Inspection Reports for
Rutland Nursing Home
585 Schenectady Ave, Brooklyn, NY 11203, United States, NY, 11203
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
Two standard health citations related to administration and safe/clean/comfortable/homelike environment with level 2 severity; no immediate jeopardy but minor discomfort and potential for more than minimal harm.
Findings
Two standard health citations related to administration and safe/clean/comfortable/homelike environment with level 2 severity; no immediate jeopardy but minor discomfort and potential for more than minimal harm.
Deficiencies (2)
Administration — quality of care and reporting issues
Safe/clean/comfortable/homelike environment — quality of care
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
The inspection was conducted in response to complaints submitted regarding high temperatures throughout the facility, including a specific complaint about loss of air conditioning on the sixth floor.
Complaint Details
The visit was complaint-related based on Complaint NY00384371. Complaints included loss of air conditioning on the sixth floor and high temperatures throughout the facility affecting all residents. The complaints were substantiated by observations and interviews.
Findings
The facility failed to maintain safe and comfortable temperature levels in resident rooms and common areas, with temperatures exceeding federal and state requirements. The facility's air conditioning system was inadequate, leading to discomfort among residents and staff, and the facility ordered portable air conditioning units to address the issue.
Deficiencies (2)
Failed to maintain safe and comfortable temperature levels in resident rooms and common areas, with temperatures above federal and state requirements.
Failed to administer the facility in a manner that enables effective and efficient use of resources to maintain safe temperature levels.
Report Facts
Rooms with temperatures above required range: 22
Resident floors affected: 6
Temperature readings: 86.9
Portable air conditioning units ordered: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Stated equipment was old and air circulation was weak; portable units were ordered. | |
| Director of Nursing | Reported energy company reduced power voltage but no residents were affected; residents' medical conditions were monitored. | |
| Certified Nursing Assistant #1 | Reported facility was hot and residents and staff were complaining; portable air conditioning units were installed. | |
| Medical Director | Stated no residents were impacted by the heat wave or sent to hospital; emergency preparedness plan was implemented. | |
| Administrator | Received complaint about warm unit; ordered portable air conditioning units after Department of Health visit. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
One standard health citation for free from abuse and neglect with level 3 severity indicating actual harm; isolated scope; no systemic quality of care problems.
Findings
One standard health citation for free from abuse and neglect with level 3 severity indicating actual harm; isolated scope; no systemic quality of care problems.
Deficiencies (1)
Free from abuse and neglect — quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Mar 31, 2025
Visit Reason
Multiple standard health citations (14) and life safety code citations (2) mostly level 1 and 2 severity; deficiencies corrected as of May 30, 2025; issues included assessments, care plans, medication review, food sanitation, environment, and life safety electrical systems and exit signage.
Findings
Multiple standard health citations (14) and life safety code citations (2) mostly level 1 and 2 severity; deficiencies corrected as of May 30, 2025; issues included assessments, care plans, medication review, food sanitation, environment, and life safety electrical systems and exit signage.
Deficiencies (16)
Accuracy of assessments — quality of care
ADL care provided for dependent residents — quality of care
Baseline care plan — quality of care
Care plan timing and revision — quality of care
Develop/implement comprehensive care plan — quality of care
Drug regimen review, report irregular, act on — quality of care
Encoding/transmitting resident assessments — quality of care
Food procurement, store/prepare/serve-sanitary — quality of care
Free from unnec psychotropic meds/prn use — quality of care
Free of accident hazards/supervision/devices — quality of care
Medicaid/medicare coverage/liability notice — quality of care
Notice requirements before transfer/discharge — quality of care
Respiratory/tracheostomy care and suctioning — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Electrical systems - essential electric syste — life safety
Exit signage — life safety
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Mar 31, 2025
Visit Reason
The inspection was conducted as a Recertification survey from 03/24/2025 to 03/31/2025 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide timely and accurate Medicare Part A benefit termination notices, inadequate maintenance of a clean and homelike environment, delayed discharge notifications to the Ombudsman, late submission and inaccuracies in Minimum Data Set assessments, incomplete baseline care plans, lack of comprehensive and updated care plans, failure to provide recommended nursing rehabilitation services, improper respiratory care, failure to act on pharmacist medication regimen review recommendations, inappropriate use of psychotropic medications, and food safety violations related to staff not wearing beard restraints.
