Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ark Healthcare & Rehabilitation At St. Camillus during CMS and state inspections, most recent first.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility, was left unattended by a single nurse aide during incontinent care. The aide attempted to turn the resident alone, resulting in the resident falling from bed and sustaining a displaced spiral femur fracture that required surgical intervention. This occurred despite clear physician orders and care plan directives for two-person assistance and use of bed rails.
The facility failed to provide accessible contact information for the State Long-Term Ombudsman Program. Residents were unaware of the Ombudsman and where to find contact details. The information was posted high on elevator walls, inaccessible to wheelchair users and not visible to those facing forward. It was also absent from bulletin boards outside elevators and on units, violating facility policy.
The facility did not inform residents about the grievance process or ensure that grievance forms were accessible. Residents were unaware of how to complete a grievance or where to find the forms. A social worker could not locate the forms in the designated area and acknowledged they were not easily accessible. Despite a request, a copy of the grievance policy was not provided.
The facility failed to revise care plans for three residents, leading to deficiencies in managing physical limitations, skin integrity, and fall risk. A resident with hand deformities did not have a care plan update to manage the condition. Another resident with a stage 3 pressure ulcer lacked a care plan for offloading boots, despite recommendations. A third resident's care plan was not updated after a fall, missing necessary interventions.
A resident at risk for pressure ulcers developed a new DTI on the left heel due to the facility's failure to consistently document turning and repositioning. Despite recommendations from a wound physician, the facility did not obtain physician's orders for offloading boots, contributing to the ulcer's progression to stage 3. Interviews revealed a lack of communication and documentation regarding pressure-relieving interventions, indicating non-compliance with the facility's skin care management policies.
The facility failed to ensure timely evaluation and treatment for residents with limited mobility and contractures. A resident developed bilateral hand deformities without proper evaluation or treatment, while another experienced contractures post-stroke with delayed intervention. Additionally, a resident prescribed splints for contracture management did not receive them as ordered, with staff unaware of the requirements.
The facility's kitchen was found to be unsanitary, with issues such as dirty ceiling tiles, a broken dishwasher cover, and unlabeled food items. Temperature logs were incomplete, and a cook was not wearing a beard guard. The Dietary Manager acknowledged these deficiencies.
The facility failed to properly dispose of garbage and refuse, with numerous debris items found alongside the dumpsters, including mattresses, televisions, and broken furniture. The Dietary Director had informed the Maintenance Director about the need for cleanup two weeks prior, and the Maintenance Director confirmed the situation, stating that a company was scheduled to pick up the items.
The facility failed to investigate a missing item report for a resident, resulting in confusion about the item's recovery. Additionally, the facility environment was unsanitary, with a rusted medicine cabinet, dusty fan, and poorly maintained shower rooms. Maintenance staff were unaware of repair needs, and there was no documentation of maintenance rounds or cleaning policies.
A facility failed to ensure the accuracy of the MDS assessment for a resident with a serious mental illness. The resident, diagnosed with dementia and schizoaffective disorder, was incorrectly coded on the MDS as not having a PASRR related condition. An RN responsible for MDS coding admitted to the oversight, despite the RAI instrument directing that such conditions be coded under Section A 1500 PASRR related condition.
A resident with Type 2 diabetes and incontinence was given Lactulose syrup borrowed from another resident's supply due to a depletion of their own medication. The LPN admitted to routinely borrowing medications, contrary to facility policy, which states that medications should not be shared and the pharmacy should be contacted if a medication is unavailable.
A resident with heart failure, diabetes, and neuropathy was found with long, dirty fingernails despite being dependent on staff for personal hygiene. The resident had requested nail care but did not receive it, and there was no documentation of nail care being offered or refused. Staff interviews revealed no specific schedule for nail care, and the DNS stated that staff should proactively offer nail care. The facility's policy required daily cleaning and regular filing of nails.
A resident with Alzheimer's and wandering behavior was inadequately supervised, leading to unsupervised wandering and access to potentially hazardous items. Despite being on 15-minute checks, the resident was observed without supervision, entering another resident's room, and handling personal items, highlighting a failure in implementing the care plan and facility policy.
A facility failed to maintain a complete communication log for a resident receiving dialysis, missing critical information such as nurse names, access site conditions, vital signs, and meal times. Staff interviews revealed inconsistencies in understanding documentation requirements, leading to incomplete records despite the facility's policy for comprehensive communication with the treatment center.
