence on the Documentation Survey Report or Resident Nursing Instructions form describing how staff should supervise this resident to prevent falls. On 12/06/2025 at approximately 5:10 PM, an Occupational Therapist Assistant observed the resident sliding off a wheelchair on the third floor. The assistant reported that the resident got up independently, sat back in the wheelchair, and then slid off again, after which the assistant informed an LPN and wrote a statement left at the nursing station. There was no documented body assessment, no documentation that the physician or family were notified, and no documented facility investigation of the incident. The RN Supervisor later stated they were informed that the resident slid out of the wheelchair, asked the resident what happened, and performed a body assessment but did not document a fall assessment because there was no trauma, injuries, or skin changes, and did not inform the physician. The Director of Nursing stated they were not aware of the incident and acknowledged that the RN Supervisor should have initiated an incident report, collected staff statements, and reported the fall to the physician and the resident’s family representative.
Failure to Document Nursing Assessment After Wheelchair Slide Incident
Penalty
Summary
Surveyors identified a failure to maintain medical records in accordance with accepted professional standards when an incident involving a resident sliding from a wheelchair to the floor was not documented by nursing staff or a physician. The facility’s Charting and Documentation policy, dated 01/2026, requires that all services provided, and any incidents, accidents, or changes in a resident’s condition, be recorded in the medical record. Occupational Therapist Assistant #1 documented on 12/06/2025 at 5:00 PM that Resident #1 was seen sliding from a wheelchair to the floor. However, review of the medical record from 12/01/2025 through 12/30/2025 revealed no nursing or physician documentation indicating that the resident was assessed following this event. Resident #1 had diagnoses including constipation, chronic pain syndrome, a history of falling, and was documented on the 11/22/2025 MDS as having moderately impaired cognition. During an interview, Registered Nurse Supervisor #2 stated that on 12/06/2025 they were informed that Resident #1 had slid from the wheelchair to the floor and that the resident reported they did not fall. RN Supervisor #2 acknowledged they did not write any progress note in the resident’s medical record regarding this incident. In a separate interview, the Director of Nursing confirmed that RN Supervisor #2 had been working at the time and stated that RN Supervisor #2 should have written a nursing progress note in the resident’s medical record. This lack of documentation was cited under 10 NYCRR 415.22(a)(1-4).
Failure to Maintain Fire Extinguisher Inspection Records
Penalty
Summary
The facility failed to maintain proper records of monthly inspections for portable fire extinguishers as required by NFPA 101 and NFPA 10 standards. During a life safety survey, it was observed that the fire extinguisher located in the 1st floor atrium had a hang tag with no monthly inspections recorded. A vendor was seen changing the tag on this extinguisher shortly before the finding, and the Director of Maintenance explained that it was their policy to remove old tags if the record was full. However, the new tag also lacked any recorded inspections. Further inspection revealed that no monthly inspections were recorded for any extinguishers on all four floors of the building. Additionally, the facility's fire extinguisher inspection log was incomplete, lacking a full inventory of all extinguishers in the building. This deficiency indicates a failure to comply with the required standards for fire safety equipment maintenance and documentation.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: All fire extinguishers in the building including the 1st floor atrium, were inspected immediately to ensure compliance with fire safety standards. The maintenance staff will ensure that each extinguisher has a correctly dated inspection tag. Old hangtags will only be removed after transferring all records to the new tag. A specific protocol was established for transitioning all records to the new tag. A specific protocol will be established for transitioning between old and new tags to prevent lapses in inspection documentation. A meeting will be held with the vendor to review their inspection responsibilities and documentation standards. Element 2: All residents have the potential to be affected by this practice; however, no residents were affected as a result of this practice. Element 3 Systemic Changes: Policy was reviewed and revised to reflect that old hand tags will only be removed after transferring all records to the new tag. A specific protocol will be established for transitioning between old tags to prevent lapses in inspection documentation. The maintenance will implement a Fire Extinguisher log to ensure compliance. The maintenance director will audit to ensure all fire extinguishers are inspected and documentation is up to date. Element 4: The maintenance director will audit to ensure all fire extinguishers are inspected monthly and documentation is up to date. The maintenance director will monitor compliance and report findings to the administrator monthly. The maintenance director will report findings to the QAPI Committee on a quarterly basis for 3 quarters. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance director.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of deficiencies across various units. Resident rooms were found with scratched and damaged furniture, mismatched paint, holes in drywall, and duct tape on floors. Additionally, enteral feeding pumps and poles were observed with cream-colored stains, and shared bathrooms and whirlpool tubs were noted to be dirty and in disrepair. The kitchen area also exhibited several issues, including leaking kettles, cracked tiles, and grease residue on metal shelves. Interviews with staff revealed that maintenance and cleaning protocols were not consistently followed or effectively communicated. Dietary aides reported broken kitchen tiles and leaking kettles, while housekeeping staff were unsure of reporting procedures for damaged furniture. Maintenance staff acknowledged the need for repairs and replacements but indicated that matching paint and replacement doors were still pending. The Director of Maintenance confirmed ongoing remodeling efforts but did not provide specific timelines for completion. The facility's policies on cleaning and disinfecting resident care items and equipment were not adequately implemented, as evidenced by dusty and stained medical equipment and furniture. Staff interviews highlighted a lack of clarity regarding cleaning responsibilities and the frequency of maintenance checks. Despite some efforts to address these issues, the facility's environment remained substandard, compromising the residents' right to a homelike and safe living space.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **F584 Element 1 Immediate Corrective Action:** The Maintenance Director and Food Service Director immediately took action to correct the deficiencies identified in the kitchen. A 1/2-inch quick valve was replaced to correct the leak on the kettle. The Quarry floor tile has been ordered, and all cracked kitchen tiles will be replaced throughout the kitchen. The gap in the wall edge by refrigerator #3 will be repaired. Metal shelving in the kitchen holding washed dishes was immediately cleaned. Cracked flooring and baseboard tiles in the dish room were replaced. The cracked floor tile identified in freezer #2 has been removed and will be replaced with quick-dry cement and epoxy. Next, work will begin on Refrigerator #1, and the floor will be replaced. The dish room handwashing sink opening has been closed in the tile surrounding the pipe. The metal stairs identified by the compactor were replaced on (MONTH) 14, 2025, and the wheelchair parts stored were removed. The Housekeeping and Maintenance Directors immediately acted to correct the deficiencies identified in the nursing units. **2 East:** The Director of Housekeeping audited to ensure that all feeding pumps were cleaned. Any pumps with stains, including E209, W203, and W238, were immediately cleaned or replaced. In E206, the floor tile was replaced, the duct tape was removed, and the garbage can was replaced with a new one. The drywall on the elevator bank on 2 East elevators #1, #2, and #3 was repaired and replaced with corner guards. The fan was cleaned and removed. **2 East:** The 3 areas identified with a gap around the piping in the shower rooms under the sink were filled, the shower drain cleaned, and the drain cover replaced. All debris noted in the century tub was removed and cleaned. Hoyer canvas was removed for routine cleaning. The Director of Maintenance did a whole house audit to ensure all a/c units were clean and dust-free. Areas identified were immediately cleaned to include the following rooms: W238, W203, W208, E318, E302, E311, E308, E315, E306, E302, E317, and the 4 units on 4 West Dayroom. **2 West Medication Room:** The company who built the cabinets was contacted to replace the peeling veneer on the upper middle cabinet door. The kitchenette and refrigerator/freezer in the staff lounge were cleaned immediately. **2 W room [ROOM NUMBER]:** The call light box was replaced on the wall. **room [ROOM NUMBER]:** The chip noted in the barn door was filled in, and the door was repainted. The medication cart on 2 West was removed and cleaned. **2 West Main shower room:** Debris identified in the century tub was removed, and the tub was cleaned. The bariatric shower chair was removed and cleaned, and any rusty wheels will be replaced. The cracked tile under the sink was replaced. The sharps container on the Wound Care Cart was adhered correctly to the cart to ensure it was closing. **2 West Lobby Area:** The baseboard heater cover had fallen off and was clipped back on. The ice machine vent was cleaned immediately. The hole in the wall behind the refrigerator was repaired, and the gap between the fridge and the false pantry will be repaired as we proceed. **3 East:** Brookstone Developers will begin renovating the following rooms starting (MONTH) 20, 2025: 3 East Rooms 300, 318, 306, 339, 303, 311, 308, 317, 309, 315, 305, 304, 302, 308. This will include replacing ceiling tiles and grids, flooring, painting walls, nightstands, overbed tables, wardrobe closets, a handwashing sink inside resident rooms, and new tile and showers inside each resident's bathroom. **3 West:** Brookstone Developers completed the renovation of the 3 West Main Shower Room and removed the Century Tub. This renovation includes new ceiling tiles, lighting and grids, fixtures, tile, and flooring. All old equipment, such as commodes, has been discarded. **Pantry:** All areas within the pantry were cleaned, and the metal ladle in the drawer under the microwave was discarded. **3 West Medication carts:** In (MONTH) 2023, Specialty Pharmacy provided Crown Heights Center with new medication carts; each unit has 2 medication carts and 1 treatment cart. The housekeeping department schedules the monthly cleaning of medication carts