Deficiencies (13)
Failure to ensure residents or their representatives were provided appropriate notification via mail at the termination of Medicare Part A benefits on the same day telephone notification was made.
Facility did not maintain a clean, comfortable, and homelike environment; observed lint buildup on dryer vents, dusty fans in resident rooms, water damage, broken tiles, and soiled curtains.
Failure to send timely discharge notices to the Office of the State Long-Term Care Ombudsman.
Minimum Data Set assessments were not transmitted electronically within 14 days after completion for 5 residents.
Minimum Data Set assessments did not accurately reflect Resident #743's gender.
Resident #379 and their representative were not provided with a written summary of the baseline care plan within 48 hours of admission.
Resident #102 did not have a person-centered comprehensive care plan developed and implemented for edema.
Resident #376 and Resident #194's comprehensive care plans were not reviewed and revised by the interdisciplinary team after each assessment.
Resident #120 did not receive the Nursing Rehabilitation Standing and Balance Program in March 2025 as recommended.
Resident #17 was observed receiving oxygen at 3 liters per minute via nasal cannula when the physician's order was for 2 liters per minute; nasal cannula tubing was undated and changed only upon resident complaint.
Recommendations in medication regimen reviews for Resident #125 regarding psychotropic medication prescribed for a diagnosis other than an approved chronic psychiatric condition were not addressed by the attending physician.
Resident #125 was prescribed psychotropic medication without an appropriate diagnosis and was not provided with nonpharmacological interventions before restarting antipsychotic medication.
Dietary staff with visible facial hair were observed assisting with food tray preparation and removing cleaned items from the dish machine without wearing beard restraints, violating food safety and infection control policies.
Report Facts
Residents reviewed for Beneficiary Notification: 39
Residents reviewed for Care Planning: 39
Residents reviewed for Resident Assessment: 5
Residents reviewed for Unnecessary Medication: 5
Residents reviewed for Rehab and Restorative: 2
Residents reviewed for Respiratory Care: 3
Residents reviewed for Food Safety: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Reimbursement | Interviewed regarding Medicare Part A notification process and Minimum Data Set assessment submissions | |
| Administrator | Interviewed regarding Medicare Part A notification and discharge notification process | |
| Housekeeper #1 | Interviewed regarding cleaning of fans | |
| Facilities Manager | Interviewed regarding environmental rounds and cleaning procedures | |
| Building Services Aide | Interviewed regarding cleaning of dryer vents and fans | |
| Assistant Director of Building Services | Interviewed regarding maintenance and cleaning schedules | |
| Director of Admissions | Interviewed regarding discharge notification process and Minimum Data Set gender entry | |
| Registered Nurse #4 | Registered Nurse | Interviewed regarding baseline care plan provision |
| Social Worker #2 | Interviewed regarding care plan meetings | |
| Director of Nursing | Interviewed regarding care plan provision and updates | |
| Registered Nurse #10 | Nurse Manager | Interviewed regarding care plan reviews |
| Registered Nurse #8 | Interviewed regarding care plan for edema | |
| Licensed Practical Nurse #5 | Interviewed regarding care plan updates | |
| Registered Nurse #5 | Unit Clinical Nurse Manager | Interviewed regarding intravenous antibiotic care and care plan updates |
| Senior Associate Director of Nursing | Interviewed regarding care plan updates | |
| Director of Nursing Services | Interviewed regarding nursing rehabilitation oversight | |
| Director of Rehabilitation | Interviewed regarding nursing rehabilitation program | |
| Rehabilitation Aide #1 | Interviewed regarding nursing rehabilitation program | |
| Licensed Practical Nurse #1 | Interviewed regarding oxygen therapy and nasal cannula care | |
| Registered Nurse #1 | Registered Nurse Manager | Interviewed regarding oxygen therapy and nasal cannula care |
| Food Service Supervisor #2 | Interviewed regarding food service safety and uniform policy | |
| Food Service Supervisor #1 | Production Manager | Interviewed regarding food service safety and uniform policy |
| Food Service Director | Interviewed regarding food service safety and uniform policy | |
| Dietary Aide #1 | Interviewed regarding beard net use | |
| Dietary Aide #2 | Interviewed regarding beard net use | |
| Dietary Technician #1 | Interviewed regarding beard net use | |
| Dietary Aide #3 | Interviewed regarding beard net use | |
| Dietary Aide #4 | Interviewed regarding beard net use | |
| Dietary Aide #5 | Interviewed regarding beard net use | |
| Medical Doctor #2 | Medical Doctor | Interviewed regarding medication regimen reviews and psychotropic medication use |
| Psychiatric Nurse Practitioner #1 | Interviewed regarding psychotropic medication use and medication regimen reviews | |
| Medical Director | Interviewed regarding medication regimen reviews and psychotropic medication use |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 31, 2025
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey from 03/24/2025 to 03/31/2025 to investigate allegations related to inadequate supervision and assistance devices leading to resident accidents.