A facility failed to ensure staff was knowledgeable about using electronic care cards, leading to a resident experiencing pressure on their feet and legs due to improper use of offloading booties. The RN supervisor could not find a physician order or care plan for the booties, and a nurse aide was unaware of their necessity due to a lack of available care cards and reliance on verbal reports. The process for reviewing assignments and documenting care on electronic tablets was not followed, and there was no documentation of the booties' implementation or effectiveness.
A resident's prescribed Lactulose medication was unavailable, leading an LPN to use another resident's medication, contrary to facility policy. The facility's policy prohibits borrowing medications and emphasizes timely reordering to ensure availability.
The facility's PBJ data for Quarter 3 of 2023 was found to be incomplete and inaccurate, with excessively low weekend staffing levels. Despite meeting state staffing requirements on certain dates, the HR Director could not explain the low weekend staffing trigger. Staffing data was compiled from payroll and agency invoices and submitted to CMS by an outside consultant.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Failure to Provide Required Assistance with Bed Mobility Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to provide the required assistance with bed mobility for a resident with significant cognitive and physical impairments. The resident had diagnoses including Parkinson's disease, dementia, abnormal gait, and generalized muscle weakness, and was assessed as severely cognitively impaired and fully dependent for bed mobility and ADLs. Physician orders and the care plan specified that two staff members were required to assist with bed mobility, and that 1/4 bed rails should be used as an enabler during repositioning. Despite these directives, a nurse aide provided incontinent care to the resident alone, without seeking assistance, because other aides were busy and she believed she could manage by herself. During the process of turning the resident, the aide turned the resident onto their right side, at which point the resident's foot slid off the mattress and the resident fell out of bed onto the floor. Initial assessment did not reveal injuries, but swelling and deformity of the left leg were noted the following morning, and subsequent hospital evaluation confirmed a displaced spiral fracture of the left femur requiring surgical intervention. The Director of Nursing confirmed that the nurse aide did not follow physician orders, which were in place to prevent such falls, and the facility's fall prevention policy required individualized interventions to prevent falls.
Inaccessible Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that residents were provided access to the contact information for the Office of the State Long-Term Ombudsman Program in a manner that was accessible and understandable. During a meeting with eight residents, it was identified that they were unaware of who the State Ombudsman was and where to locate the contact information. An interview with a social worker revealed that the contact information was posted on bulletin boards located on each elevator. However, observations showed that the information was posted high on the back wall of the elevator, making it inaccessible to individuals in wheelchairs and not visible to residents facing the front of the elevator. Additionally, the information was not posted on bulletin boards outside the elevator doors or on the units, contrary to the facility's policy requiring such postings to be accessible and understandable to residents and their representatives.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to inform residents about the grievance process and ensure that grievance forms were accessible and available to residents and visitors. During a meeting with eight residents, it was revealed that they were unaware of how to complete a grievance or where to find the forms. An interview with a social worker indicated that the grievance forms were supposed to be located in the nursing office behind the nursing station on both floors. However, during an observation, the social worker was unable to locate the forms in the designated area and could not provide any other location for them. The grievance policy, which was reviewed, stated that forms should be easily accessible, especially for those wishing to remain anonymous. The social worker acknowledged that the forms were not easily accessible and mentioned that the location would be changed to better meet the residents' needs. Despite a request, a copy of the facility's grievance policy was not provided.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #13, who was identified with physical limitations of the hands. Despite the resident's left-hand deformity being noted in an interdisciplinary rehabilitation screen and bilateral hand contractures being documented in progress notes, the care plan did not include any interventions for managing these deformities to prevent progression. The Director of Nursing acknowledged that the care plan should have been revised once the physical limitation was identified. For Resident #98, the facility did not develop a care plan to address the resident's skin integrity to prevent further skin breakdown. The resident, who had a stage 3 pressure ulcer on the left heel, was recommended to use offloading boots by a wound physician. However, there was no physician's order for the boots, and the care plan was not updated to reflect this recommendation. The wound care nurse confirmed that the recommendation for offloading boots was overlooked, and the care plan did not include this intervention until after surveyor inquiry. Resident #54 experienced a fall, but the facility failed to revise the resident's care plan timely post-fall. Although the care plan indicated the resident was at risk for falls, it did not show updated interventions after the fall occurred. The Director of Nursing stated that staff are expected to update the care plan with new interventions to prevent injuries after a fall, but the care plan reviewed was the most updated version available, lacking any new interventions post-fall.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently provide evidence of turning and repositioning a resident, leading to the development of a pressure ulcer. The resident, who was at risk for pressure ulcers due to paraplegia, diabetes mellitus, and incontinence, developed a new Deep Tissue Injury (DTI) on the left heel. Despite having a care plan that included interventions to prevent pressure ulcers, there were multiple instances of missing documentation for turning and repositioning the resident, which is a fundamental practice to prevent pressure ulcers. Additionally, the facility did not obtain physician's orders for recommendations made by a consulting wound physician, which contributed to the further decline of the pressure ulcer. The wound physician recommended the use of offloading boots to prevent further injury, but there was no physician's order for their use, and the care plan did not reflect this intervention. The resident's pressure ulcer progressed from a DTI to a stage 3 pressure ulcer, indicating a lack of timely and appropriate intervention. Interviews with staff revealed that there was a lack of communication and documentation regarding the use of offloading boots and other pressure-relieving interventions. The facility's policies on skin care management and prevention of pressure injuries were not adequately followed, as evidenced by the missing documentation and lack of physician's orders for recommended treatments. This deficiency highlights the need for consistent documentation and adherence to care plans to prevent the development and worsening of pressure ulcers.