using a pressure washer. During this process, the Director of Housekeeping will in-service the staff to clean the bottom of the medication cart. All medication carts identified as being dusty or soiled were immediately cleaned. **4 West:** The 4th-floor hallway and the opposite side of the elevators were repainted. Room [ROOM NUMBER] was completely renovated and painted. W 417 Resident Room chair was replaced. The 5 Tier Linen cart with a cracked left edge was repaired. Bedside tables will be replaced in the following rooms: W400, 414, 406, 403, 408, 407, 409, 417, 421, 432, 428, 405. **Element 2 Residents at Risk:** All residents have the potential to be affected by this practice. The Food Service Director immediately audited all trays. Any cracked trays will be removed. The Director of Maintenance and the Director of Housekeeping conducted a visual inspection of the entire facility, and no other issues were identified. **Element 3 Systemic changes:** Policies and procedures were reviewed, and no revisions were necessary. On (MONTH) 6, 7, and 8th, maintenance and housekeeping staff were in-serviced to maintain a safe, clean, and comfortable environment. The housekeeping director is responsible for ensuring all equipment is clean and operable. The director of maintenance is responsible for ensuring preventative environmental rounds are routinely conducted and any identified issues are corrected immediately. An audit tool has been developed to monitor compliance. **Element 4 Monitoring of Corrective Action:** On a weekly basis for 6 months, Maintenance and Housekeeping directors will conduct environmental audits. The maintenance and housekeeping director will report findings to the administrator monthly. Any issues identified will be corrected as soon as possible. Maintenance and housekeeping directors will report findings to the QAPI Committee for two quarters. The QAPI Committee will determine if any further action is required. **Element 5 Responsibility:** Director of Maintenance, Housekeeping Director, and the Administrator.
Failure to Report Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report several incidents of abuse and injuries of unknown origin to the New York State Department of Health within the required timeframe. One incident involved a resident with Alzheimer's disease who was found with a hematoma on the forehead. Despite the family expressing concerns about the injury resembling a punch, the facility did not report the incident as an injury of unknown origin. The investigation did not provide evidence of how the injury occurred, and the facility's interdisciplinary team concluded that the incident was not reportable. Another incident involved a resident-resident altercation where one resident pushed two others, resulting in injuries that required hospital evaluation. The aggressor was identified, but the incident was not reported to the Department of Health. The Director of Nursing and Assistant Director of Nursing reviewed the incident but decided it did not meet the criteria for reporting, despite regulations requiring immediate reporting of abuse allegations. A third incident involved a resident with a severely impaired cognition who sustained a laceration and fracture to the toes. The injury was attributed to contact with a radiator, but there was no documented evidence of sharp edges on the radiator. The facility did not report this injury to the Department of Health, as the Director of Nursing believed the cause of the injury was known and did not require reporting.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin, as evidenced by two specific incidents involving residents. In the first incident, a resident with Alzheimer's disease and severe cognitive impairment was found with a hematoma on the forehead, which was not witnessed by any staff. Despite the resident's inability to communicate how the injury occurred, the facility did not conduct a comprehensive investigation to determine the cause of the injury. Interviews with staff revealed inconsistencies in their accounts, and there was no documented evidence of a thorough investigation or rationale for not reporting the incident as required by facility policy. In the second incident, a resident-to-resident altercation occurred involving three residents, resulting in two residents being pushed to the floor and sustaining injuries. The facility's investigation was incomplete, as it did not include an incident report for the resident identified as the aggressor. Interviews with staff indicated that the incident was not reported to the Department of Health, and the facility did not consider the incident as abuse due to the cognitive impairments of the residents involved. The Director of Nursing and Assistant Director of Nursing failed to ensure that all necessary documentation and reporting were completed. Overall, the facility did not adhere to its policy on abuse prevention and reporting, which requires immediate reporting and thorough investigation of all alleged violations. The lack of a comprehensive investigation and failure to report these incidents demonstrate a deficiency in the facility's handling of potential abuse and injury cases, compromising the safety and well-being of the residents involved.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F610 Corrective Actions for Residents Identified: No further occurrences related to abuse, including injury of unknown origin, resident-to-resident altercation, neglect, and mistreatment, were identified by the ADNS/Risk Manager. All accidents/incidents will be reviewed and reported immediately if they meet the reporting criteria but not later than 2 hours. Abuse care plans are in place for all 3 residents, #251, #214, #268, and #589 (no longer in the facility). Resident #251 is placed in the hallway or the dining room with activities for close observation. Resident #214 is placed in the hallway or in the dining room with activities for close observation. Resident #268 is placed at the nursing station with activities for close observation. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The ADNS and DNS completed an audit tool to review accidents/incidents investigated in the past three months to determine whether an occurrence is abuse, neglect, injury of unknown origin, or mistreatment. This alleged deficient practice has not identified similar findings or adverse effects. Element 3 Systemic Changes: The Administrator, Director of Nursing, Assistant Director of Nursing, and Medical Director will continue to review and revise, as indicated, the policies and procedures related to Abuse Prevention, including timely reporting of all allegations and or observations of abuse to the Administrator and other officials as outlined in the regulations and State Law. The ADNS will in-service staff in all departments on abuse prevention, focusing on initiating an investigation of abuse allegations. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: ADNS (Risk Manager) or designees will review the 24-hour report and all accidents or incidents to ensure there are no allegations that need to be investigated or any occurrences that require investigation for the next 4 weeks. The DNS will audit all AI weekly for four weeks to ensure that outstanding issues and incidents requiring investigation are compliant and have no outstanding issues. DNS will report to the Administrator. DNS will report to QAPI for one quarter. QAPI Committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Responsible Person: Director of Nursing, Assistant Director of Nursing, and Administrator.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. During the recertification survey, multiple instances were observed where staff did not wear appropriate hair and beard restraints in the kitchen. The Food Service Director, Dietary Aides, and a contracted pest control person were all observed without proper hair or beard nets, despite having noticeable facial hair. Interviews with the staff revealed that some were aware of the requirement but failed to comply due to discomfort or forgetfulness. Additionally, the facility's dry storage room was found to have an open box of instant food beverage thickening powder with a torn plastic bag and a paper cup inside. This box was observed on two separate occasions, indicating a lack of proper storage practices. The Dietary Aide responsible for checking the dry storage room admitted to not knowing who tore the bag and acknowledged that the food should be covered to prevent contamination. The Director of Food Services confirmed that the thickener should be stored in a container and not left open. The facility's dietary policies and procedures were found to be lacking in specific uniform requirements related to food handling. Although the policies outlined the need for safe and sanitary food preparation and handling, they did not explicitly mention the use of hair and beard nets. The facility's sanitation inspection and audit processes were also noted, but the observed deficiencies suggest that these measures were not effectively implemented or enforced.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 Element 1 F812 Corrective Action: The Staff that were observed not wearing a beard net were immediately educated on wearing appropriate face beard covers inside the kitchen. All vendors will also be educated on the hair and beard coverings procedure. The open thickener box was removed, and the product was disposed of properly. A complete inspection of all dry storage areas was conducted to identify and remove any other improperly stored items. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All Dietary Staff were monitored to ensure compliance with beard and hair net coverings were in place. All dry storage areas were inspected to identify and remove any other improperly stored items. There were no issues that were identified. Element 3 Systemic Changes: Personal hygiene and protective equipment policies were reviewed to reflect strict enforcement of beard and hair nets. All dietary staff received mandatory in-service training on proper food safety protocols, including wearing hair and beard nets. Policies on food and dry storage were reviewed to ensure they included all food and beverages in dry storage that are labeled, and in approved containers. No revisions were required. Staff received training on proper storage requirements and food safety protocols. Audit tools are being developed to monitor compliance. Element 4 Monitoring of Corrective Action: Food Service Director will conduct daily spot checks to ensure compliance with personal protective equipment requirements. Non compliance will be documented and addressed with immediate corrective action. The Food Service director or designee will conduct daily inspections of storage area to ensure compliance with food safety protocols. Non compliance will result in retraining and possible disciplinary action. Monthly audits of kitchen and storage areas will be conducted, and results will be reviewed monthly with the administrator for a period of 6 months. On a quarterly basis, the results will be presented by the Food Service director to the QAPI committee. The QAPI Committee will decide if further action is required. Element 5 Completion date: (MONTH) 19, 2025 Person responsible: Food Service Director and Food Service Supervisor.