Complaint Details
The complaint investigation found that Resident #108 fell and sustained an acute fracture of the left orbit due to poor transferring technique and improper use of the Hoyer lift sling by Certified Nursing Assistants. Resident #260 fell from an armchair after being removed from their wheelchair by a teacher, despite requiring constant supervision and harness restraints due to high activity level. The fall did not contribute to later increased intracranial pressure requiring shunt revision, as concluded by the Pediatric Medical Doctor.
Findings
The facility failed to ensure adequate supervision and proper use of assistance devices for residents, resulting in two residents (#108 and #260) sustaining injuries from falls. Resident #108 fell from a Hoyer lift due to improper sling placement and poor transfer technique by Certified Nursing Assistants. Resident #260, a highly active resident requiring harness restraints, fell after being removed from their wheelchair and placed in an armchair by a teacher, leading to subsequent medical complications.
Deficiencies (1)
Failure to ensure residents received adequate supervision and assistance devices consistent with their needs to prevent accidents, resulting in falls and injuries to residents #108 and #260.
Report Facts
Residents investigated: 2
Fall risk score: 15
Dates of incidents: Resident #108 fall on 01/20/2025; Resident #260 fall on 09/12/2024.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Assisted in transferring Resident #108 with Hoyer lift during fall incident; unable to explain sling placement. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | On one-to-one observation during Resident #108 fall; not present at incident. |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Received in-service on Hoyer lift use; no demonstration given. |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed about Hoyer lift training and sling placement. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Observed Resident #108 after fall; commented on sling strap placement. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Observed Resident #108 after fall; reported on sling placement and staff training. |
| Registered Nurse #3 | Registered Nurse | Assessed Resident #108 after fall; unaware of staff training details. |
| Staff Development Coordinator | Staff Development Coordinator | Reported on staff education and competency checks for Hoyer lift use. |
| Senior Associate Director of Nursing | Senior Associate Director of Nursing | Reported on staff in-service and investigation findings for Resident #108 fall. |
| Director of Nursing | Director of Nursing | Attributed Resident #108 fall to user error; confirmed staff training and disciplinary actions. |
| Administrator | Administrator | Reviewed investigation; confirmed no equipment malfunction; disciplinary actions taken. |
| Speech Therapist | Speech Therapist | Witnessed Resident #260 fall in playroom; reported incident. |
| Registered Nurse #6 | Registered Nurse | Observed Teacher with Resident #260 before fall; assessed Resident #260 after fall. |
| Registered Nurse #7 | Registered Nurse | Assessed Resident #260 after fall; monitored subsequent health changes. |
| Pediatric Medical Doctor | Pediatric Medical Doctor | Examined Resident #260 after fall; concluded fall did not contribute to later shunt revision. |
| Senior Director of Nursing for Pediatrics and Young Adults | Senior Director of Nursing for Pediatrics and Young Adults | Commented on Resident #260 activity level and supervision requirements. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
One standard health citation for respect, dignity/right to have personal property with level 2 severity; isolated scope; deficiency corrected as of May 23, 2025.
Findings
One standard health citation for respect, dignity/right to have personal property with level 2 severity; isolated scope; deficiency corrected as of May 23, 2025.
Deficiencies (1)
Respect, dignity/right to have prsnl property — quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of emotional and verbal abuse by a Certified Nursing Assistant towards Resident #6, following reports of disrespectful treatment and failure to provide care in a manner that promotes resident dignity.
Complaint Details
The visit was complaint-related, triggered by allegations of verbal and emotional abuse by Certified Nursing Assistant #1 towards Resident #6. The complaint was substantiated based on interviews, progress notes, and facility investigation.