Failure to Address Mobility and Contracture Needs
Penalty
Summary
The facility failed to ensure timely evaluation and treatment for residents with newly identified limited mobility and contractures. Resident #13, who was admitted with mild cognitive impairment and other conditions, developed bilateral hand deformities over time. Despite multiple screenings and observations indicating the presence of contractures, a full evaluation to determine the extent of the limitations and appropriate treatment was not conducted until after surveyor inquiry. The lack of timely intervention and preventative measures potentially contributed to the progression of the contractures. Resident #97, diagnosed with cerebral infarction and hemiplegia, also experienced a lack of timely evaluation and intervention for contractures. Initial therapy sessions identified impairments and recommended services to increase functional activity tolerance. However, after discharge from therapy, no further recommendations were made to prevent further loss of mobility. Subsequent screenings noted increased tone and contractures, but no evaluations or interventions were conducted until prompted by surveyor inquiry. The absence of a documented physician's order for a recommended splint further delayed necessary treatment. Resident #86, with a history of hemiplegia and cerebral infarction, was prescribed splints for contracture management. However, the facility failed to ensure the application of these splints as per physician's orders. Observations revealed that the resident was not wearing the prescribed splints, and staff interviews indicated a lack of awareness and communication regarding the splint application. The facility's failure to adhere to its own policies and procedures for splint application and staff training contributed to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour of the Dietary Department. Several issues were identified, including ceiling tiles with a brown substance, a broken and discolored dishwasher cover, and black substances around the dishwasher edges and on the tiles in the kitchen and dishwasher room. The floor throughout the kitchen was dirty with debris and food, and the second-floor nourishment refrigerator had a red substance inside. Additionally, the baking oven and cooktop were covered with a brown substance, and the ceiling vent in the main kitchen had a brown substance around it. The facility also failed to ensure proper food labeling and storage, with numerous items in the dry goods storage area and freezer found unlabeled or undated. The temperature logs for the freezer and refrigerator were missing several evening readings, and the day cook was not wearing a beard guard as required by policy. Interviews with the Dietary Manager revealed that staff were responsible for labeling and dating items, and that hair coverings, including beard guards, were to be worn around food. The Dietary Manager acknowledged the issues and identified that the facility had hired a company to steam clean the kitchen, but it was not as clean as expected.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed by surveyors. During an inspection with the Dietary Director, numerous debris items were found alongside the dumpsters and facility, including discarded mattresses, old televisions, a nightstand, a tire, broken pieces of wood, and chairs. The Dietary Director acknowledged that the area was not well-kept or cleaned and mentioned that these items were from maintenance, not dietary-related. He had informed the Maintenance Director about the need for cleanup two weeks prior, and noted that the dumpsters are emptied twice a week. The Maintenance Director confirmed that the Dietary Director had spoken to him about the debris on June 29, 2024. He identified the items beside the dumpsters and stated that a company was scheduled to pick them up on the day of the inspection. He also acknowledged his responsibility for maintaining the cleanliness of the dumpsters and surrounding area, and stated that the area had only been in that condition since June 29, 2024.