Failure to Post COVID-19 Vaccination Signage
Penalty
Summary
The facility was cited for failing to ensure conspicuous signage was posted throughout the facility to remind residents and staff that COVID-19 vaccinations were available. This deficiency was identified during a Recertification Survey conducted from December 12, 2024, to December 19, 2024. The Dear Administrator Letter #23-15, dated in 2023, required facilities to post such signage at entry and exit points and in each residential hallway. However, observations during the survey revealed that no signage was present in the lobby, hallways, or resident units. The facility's policy for COVID-19 vaccination for healthcare personnel, dated January 31, 2024, did not include procedures for posting signage. Interviews with facility staff revealed a lack of awareness regarding the ongoing requirement to post COVID-19 vaccination signage. The Infection Preventionist stated that the signage had been removed during facility renovations and was unaware of the continued requirement. The Director of Nursing also confirmed the removal of the signage following the lifting of the mask mandate and was not aware that the signage needed to remain posted. The Administrator acknowledged that while the facility provided COVID-19 vaccinations, they were not aware that the signage had to be maintained, as they had only circulated flu vaccine signage.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 Immediate corrective Action: On 12/19/24, signage announcing the availability of the COVID-19 vaccination was printed and posted in highly visible locations within the building, including all entryways, lobby, hallways, time clocks, and resident units. Element 2 All residents have the potential to be affected by this practice. All residents' representatives/family contacts will receive a message through the Care Connect messaging system informing them of the availability of the COVID-19 vaccine. The Activities Department will inform all residents currently residing in the building of the availability of the COVID-19 vaccine. Element 3 The facility updated the infection control policy to include a requirement for posting of COVID-19 vaccination signage. The policy outlines the specific locations for signage placement and a procedure for routine checks to ensure compliance. Element 4 The Infection Preventionist or designee will conduct weekly environmental rounds for 3 months to ensure signage is posted. The Results of the environmental rounds will be reported to the Administrator monthly. The Infection Preventionist will report the findings of the audit to the QAPI Committee for the 1st quarter of 2025. QAPI Committee will decide if further action is required. Element 5 Completion Date: (MONTH) 19, 2024 Person Responsible: Infection Preventionist or designee.
Non-compliance with Building Construction Type Limitations
Penalty
Summary
The facility was found to be non-compliant with the 2012 NFPA 101: 19.1.6.1 regulation, which limits existing health care occupancies to specific building construction types. The building in question was identified as Type II (000) construction, which is restricted to two stories in height and requires complete automatic sprinkler protection. However, the facility was observed to have four floors, indicating a violation of the construction type limitations. This deficiency was noted during a life safety survey conducted on December 17, 2024, between 8:30 am and 11:00 am. The facility is currently working to create a rated ceiling system throughout to address this non-compliance, and a time-limited waiver is in place until October 31, 2025, to allow for the completion of the necessary repairs.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K 161 Corrective Action: The facility was approved for a limited-time waiver with an expiration date of (MONTH) 31, 2025. Brookstone Contractors began the current ceiling replacement with materials and assemblies that are UL-listed to provide a 2-hour rating, and this project started on (MONTH) 19, 2024. Project Status: - Lobby: All ceiling grids, tiles, and lighting have been replaced throughout the lobby, kitchen, IT Room, and all non-clinical areas. - 2 East: Dayrooms/Common area grids, ceiling tiles, and lighting have been completed. - 3 West: Dayroom/Common area grids, ceiling tiles, and lighting have been completed. - 3 East: Dayroom Common area grids, ceiling tiles, and lighting have been replaced. Work to begin on (MONTH) 11, 2025, in the following resident rooms: E 300, 302, 303, 304, 305, 306, 308, 309, 311, 315, 317, 318, 339. - 4 East: Completed. - 4 West: Dayroom Common area grids, ceiling areas, and lighting have been completed. Work on the following resident rooms has been completed: 400, 402, 404, 406, 408, 410. Element 2: All residents have the potential to be affected by this practice. Element 3: The maintenance director oversees the project to ensure Interim Life Safety plan compliance. Staff members responsible for facility maintenance are trained on the periodic inspection of fire-rated ceiling systems. The facility will communicate quarterly updates to the Department of Health. Element 4: Monitoring: The maintenance director will audit weekly measures such as fire watch during construction, increased fire drills, and staff training at the facility. The results of this audit will be reported to the administrator monthly. The maintenance director will submit quarterly reports to the QAPI Committee for 3 quarters. The QAPI Committee will determine if any further action is required. Element 5: Person Responsible: Director of Maintenance.