Deficiencies in Resident Safety and Facility Maintenance
Penalty
Summary
The facility failed to thoroughly investigate a report of a missing item for a resident diagnosed with morbid obesity, heart failure, and an above-the-knee amputation. The resident, who was cognitively intact, reported a missing Apple watch, which was initially documented as recovered by a social worker. However, subsequent interviews revealed that the watch had not been located, and there was confusion about whether the resident actually possessed the watch. The facility's policy for missing items was not followed, as there was no detailed investigation or conclusion documented regarding the missing watch. The facility environment was found to be unsanitary and not homelike, with a rusted medicine cabinet without doors and disconnected light bulb sockets in a bathroom. Maintenance staff were unaware of how long the cabinet had been in disrepair, and there was no documentation of repair requests or maintenance rounds. Additionally, a resident with chronic obstructive pulmonary disease had a fan in their room that was covered in dust, which had not been cleaned for at least six months. The facility lacked a policy for cleaning fans, and the housekeeping/maintenance director was unsure of the cleaning procedures. The facility's shower rooms were observed to be in poor condition, with chipped and cracked paint, black substances on floors and walls, torn wallpaper, and rusty shower curtain rods. The director of housekeeping/maintenance acknowledged the need for repairs but failed to document any concerns in the environmental rounds logs. The facility did not provide a maintenance policy or documentation of maintenance rounds, indicating a lack of oversight and attention to maintaining a safe and sanitary environment for residents.
Inaccurate MDS Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident identified with a serious mental illness. This deficiency was identified during a review of clinical records, facility policy, and interviews. Specifically, for one of the sampled residents, the facility did not accurately code the Preadmission Screening and Resident Review (PASRR) related condition on the MDS. The resident in question was admitted with diagnoses including dementia and schizoaffective disorder, and a PASRR level II outcome had previously identified the resident as meeting criteria for a serious mental illness. However, the Annual MDS assessment incorrectly indicated that the resident did not have a PASRR related condition for serious mental illness or intellectual disability. An interview with a Registered Nurse (RN) revealed that she was responsible for MDS coding and acknowledged that the PASRR should be coded on the MDS upon admission, annually, and with significant changes. Despite this, the RN entered incorrect information on the MDS due to an oversight, even though social services were responsible for coding the MDS for residents with serious mental illness. The Resident Assessment Instrument (RAI) used for MDS coding directs that all conditions related to serious mental illness or intellectual disability be coded under Section A 1500 PASRR related condition.
Medication Borrowing Leads to Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality during medication administration for a resident diagnosed with Type 2 diabetes mellitus and incontinence. The resident had a physician's order for Lactulose Oral Solution to be administered daily for constipation. However, during an observation, it was noted that the Lactulose syrup administered to the resident was borrowed from another resident's supply because the resident's own supply was depleted. The LPN involved admitted that it was their usual practice to use other residents' medications when a resident's supply was unavailable. The facility's policy clearly states that medications prescribed for one resident should never be administered to another resident, and if a medication cannot be located, the pharmacy should be contacted. Despite this policy, the LPN did not adhere to the guidelines, leading to the deficiency. The RN Unit Manager confirmed that the facility's practice is not to borrow medications and emphasized the importance of reordering medications to ensure availability for residents.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that a resident's fingernails were clean and cut, as observed in the case of a resident with diagnoses including heart failure, diabetes mellitus, and neuropathy. The resident was cognitively intact and required substantial assistance for personal hygiene. Despite being dependent on staff for bathing and personal hygiene, the resident's fingernails were observed to be long with a black and brown substance underneath. The resident reported having requested nail care about a week prior but could not recall the staff member they spoke to. The medical records from the relevant period did not document any offer or refusal of nail care. Interviews with staff revealed that there was no specific schedule for cutting residents' fingernails, although nurse aides were expected to notice and address long or dirty nails during routine care. The Director of Nursing Services (DNS) indicated that staff should proactively ask residents if they would like their nails cut, rather than waiting for residents to request it. The facility's policy on fingernail care emphasized daily cleaning and regular filing to prevent infection, but this was not adhered to in the case of the resident in question.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with Alzheimer's disease, disorientation, wandering, unspecified dementia, and unspecified psychosis. The resident was identified as cognitively impaired and at risk for elopement, with a care plan that included frequent safety checks and supervision when off the unit. Despite these interventions, the resident was observed wandering without supervision, entering another resident's room, and handling personal items, which posed a safety concern. On the morning of the incident, the resident was seen walking in the hallway without undergarments and later wandering in socks without shoes. The resident was redirected by staff but continued to wander unsupervised, eventually obtaining a bowl of applesauce from a medication cart and entering another resident's private room. The resident handled items such as shaving cream and a bottle of sterile water and attempted to drink from a used coffee mug before being assisted by a nurse aide. The facility's policy on wandering and elopements aimed to prevent harm while maintaining a least restrictive environment. However, the resident's frequent checks were not adequately documented or executed, as evidenced by the resident's unsupervised wandering and access to potentially hazardous items. The Director of Nursing Services acknowledged the safety concerns and indicated that the resident was on 15-minute checks, but the checks were not effectively implemented, leading to the observed deficiencies.