Electrical System Safety Deficiencies
Penalty
Summary
The facility failed to maintain all components of the electrical system in a safe manner, as observed during a life safety survey. Specifically, electrical circuit panels were found to be unlocked in areas accessible to the public, which poses a safety risk. Additionally, these panels were lacking panel directories, which are essential for identifying circuits and ensuring proper maintenance and emergency response. Furthermore, non-GFCI outlets were identified within six feet of a sink in the employee cafeteria and connected to a fish tank in the atrium off the lobby. This is a violation of the National Electrical Code, which requires ground-fault circuit-interrupter protection for receptacles in such locations to prevent electrical shock hazards. These deficiencies indicate a failure to comply with established safety standards for electrical systems.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: All circuit panels identified as unlocked were immediately secured with compliant locking mechanisms. All electrical circuits panels were checked for complete directories. Any electrical circuit panels found lacking directories were corrected. Element 2: All residents have the potential to be affected by this practice; however, no residents were harmed by this specific practice. All areas were checked for similar deficiencies. None were found. Element 3 Systemic Changes: A policy has been implemented requiring all electrical panels in public areas to be locked at all times. The maintenance staff have been in-serviced on the revisions to this policy to ensure compliance on securing electrical panels as a part of safety compliance. Element 4 Monitoring: The maintenance director will audit all outlets monthly that are near water sources throughout the facility to identify any additional non-compliant areas. The maintenance director will audit all electrical panels monthly for directories throughout the facility to identify any additional non-compliant areas. The maintenance director and consultant from Ridgefield Associates will inspect records and maintenance logs quarterly to ensure sustained adherence to electrical safety standards. The results of all audits will be reported to the administrator for compliance. Any areas identified as non-compliant will be corrected immediately. The maintenance director will report the results of all audits to the QAPI Committee quarterly for a period of 3 quarters. The QAPI Committee will determine if any further action is required. Element 5 Person Responsible: Maintenance director
Deficiencies in Hazardous Area Enclosures
Penalty
Summary
The facility failed to ensure that all hazardous areas were properly enclosed in accordance with the 2012 NFPA 101 standards. During a life safety survey, several deficiencies were observed on the first floor. In the generator room, a plywood wall covering was not labeled as fire-resistant, and there was a large opening in the concrete wall that communicated with the adjacent automatic transfer switch room. Additionally, the door to this room was propped open. The automatic transfer switch room lacked sprinkler coverage, had missing ceiling tiles exposing unprotected steel beams, and wall penetrations were sealed with non-approved fire blocking foam. The trash compactor room door was not self-closing and lacked a latch due to missing hardware. Similarly, the boiler room door was missing hardware, allowing smoke to pass into the corridor. Lastly, the maintenance shop room door was held open with a magnet not connected to the fire alarm system.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K321 Corrective Action: The maintenance director immediately audited all areas within the building to ensure any hazardous area has a 1-hour fire resistance rating, and the areas shall be separated from other spaces by smoke partitions in accordance with 2012 edition of NFPA 101. The following corrections have been made: On 12/20/2024, the concrete wall surrounding the generator room had an opening of 3-4', communicating with the adjacent transfer switch room. This area has been sealed with concrete blocks to comply with a 1-hour fire rating. The tiles missing in the automatic transfer switch room were replaced. On (MONTH) 13, 2025, the door to the trash compactor room had the hardware replaced to include a panic bar door handle and latch to ensure the door was self-closing. On (MONTH) 13, 2025, the hardware on the boiler room door was replaced to ensure it was self-closing and did not allow the penetration of smoke. All penetrations in the walls that were sealed with fire blocking foam have been removed and replaced with an approved fire rated stopping material. Element 2 Residents at Risk: While no other residents were affected by this practice, the potential existed for all residents and staff to be affected by this practice. All hazardous areas were inspected for similar deficiencies. None were found. Element 3 The policy and procedure for hazardous doors was reviewed and revised. All maintenance staff will be in-serviced on 2012 NFPA 101 19.3.2.3 hazardous areas shall be safeguarded with a 1-hour fire rating. Documentation checklist for Life Safety Code Standards Observations will be implemented and include all components of hazardous areas shall be safeguarded by a fire barrier having a one-hour resistance rating. Any negative findings will be addressed immediately. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director or designee will inspect all Hazardous Areas to ensure all areas are safeguarded by a fire barrier having a 1-hour fire resistive rating. The findings of all these audits to inspect all Hazardous Areas to ensure a 1-Hour Fire Rating will be reviewed monthly and reported to the Administrator. The maintenance director or designee will report findings to the QAPI Committee quarterly for a period of 6 months. The QAPI Committee will determine any further actions. Element 5 Person Responsible: Maintenance Director
Obstructed Egress and Locked Exit Gate
Penalty
Summary
The facility failed to maintain clear and unobstructed means of egress as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the first-floor corridor near the morgue was obstructed by combustible items, including wheelchairs and a floor polishing machine, stored next to the door leading to an adjacent corridor. Additionally, in the first-floor corridor behind the kitchen, numerous boxes were stored on either side, reducing the corridor's width to less than the required 48 inches. These obstructions were noted during the survey and were stated by the facility to be temporary, yet they persisted over multiple observations. Furthermore, the discharge from stair B, which leads to a sprinklered parking structure and then out to a gate leading to the public way, was found to be locked. A means to open this gate was not made available to all staff, further impeding the egress route. These deficiencies were acknowledged by the Director of Maintenance at the time of the survey, indicating a lapse in maintaining the required safety standards for egress in the facility.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 K 211. Immediate Corrective Action: The maintenance and housekeeping director immediately removed the wheelchairs, floor polishing machines, and other obstructive items stored near egress routes. All boxes observed in the corridor were removed. Metro Fire Alarm system and Technology tied the garage gate to the fire alarm system on (MONTH) 6, 2025; the gate now opens when the Fire alarm is activated. Element 2: All residents have the potential to be affected by this practice. The maintenance and housekeeping director immediately audited all hallways within the building to ensure means of egress were not blocked, and no other issues were identified. Element 3: The fire alarm system's policy and procedure were reviewed, and the installation of an automatic parking lot gate opening will be added to the policy. All staff will be in-serviced for this new procedure. Maintenance and security will be trained to ensure that the gate is opened due to fire alarm activation and that it immediately closes when the alarm has been cleared. Element 4: The maintenance and housekeeping director will audit all corridors weekly to ensure they are free of impediments to egress and maintained at 48 in width. Results will be reported to the administrator monthly. On a monthly basis for three quarters, the maintenance and housekeeping director will report findings to the QAPI Committee for review. QAPI Committee to determine if further action is required. Element 5: Persons responsible: Maintenance and housekeeping director.
Sprinkler System Maintenance Deficiency
Penalty
Summary
The facility failed to inspect, test, and maintain all components of the sprinkler system in accordance with the 2011 NFPA 25 standards. During a life safety survey conducted on December 16 and 17, 2024, it was observed that sprinkler heads were missing escutcheons in several areas, including the 1st floor IT room, the secondary ATS room next to the IT room, the 1st floor oxygen storage room, and the exit passageway leading from the 1st floor landing of stair C. Additionally, there was no record of the required 5-year internal pipe inspection in the maintenance, testing, and inspection records. These deficiencies were acknowledged by the Director of Maintenance at the time of the survey.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: 1) The facility installed escutcheon plates on the identified sprinklers on the 1st floor next to the IT room, the secondary ATS room on the 1st floor next to the IT room, the 1st floor oxygen storage room, and the exit passageway leading from the 1st floor landing of stair C. 2) The facility engaged our licensed sprinkler inspection and testing vendor to complete the 5 year internal pipe inspection; testing was completed on (MONTH) 8, 2025. Element 2: While no residents were affected by this practice, the potential exists for residents to be affected by this practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy requirements to maintain the sprinkler system. Training will include: Inspection and testing requirements for the Automatic Sprinkler system in accordance with 2012 NFPA 25, and the maintenance of all components of the sprinkler system. An audit tool was developed to monitor compliance. Element 4: Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis for 3 quarters/6 months. The QAPI Committee will determine if further action is required. Element 5: Person Responsible: Maintenance director
Deficiencies in Egress Stairs and Fire Door Labeling
Penalty
Summary
The facility was found to have deficiencies in maintaining egress stairs in accordance with the 2012 NFPA 101 standards. During a life safety survey, it was observed that all four of the facility's stairwells, labeled as A, B, C, and D, were lacking the required contrasting colored marking stripes on the handrails and landings. This deficiency indicates a failure to comply with the specific requirements for exit stair treads, landings, and handrails as outlined in the NFPA 101, which mandates that these components must have consistent and uniform marking stripes to ensure safe egress. Additionally, the survey noted that the door at the first-floor landing was missing the required fire rating label, which is a violation of the NFPA 80 standards for fire doors and other opening protectives. This oversight suggests a lapse in the facility's adherence to fire safety protocols, as fire-rated door assemblies are crucial for preventing the spread of fire and smoke. The Director of Maintenance acknowledged these deficiencies during the survey, indicating awareness of the issues at hand.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1: Immediate Corrective Action: A full inspection of all stairways used as a means of egress was audited to identify areas lacking compliant marking stripes and was conducted by the maintenance director. The maintenance staff immediately began marking the handrails and landings in all areas noted for compliance. The facility engaged a licensed Fire Door vendor to inspect and affix a fire rating tag on the identified fire door on the 1st floor landing. Element 2: All residents have the potential to be affected by this practice. No residents were harmed due to this practice. Element 3: The policy and procedure for Egress and marking stripes were reviewed, and revisions have been made on means of egress and marking of handrails and landings. The maintenance director was educated on the means of egress requirements, explicitly marking the handrails and landings in all stairwells. Education and training will be given to all staff on the markings of handrails and landings. Element 4: Monitoring of Corrective Action: The maintenance director or designee will audit all stairwells and fire doors weekly to ensure that all handrails and landings are appropriately marked in accordance with 2021 NFPA 101. The results of this audit will be reported to the administrator monthly. The maintenance director will report the findings of this audit for one quarter to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Maintenance director
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessments accurately reflected the status of two residents. For one resident with diagnoses including unspecified dementia, anxiety disorder, and depression, the MDS assessment inaccurately documented that it was not very important for the resident to keep up with the news and do their favorite activities. This was contrary to an Activities Evaluation which indicated these activities were very important to the resident. The Activities Director admitted to an error in coding due to being busy, which led to the inaccurate documentation in the MDS assessment. For another resident with diagnoses including unspecified dementia, muscle weakness, and difficulty in walking, the MDS assessment failed to document the use of a wander guard, which was ordered by a physician and used for safety due to the resident's wandering behavior. The MDS Assessor did not recall the presence of the wander guard during the assessment and acknowledged the error after reviewing the medical record. The MDS Coordinator stated that their role was to ensure timely completion and submission of MDS assessments, not to review their accuracy.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F641: The MDS assessments for resident #237 were modified, and television was immediately provided to the resident. Resident #237 was re-interviewed, and the activity preference was updated to reflect the current choices. The Care Plan was updated and implemented. Activity staff will continue to monitor for changes in preference. On 12/19/2024, the MDS for resident #436 had not been locked for submission; therefore, no MDS modification was required. The MDS was reviewed and locked on 12/19/2024 and cued for submission, which was still within the allowable time frame. MDS Nurse was re-in-serviced to properly assess and review records to accurately reflect resident needs in MDS. Element 2 Residents at Risk: This practice could affect all residents. A full audit was conducted on all active MDS assessments within the last 90 days to identify any additional inaccuracies. No other issues were identified. Element 3 Systemic changes: The Policy and Procedures for MDS Guideline for Completion were reviewed, and no revisions were required. All RN Assessors were re-in-serviced on the Policy and Procedure MDS Guidelines for Completion, emphasizing that MDS accurately reflects the residents' current status with emphasis on Section P. Activities director/designees will cross-check Section F for MDS accuracy. Training includes proper data collection, resident interviews, and validation of information before transmission. The Activity Director will audit for accuracy every week to ensure the accuracy and consistency of the resident's preferences. Staff will complete the activity form on all comprehensive assessments, initiate and implement the care plan, and complete MDS. Activity will complete activity preference form on all comprehensive assessments and as needed if residents' preferences change. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: To ensure ongoing accuracy, the MDS Coordinator/RN assessors and Activities Director will conduct random audits of 10% of completed MDS assessments weekly for 3 months. The audit results will be reported to the Administrator and Director of Nursing for compliance. Audit results will be reviewed in quarterly QAPI meetings for one quarter. If any trends of inaccuracy are noted, additional interventions will be implemented. QAPI Committee will determine if any further action is required. Element 5 Completion Date: February 12, 2025 Responsible Persons: MDS Coordinator, RN Assessors, Activities Director.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of three residents. These residents were not provided with activities that aligned with their preferences, specifically the ability to watch television in their rooms. The facility's policy required the Activity Leader to record the recreational interests and needs of each resident upon admission, and the Activity Director was responsible for planning a varied program of activities to meet these needs. However, this was not implemented effectively for the residents in question. Resident #219, diagnosed with Alzheimer's disease and other conditions, expressed a desire to watch television in their room, a preference that was not met due to the removal of the television set for maintenance. Despite being cognitively intact and having no vision or hearing problems, Resident #219 was left without their preferred activity for several weeks. The Comprehensive Care Plan and Activities Evaluation both documented the importance of keeping up with the news and engaging in favorite activities, yet no alternative activities were provided. Similarly, Resident #237, with diagnoses including dementia and anxiety disorder, and Resident #436, with dementia and muscle weakness, were also left without their preferred activity of watching television. Both residents had tablets in their rooms, but they did not know how to use them. The facility's staff, including the Activities Director and the Director of Maintenance, acknowledged the issue but failed to resolve it promptly. The delay in reinstalling the television sets was attributed to the need for new equipment, but no interim solutions were provided to ensure the residents' activity preferences were met.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1: F679 Corrective Actions for Residents Identified Interest and activity preferences of residents #219, #237, and #436 were reviewed. Televisions were immediately installed inside the rooms of the identified residents. Care Plans were updated, reflecting changes in interests or abilities. Element 2: Residents at Risk All residents have the potential to be affected by this practice. The activities department audited to ensure all resident assessments and activities of choice were accurately provided based on their documented interest and needs. There were no more issues identified. An audit tool was developed to monitor compliance. Element 3: Systemic Changes Policies and Procedures Regarding Resident Preferences and Activity Planning were reviewed; no revisions were required. Activity staff is being trained on the importance of individualized activities and how to incorporate them into daily care. Education will be provided on creative engagement techniques for residents with dementia or sensory impairments. In-service on effective communication between activity staff, CNA, LPNs, and RN's, Social Service, and Rehab to ensure seamless integration of activities into daily routines. Tools such as Questionnaires and resident Council Meetings will gather feedback and suggestions, which will be used to refine the activity program continuously. Any outstanding findings will be immediately corrected and reported to the administrator. Element 4: Monitoring of Corrective Actions The Activities Director will conduct weekly checks for 90 days and monitor residents' participation and satisfaction with activities. Five to seven residents will be randomly selected to ensure that provided programs support their choice of activities. On a monthly basis, the Activities Director will submit findings to the administrator. The Activity Director will report findings to the QAPI Committee quarterly for 3 quarters. The QAPI Committee will determine if further action is required. Element 5: Date of completion: (MONTH) 12, 2025 Person Responsible: Activity Director.
Inadequate Supervision and Hazardous Environment Lead to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for Resident #24, who is cognitively impaired and exhibits agitated behaviors. The resident sustained a laceration and fractures to the right foot after being found with their foot on a radiator, which was reported to have sharp edges. Despite the incident, the facility did not report the accident to the New York State Department of Health as required. Resident #24 has a history of severe cognitive impairment, anxiety disorder, bipolar disorder, and schizophrenia. The resident is frequently incontinent and requires supervision for daily activities. On the day of the incident, the resident was found with a laceration on the right foot, which was bleeding. The injury was severe enough to require hospital evaluation and treatment, including orthopedic surgery and laceration repair. Interviews with staff revealed inconsistencies in the facility's response to the incident. The Registered Nurse on duty observed sharp edges on the radiator, but the Maintenance Director and Worker later reported no sharp edges. The Director of Nursing did not report the incident, believing it was unnecessary since the cause of the injury was known. This lack of communication and failure to report the incident highlights deficiencies in the facility's accident prevention and reporting protocols.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F689 Corrective action for Resident Identified: Nursing conducted an immediate assessment of resident #24 to address their safety and supervision needs. Care plan for resident #24 was updated to ensure safety and proper monitoring. A review of the resident's environment was conducted to ensure any necessary devices are in proper working order and available for use. Individualized interventions such as increased supervision i.e. spending more time supervised in the activities/dayroom to mitigate risks were implemented. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The facility conducted an environmental assessment for all residents to identify potential hazards and supervision needs. Results of this assessment were reviewed by the Administrator, DNS and ADNS. No other residents were found to be affected by this practice. An audit tool was developed to monitor compliance. Element 3 Systemic Changes: The facility policy and procedure titled Accident and Incident Report was reviewed and no revisions were required. Staff Education and training: The Risk Manager/ADNS will provide training to appropriate staff (CNA, LPN, RN, maintenance, housekeeping, and social services and rehab) on accident prevention, hazard identification, and the proper use of assistive devices. The training will emphasize the importance of timely reporting and addressing potential hazards. Routine preventative room rounds conducted by all nursing staff are being implemented to ensure that residents whose preference is to remain in their room receive adequate supervision to prevent any further occurrences. Element 4 Monitoring of Corrective Action: On a weekly basis for one quarter, the DNS, ADNS, and Medical Director will audit incident reports weekly to identify trends and ensure follow-up action is completed. Monthly audits of care plans, supervision, and environmental safety measures will also be monitored. The Maintenance Director will conduct weekly routine environmental audits for 3 months to identify and eliminate physical hazards. On a monthly basis for 3 months, the results of the audits will be reported to the administrator; any negative findings will be addressed immediately. The results of the audit will be presented to the QAPI Committee for 3 quarters for monitoring and compliance. The QAPI committee will determine if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Responsible Persons: Director of Nursing, ADNS and Maintenance Director