Incomplete Dialysis Communication Log for Resident
Penalty
Summary
The facility failed to consistently maintain a communication log for a resident receiving specialized dialysis treatment. The resident, diagnosed with end-stage kidney disease, dementia, and Parkinson's disease, required dialysis three times a week. The care plan highlighted the risk of dehydration and fluid deficit, necessitating close monitoring of intake, output, and vital signs. However, the communication log, which was supposed to document the resident's status and treatment details, was found to be incomplete on several occasions. Missing information included the nurse's name, the condition of the specialized access site, the resident's last vital signs, and the time of the last meal. Interviews with facility staff revealed discrepancies in understanding the documentation requirements. The nurse unit manager expected the log to include vital signs, weight, and access site status, while an LPN believed only vital signs were necessary. The facility's policy required comprehensive communication between the long-term care facility and the specialized treatment center, but this was not consistently followed. The specialized treatment center did not have access to the resident's electronic medical record, relying instead on the communication log and telephone updates, which were not adequately maintained.
Failure to Ensure Staff Knowledge on Electronic Care Card Use
Penalty
Summary
The facility failed to ensure that staff was knowledgeable about using the electronic care card to provide resident care according to the plan of care. During an observation and interview, it was found that a resident was experiencing pressure on various parts of their feet and legs while seated in a wheelchair. Although there was an indication that offloading booties were ordered for the resident, the RN supervisor could not find a physician order or care plan for their use. The RN supervisor also could not explain how licensed nurses were supposed to monitor for pressure on the resident's feet and heels while out of bed. Additionally, a nurse aide who had not worked on the resident's unit for some time was unaware of the need for pressure-relieving booties, as there were no care cards available in the resident's room or at the nurse's station. The nurse aide relied on verbal reports from the outgoing aide and the resident's own instructions for care. The RN supervisor identified that the process for reviewing assignments and documenting care on electronic tablets was not followed, as the nurse aide did not review the assignment at the beginning of the shift. Furthermore, there was no documentation of the implementation, consistent use, or evaluation of the effectiveness of the booties, and the nurse aide had not received prior education on using the electronic documentation system.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's supply of Lactulose medication was available for administration as per the physician's orders. Resident #45, who has a diagnosis of Type 2 diabetes mellitus and incontinence, was prescribed Lactulose Oral Solution to be administered daily for constipation. During a medication administration observation, it was found that the Lactulose syrup intended for Resident #45 was depleted, and the Licensed Practical Nurse (LPN) used medication prescribed for another resident instead. This action was contrary to the facility's policy, which prohibits borrowing medications from other residents. The incident was observed during a medication administration session, where the LPN admitted to using another resident's medication due to the unavailability of Resident #45's supply. The LPN stated that an order had been sent to the pharmacy the previous day. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed, using the Five Rights, and explicitly states that medication for one resident should never be administered to another. The RN Unit Manager confirmed that the facility's practice is to ensure medications are reordered in a timely manner to prevent such occurrences.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to ensure that its Payroll-Based Journal (PBJ) data for Quarter 3 of 2023 was complete and accurate. A review of the facility's PBJ submissions for this period revealed excessively low weekend staffing levels. Despite meeting minimum state staffing requirements on specific dates, such as May 21 and June 10, 2023, the overall data indicated inconsistencies. The Human Resource (HR) Director explained that staffing data was compiled from the facility's payroll provider and agency staffing invoices, which were then sent to an outside consultant for submission to the Centers for Medicare and Medicaid Services (CMS). However, the HR Director could not account for the low weekend staffing trigger in the PBJ data, suggesting fluctuations in staffing levels that were not accurately reflected in the submissions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stamford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stamford Care Center | 1 mi | — | 18 | 0 |
| Edgehill Health Center | 2.1 mi | — | 2 | 0 |
| Civita Care Center At Long Ridge | 3.5 mi | — | 1 | 0 |
| Nathaniel Witherell, The | 5.2 mi | — | 3 | 0 |
| Waveny Care Center | 5.7 mi | — | 7 | 0 |
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