Lack of Physician Orders for Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care, specifically for a resident undergoing dialysis. The resident, who was diagnosed with End Stage Renal Disease and Coronary Artery Disease, did not have documented physician orders for dialysis, including the frequency and monitoring of the permcath. Despite the resident's care plan indicating the need for hemodialysis, there was no evidence of physician orders to support this treatment. Observations and interviews revealed that the resident was alert and oriented, and regularly attended dialysis sessions. However, the facility's documentation did not reflect this, as there were no physician orders in the system for the resident's dialysis schedule. The facility's policy required medication order reconciliation during admissions and routine reviews, but this was not adhered to in the case of the resident's readmission. Interviews with facility staff, including a CNA, RN Manager, and the Director of Nursing, indicated that the omission of the dialysis order was an error during the resident's readmission process. The staff were aware of the resident's dialysis schedule, but the necessary orders were not documented in the system. The Medical Doctor confirmed that the resident was stable and that the omission was likely an oversight during the readmission process.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F711 Corrective Actions for Residents Identified: Resident # 71 was seen by an attending physician on 12/19/2024. During the visit, the resident's total program of care, including medications and treatments, was reviewed and documented. Resident # 71 received [MEDICAL TREATMENT] without interruption of services; Resident # 71 had an order placed immediately. The Care Plan was initiated on 8/19/2024 and has been reviewed and updated for [MEDICAL TREATMENT]. Element 2 Residents at Risk: All Residents receiving [MEDICAL TREATMENT] have the potential to be affected by this practice. A list of current residents receiving [MEDICAL TREATMENT] in the past three months was obtained, and the Medical Record was audited to ensure that all physician orders [REDACTED]. No Other issues were identified. Audit tool was developed to monitor compliance. Element 3 Systemic Changes: Policy and Procedure for physician's orders [REDACTED]. All Registered Nurses are being educated on the importance of timely physician visits, documentation review, and order accuracy. The nursing supervisor will review care notes weekly to ensure all visits and orders are correctly documented. An audit tool was created to confirm that all physician orders [REDACTED]. Element 4 Quality assurance Monitoring: Conduct weekly audits for 90 days to ensure compliance with physician visits, regulations, care note reviews, and orders. Findings will be reported to the administrator monthly, and any negative findings will be corrected immediately. On a quarterly basis, x 3 quarters ADNS or designee will report findings to the QAPI Committee. QAPI Committee to determine if further action is required. Element 5: Persons Responsible: Completion Date: (MONTH) 12, 2025 Director of Nursing Services: Oversee the P(NAME) implementation and staff education. Medical Director: Collaborate with physicians to ensure timely visits and documentation.
Expired Medications Found in Facility Medication Rooms
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in accordance with professional standards of practice, as evidenced by the presence of expired Heparin lock flush syringes and intravenous fluids in the medication rooms of two units. During the recertification survey, it was observed that eighteen expired Heparin lock flush syringes were stored in the medication rooms on the 2 [NAME] and 2 East Units. Additionally, a bag of expired intravenous dextrose was found. The facility's policy requires that expired medications be removed and disposed of immediately, but this was not adhered to. Interviews with staff revealed a lack of consistent monitoring and removal of expired medications. Licensed Practical Nurse #4 and Registered Nurse #2 acknowledged the presence of expired items and admitted that the medication room is stocked weekly, but expired items were not always identified and removed. Housekeeping staff found expired items but left them for nursing staff to sort, indicating a breakdown in communication and responsibility. The Consultant Pharmacist confirmed that monthly inspections are conducted, and reports are emailed to the facility, yet expired items remained in the medication rooms. The Assistant Director of Nursing/Infection Preventionist stated that daily rounds are conducted, but they had not specifically checked the Heparin flushes. The Unit Manager and other nursing staff admitted to not regularly checking for expired medications, with some not having checked since April 2024. This lack of regular and thorough inspection contributed to the oversight, resulting in expired medications being available in the facility, which is against the facility's protocol and poses a risk to resident safety.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F 761 Immediate corrective Action: The expired [MEDICATION NAME] was removed from the medication room on 2 West and 2 East and discarded immediately on [DATE]. The RNs and the medication nurses on duty were in-serviced on medication storage on [DATE]. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. All medication carts and storage rooms were inspected for medications and biologicals beyond their expiration date, and none were found. Element 3 Systemic changes: The facility policy titled Medication Storage was reviewed, and no revisions were needed. All nurses are being in-serviced on Medication Storage policy and procedure. A new process is being implemented for medication storage monitoring to ensure compliance (LPN to check med carts daily; Unit RN to check med rooms daily). An audit tool was developed to monitor for compliance. Element 4 Monitoring of Corrective Changes: On a weekly basis for one quarter, DNS or designee will inspect 2 medication rooms and 2 medication carts, to ensure compliance with medication storage. Any outstanding issues will be addressed immediately. On a monthly basis, DNS or designee will report findings to Administrator. On a monthly basis, DNS or designee will report findings to QAPI Committee. QAPI Committee to determine if further action is required. Element 5 Monitoring of Corrective Action: Completion Date: (MONTH) 19, 2025 Director of Nursing ADNS/ Designee.
Menu Substitution Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure that menus were followed as written, resulting in food items being omitted or substituted without informing the residents. This deficiency was observed during the Dining Observation task for five residents. The facility's policy requires that any menu substitutions be documented, including the reason for the substitution, and that these changes be visible to residents. However, the survey found that items such as milk, salad, and tartar sauce were crossed out on tray tickets without appropriate substitutions or notifications to the residents. Several residents with varying degrees of cognitive impairment were affected by these omissions. For instance, one resident with severe cognitive impairment was served a dinner tray missing milk, which was crossed out on the tray ticket. Another resident, also with severe cognitive impairment, was served a tray missing assorted juice, which was similarly crossed out. These omissions were not documented in the menu substitution log, and the residents were not informed of the changes. Interviews with staff revealed inconsistencies in the handling of menu substitutions. Certified Nursing Assistants and Dietary Aides indicated that items were crossed out when unavailable, but there was no consistent process for substituting or notifying residents. The Director of Food Service and the Registered Dietitian were not always consulted on these changes, which is contrary to the facility's policy. This lack of communication and documentation led to the deficiency noted in the survey.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F803 Corrective Actions for Residents Identified: The Registered Dietitian reviewed menus for residents #97, #156, #212, #252, and #271 to ensure they met their nutritional needs as per national guidelines (e.g., Dietary Guidelines for Americans, RDA). The Registered Dietitian interviewed residents or resident representatives #252, #271, and #212 to review and discuss their meal preferences. Meal tickets were adjusted to reflect their preferences. Residents #97 and #156 were discharged, and no changes were required. Dietary staff immediately received training on following planned menus and compliance with meal tickets. Element 2 All residents have the potential to be affected by this practice. All residents were immediately audited to ensure all dietary preferences were being met. All meal tickets were reviewed to ensure that what was printed on the resident's meal ticket was being served; no issues were identified. Element 3 Systemic Changes: Policy and Procedure for Resident food Preferences were reviewed, and no revisions were required. All menus will be reviewed and approved quarterly by a licensed RD to ensure nutritional adequacy and compliance with guidelines. Monthly Food Committee meetings will be scheduled to ensure menus reflect resident preferences while maintaining nutritional needs. Food purchasing, inventory management, and meal preparation will be implemented to ensure timely adherence to planned menus. Dietary staff will be in-serviced regarding menu preference, menu item substitution, and adherence to meal tickets on the tray line. The new process was implemented to notify residents of any menu substitution by posting changes in each nursing unit. This new process will be discussed at the next resident council meeting on (MONTH) 21, 2025. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Actions: 10 resident trays will be audited daily for 30 days to confirm that meals served match planned menus, resident preferences, and nutritional standards are being met. Documentation will be maintained of all menu changes, resident-specific adjustments, and training sessions. The RD will conduct quarterly audits x 2 quarters to monitor menu compliance and resident preferences, including nutritional analysis. The audit results will be shared with the administrator monthly. QAPI Integration will include menu compliance as a standing agenda in QAPI Meetings for 2 quarters. The Audit results, including resident feedback and RD recommendations, will be reviewed during QAPI meetings to identify and implement further improvements for 2 quarterly meetings. QAPI Committee will make sure to figure out if further action is required. Element 5 Completion Date: (MONTH) 12, 2025 Persons Responsible: Registered Dietitian, Food Service Director, and Food Service Supervisor.
Infection Control Deficiencies in Hand Hygiene and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed during a recertification survey. A Certified Nursing Assistant (CNA) was seen assisting multiple residents with hand hygiene in the dining room without performing hand hygiene between residents. The CNA used bare hands to distribute hand wipes and assist residents, failing to wash hands between interactions, which is against the facility's hand hygiene policy. This oversight was acknowledged by the CNA during an interview, where they admitted to not noticing the lapse in hand hygiene during the dining service. Additionally, a Licensed Practical Nurse (LPN) did not adhere to infection control protocols during a wound care procedure for a resident with a stage 4 pressure ulcer. The LPN placed supplies on the resident's mattress, failed to wash hands between glove changes, and did not wear a gown as required by the facility's Enhanced Barrier Precautions policy. The LPN acknowledged forgetting to wash hands between glove changes and not using a gown during the procedure, despite being trained on these protocols. The resident involved in the wound care incident had a history of stroke, neurogenic bladder, and hemiplegia, and was admitted with a stage 4 pressure ulcer. The facility's policies require specific infection control measures, including the use of gowns and gloves during high-contact care activities, especially for residents with wounds. Interviews with the Wound Care Coordinator and the Director of Nursing confirmed that staff had been educated on these precautions, but the observed practices did not align with the training provided.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 Element 1 F880: The CNA's who were observed failing to follow hand hygiene, particularly in between resident interactions, were in-serviced. Provided on the spot training and counseling to the CNAs regarding proper hand washing. Ensured all hand washing wipes were available in the dining room and other resident care areas. The identified LPN was immediately educated and retrained on proper infection prevention and control protocols, including hand hygiene and the use of personal protective equipment. All residents involved were assessed for any potential risks of infection. No adverse outcomes were identified. Element 2: All residents have the potential to be affected by this practice. The Infection Control Practitioner/or designee will monitor all CNA's, LPNs, and RNs for adherence to proper infection control practices. Proper handwashing and the proper use of personal equipment will be included in this routine monitoring. Immediate corrective action, such as re-education or disciplinary action, will be implemented for identified infection control breaches. Training sessions will be documented, and staff will be required to demonstrate competency. An audit tool was developed to monitor for compliance. Element 3: Systemic changes: On (MONTH) 10, 2025, the Administrator, Medical Director, Director of Nursing, and Infection Preventionist reviewed the facility's Infection Control Policy and Procedures for Handwashing between residents and the proper use of personal protective equipment; no revisions were required. Education will be provided to all CNAs, LPNs, and RNs related to general infection prevention and control practices. Education will emphasize the staff member's responsibility for proper handwashing. Education will continue to be provided to all staff during orientation and annually, and on an as-needed basis related to general infection prevention and control practices and protocol. In addition to hand hygiene competency upon hire and annually, the facility will conduct periodic hand hygiene competencies on handwashing and infection control practices. Element 4: Monitoring of corrective action: The facility will develop an audit tool to monitor compliance with Infection Prevention and Control protocol related to proper hand washing. On a weekly basis for one quarter, the DNS/designee will observe 2-5 direct care staff for proper handwashing technique and proper use of PPE. Any outstanding issues will be addressed immediately. All audit findings will be reported to the Administrator monthly for 3 months. All audit findings will be reported to the QAPI Committee for 1 quarter for evaluation, discussion, and follow-up. At this time, the QAPI Committee will make a determination for the need for ongoing auditing. The Infection Preventionist will continue to report a summary of all infection control activities and audit findings to the QAPI Committee for one quarter. The QAPI Committee will determine if further action is required. Element 5: Persons responsible: Director of Nursing and Infection Preventionist.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of pests and rodents during the recertification survey. A live rodent was found in a box trap in the dining room while residents were present, and flies were observed in various units, including near the nurse's station and in resident rooms. Additionally, roach droppings were noted on stored equipment in the atrium, and bait traps had not been updated since October 2024. Interviews with staff and residents revealed sightings of mice and flies, with some residents expressing concern about the presence of mice in their rooms. The facility's pest control policy, revised in May 2024, outlines a comprehensive program involving weekly services from an outside pest control company. However, the observations and interviews indicate that the program is not effectively implemented. Staff members, including the Director of Maintenance and the Infection Preventionist, acknowledged the presence of pests and the potential infection control issues they pose. Despite the facility's policy and procedures, the presence of pests and rodents suggests a deficiency in the execution of the pest control program.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element 1 F925 Corrective Action: The Housekeeping and Maintenance Director responded to, 2 West Dayroom, Nurses' station, room [ROOM NUMBER], 238, 239, 4 West Nursing Station, 4 West Hallway, Kitchen, and Atrium, to check all areas for flies and rodents. Any exposed food was either discarded or placed inside a plastic container. The Exterminator treated all areas on 12/26/24, 1/2/25, and 1/6/25. Element 2 Residents at Risk: All residents have the potential to be affected by this practice. The Housekeeping and Maintenance Directors immediately inspected all areas in the building; no other pest control issues were identified. Element 3 Systemic Change: The Pest Control Policy was reviewed; no changes were required. All Dietary, Housekeeping, Maintenance, Nursing (CNA's, LPN, RN's), Activities, and Rehab staff are being in-serviced on the procedure to follow when any areas within the facility require treatment. The Pest Control Company, in addition to 3 weekly visits, will be available for additional visits on an as-needed basis. An audit tool was developed to monitor compliance. Element 4 Monitoring: 3 times per week for one quarter, the Food Service Director/Designee will conduct rounds and audits for sanitation and signs of pest activity. Any adverse findings will be logged into the pest control book and reported to the administrator. For one quarter, the director of maintenance or designee will audit the environment weekly to assist in monitoring pest control service. Any issues identified will be responded to immediately, and reports will be made to the administrator weekly. The results of all audits will be reported to the QAPI Committee quarterly for 2 Quarters/six months. The QAPI Committee will determine if further action is required. Element 5 Date of Correction: (MONTH) 12, 2025 Persons responsible: Food Service, Housekeeping, and Maintenance Directors.
Improper Use of Power Strips in Employee Cafeteria
Penalty
Summary
The facility was found to be in violation of its policy regarding the use of relocatable power strips. During an inspection on December 16, 2024, at approximately 9:50 AM, a refrigerator in the employee cafeteria on the first floor was observed to be plugged into a relocatable power strip. This action was contrary to the facility's policy, which explicitly states that power strips must not be connected to high amperage loads. This indicates a failure to adhere to established safety protocols concerning electrical equipment usage within the facility. Additionally, the facility lacked records for the periodic testing of power strips throughout the building. This omission suggests a broader issue with compliance to safety standards and maintenance protocols, as regular testing is essential to ensure the safe operation of electrical equipment. The Director of Maintenance acknowledged the deficiency at the time of the finding, indicating awareness of the issue but not addressing any corrective measures taken at that moment.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 The refrigerator in the first floor employee cafeteria was immediately unplugged from the relocatable power strip and plugged directly into a wall outlet to comply with the facility policy and ensure safety. A comprehensive inspection of all power strips throughout the facility was conducted to identify any other instances of improper use such as high amperage being connected to power strips. No other issues were identified. The facility's policy regarding the proper use of power strips was reviewed; no revisions were required. Element 2 All residents have the potential to be affected by this practice; however, no other residents were affected by this practice. Element 3 The maintenance staff will receive training on the policy with emphasis on the risks associated with improper power strip usage and how to identify appropriate outlets for high-amperage appliances. The maintenance director will develop a log to monitor power strips and ongoing compliance and safety. Element 4 The maintenance director will conduct random monthly audits of power strip usage in the building to ensure ongoing compliance. Audit results will be reviewed and submitted to the administrator monthly. The maintenance director will submit results of the audit on a quarterly basis for 3 quarters to identify any patterns or recurring issues for 6 months. The QAPI Committee will determine if further action is required. Element 5 Person Responsible: The Maintenance Director
Egress Illumination Deficiency Due to Manual Switches
Penalty
Summary
The facility failed to ensure that the illumination of means of egress was protected from manual operation, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that the egress passageway on the 1st floor, leading from stair C, was equipped with switches that could turn off all lights in the area. This deficiency was identified through observation and staff interviews, specifically with the Director of Maintenance, who acknowledged the issue.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1: Corrective Action: The light switches from stair C that shut off all lights in the 1st floor egress passageway were disconnected. The light source was reconnected to ensure that egress lighting is permanently powered and cannot be manually deactivated during building occupancy. Element 2: All residents have the potential to be affected by this practice. No residents were found to be harmed by this practice. All means of egress were inspected for similar deficiencies. None were found. Element 3: The policy for means of egress will be revised to reflect this new revision. Maintenance staff will be educated on this new revision. Element 4: Monitoring: The maintenance director will monitor all the stairwells monthly to ensure the handrails and landings are marked per NFPA 101 Illumination means of egress. The audit results will be reported to the administrator, and any areas of non-compliance will be immediately corrected. The maintenance director will report for one quarter the results of the audit to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance Director.
Inadequate Sprinkler System Coverage and Improper Use of Sprinkler Piping
Penalty
Summary
The facility failed to ensure that all areas of the nursing home were adequately protected by an automatic sprinkler system, as required by the 2012 NFPA 101 standards. During a life safety survey, it was observed that there was no sprinkler protection underneath stair D at the first-floor lowermost landing. Additionally, the atrium off the lobby had sprinklers installed above the windows on one side, but it was unclear if these provided sufficient coverage for the entire space, which measured approximately 30' by 40'. Furthermore, in the fire pump room, electrical BX cable was improperly suspended from the sprinkler piping, violating the standard that prohibits using sprinkler piping or hangers to support non-system components. These deficiencies were noted during the survey and discussed with the Administrator during the exit conference.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: The facility immediately consulted a licensed fire protection vendor to add a head to provide sprinkler coverage under stairway D. The fire protection vendor conducted a thorough assessment to verify sprinkler head placements above the Atrium/Lobby windows. Additional sprinkler heads will be added every 7 feet to ensure necessary coverage for the entire space in the atrium. The BX cable suspended from sprinkler piping was immediately secured using appropriate non-piping support brackets to comply with NFPA 2012 101 19.3.5.1 requirements. All sprinkler piping in the facility was inspected to ensure no other electrical cables or utilities are improperly supported. The maintenance director visually inspected the entire facility; no other issues were identified. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: Maintenance and engineering staff were retrained on sprinkler system requirements including proper sprinkler head placement and coverage. Prohibition of using sprinkler pipes for utility support was emphasized. The facility's preventive maintenance program was updated to include a semi-annual review of sprinkler systems by our Life Safety Consultant from Ridgefield Associates. Maintenance logs will be reviewed by the maintenance director monthly to ensure compliance. Element 4 Monitoring: The maintenance director will conduct monthly inspections of sprinkler systems coverage and utility compliance. Quarterly audits of sprinkler systems will be conducted by an external fire protection contractor and Ridgefield Associates for the next 12 months. Audit results will be reported to the administrator for compliance; any negative findings will be corrected immediately. The maintenance director will report for the next 3 quarters the results of the inspections to the QAPI Committee. The QAPI Committee will determine if further action is required. Element 5 Person responsible: Maintenance Director
Lack of Fire Alarm System Impairment Policy
Penalty
Summary
The facility failed to ensure occupant safety during a period when the fire alarm system was impaired for more than four hours. During a life safety survey, it was discovered that the facility lacked a policy and procedure outlining the necessary actions to be taken if any part of the fire alarm system was out of service. This deficiency was identified during a document review of the facility's maintenance, inspection, and testing records. The absence of such a policy meant that there were no predefined measures to protect occupants in the event of a fire alarm system failure, leaving them potentially unprotected during the impairment period.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: On (MONTH) 12, 2025, the facility developed a comprehensive policy and procedure to outline the actions to be taken in the event of any impairment to the fire alarm system. The policy includes: - Immediate notification procedures for staff, residents, and local fire authorities. - Temporary fire watch procedures, as per NFPA 101, Life Safety Code guidelines. - Vendor contacted to correct impairment. - Documentation of the impairment and actions taken. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for all residents to be affected by this deficient practice. Element 3 Systemic Changes: A policy and procedure on Fire Watch was created. All maintenance and administrative staff will be trained on the newly developed fire alarm impairment policy. An updated maintenance checklist will be implemented to include a review of the fire alarm system and a requirement to verify that the impairment procedures are readily available. The facility contracts with a vendor to perform routine inspections and testing to proactively prevent system impairments. An audit was created to monitor compliance with the requirements of a Fire Watch. Element 4 Monitoring: The maintenance director will conduct monthly audits of fire safety documentation to ensure adherence to the fire alarm impairment policy. Results of the audit will be reported to the administrator monthly. Any deficiencies identified during the audits will be addressed immediately, and retraining will be provided if necessary. The results of the audit will also be reported quarterly to the QAPI Committee for two quarterly meetings. The QAPI Committee will determine if further action is required. Element 5 Person responsible: The Maintenance Director.
Deficiency in Fire Protection System Policy
Penalty
Summary
The facility failed to prepare and maintain a policy for actions to be taken if the sprinkler system is out of service, leading to a deficiency. On December 16, 2024, a surveyor found a sprinkler head in a closet on the first floor, which was under construction, fitted with a protective cover. This cover rendered the sprinkler head inoperable in the event of an emergency. It was unclear how long the sprinkler head had been covered, and there was no record of a fire watch being conducted in this area while the sprinkler head was impaired. Further review on December 17, 2024, revealed that the facility's sprinkler documents and emergency preparedness policy lacked a policy for the protection of occupants if the automatic sprinkler system was out of service for more than 10 hours. During the exit conference, the facility's Administrator acknowledged the absence of such a policy and stated that they would develop one. This lack of policy and oversight in ensuring the operability of the fire protection system led to the cited deficiency.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Corrective Action: The protective cover was removed immediately upon identification to restore full operability of the sprinkler head. A facility-wide inspection was conducted to ensure no other sprinkler heads were obstructed or otherwise impaired. All sprinkler heads were confirmed to be in proper working condition. A policy was developed and implemented to address the following: Procedures for protecting occupants when the sprinkler system or a portion of it is out of service for more than 10 hours, including interim life safety measures. Routine inspection of sprinkler systems during construction or maintenance projects. Prohibition of any action that impairs the functionality of sprinkler systems without proper documentation, risk assessment, and notification. Element 2 Residents at Risk: While no residents were affected by this practice, the potential existed for residents to be affected by this deficient practice. Element 3 Systemic Changes: All maintenance personnel will be educated on the new policy and requirements to maintain the sprinkler system. Training will include: Recognizing and reporting conditions that impair sprinkler system operations. Steps to implement life safety measures when sprinklers are out of service. An audit tool was developed to monitor compliance. Element 4 Monitoring of Corrective Action: The maintenance director will audit all sprinkler heads monthly to ensure no sprinkler heads are obstructed. The maintenance director will report all findings to the administrator on a monthly basis. The maintenance director will submit results of the audit to the QAPI Committee on a quarterly basis. The QAPI Committee will determine if further action is required. Element 5 Person Responsible: Maintenance Director
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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