Findings
The facility failed to ensure Resident #6 was treated with respect and dignity, as evidenced by verbal abuse from Certified Nursing Assistant #1. The investigation confirmed emotional abuse occurred, with the staff member admitting to telling the resident off and not following protocol to stop care when the resident complained of pain. Resident #6 was assessed by medical and psychological staff and provided emotional support.
Deficiencies (1)
Failure to treat Resident #6 with respect and dignity, including verbal and emotional abuse by Certified Nursing Assistant #1.
Report Facts
Residents Affected: 1
Residents Sampled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in verbal and emotional abuse findings towards Resident #6. | |
| Licensed Practical Nurse #1 | Reported observations and provided statements related to the incident involving Resident #6. | |
| Registered Nursing Supervisor #3 | Provided statements regarding Certified Nursing Assistant #1's admission of telling off Resident #6. | |
| Director of Nursing | Initiated investigation and concluded verbal abuse occurred. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jan 31, 2025
Visit Reason
The abbreviated survey was conducted due to an incident involving resident-to-resident abuse between two residents, Resident #1 and Resident #2, including an altercation in the elevator and a subsequent assault in Resident #1's room resulting in injury.
Findings
The facility failed to ensure Resident #1 was free from resident-to-resident abuse, resulting in an acute fracture to Resident #1's left fourth rib. The facility did not implement timely safety measures such as close visual monitoring after the initial incident. Resident #2 was removed from the facility following law enforcement involvement and an order of protection was issued.
Deficiencies (1)
Failed to protect residents from resident-to-resident abuse resulting in actual harm to Resident #1.
Report Facts
Residents affected: 1
Date of incident: Jan 31, 2025
Time of initial incident: 1450
Time of second incident: 1725
Date of survey completion: Jun 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Witnessed the initial altercation in the elevator and intervened | |
| Registered Nurse Supervisor #1 | Assessed residents after altercations and documented findings | |
| Medical Doctor #1 | Medical Doctor | Assessed Resident #1 and reviewed imaging results |
| Medical Doctor #2 | On-call Medical Doctor | Ordered transfer of Resident #1 to emergency department |
| Social Worker #1 | Social Worker | Spoke to residents and documented incident report |
| Director of Nursing | Director of Nursing | Informed about incidents and coordinated response |
| Administrator | Administrator | Received reports about incidents and survey |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 1
Date: Jul 10, 2024
Visit Reason
One deficiency related to abuse reporting documentation.
Findings
One deficiency related to abuse reporting documentation.
Deficiencies (1)
R9-10-803.J — Abuse reporting documentation
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 23, 2023
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey from 10/16/2023 to 10/23/2023 to investigate complaints related to resident care planning and supervision.
Complaint Details
The complaint investigation focused on incidents involving Resident #212's care plan not being updated after a physical abuse event on 7/20/23, and Resident #592 eloping from the facility on 9/3/23 without adequate supervision. The abuse allegation was substantiated with findings that care plans were not updated. The elopement was confirmed with documentation of the resident leaving the unit undetected and being found at their parent's home.
Findings
The facility failed to ensure a comprehensive person-centered care plan was reviewed and revised after a resident-to-resident physical abuse incident. Additionally, the facility did not provide adequate supervision to prevent a resident from eloping, resulting in the resident leaving the unit undetected and being found later at their parent's home.
Deficiencies (2)
Failure to review and revise Resident #212's comprehensive care plan after a resident-to-resident physical abuse incident on 7/20/23.
Failure to provide adequate supervision to prevent Resident #592 from eloping on 9/3/23, allowing the resident to leave the unit undetected and be missing for several hours.
Report Facts
Residents investigated for abuse: 3
Total residents sampled: 43
Residents investigated for accidents: 3
Time resident missing: 6.3
Date of abuse incident: Jul 20, 2023
Date of elopement incident: Sep 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Nurse Manager of day shift | Interviewed regarding care plan updates after resident-to-resident altercation. |
| RN #4 | Nurse Coordinator of evening shift | Interviewed regarding care plan updates after resident-to-resident altercation. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding responsibility for care plan updates and elopement incident. |
| RN #7 | Registered Nurse | Medication nurse on duty during Resident #592 elopement incident. |
| RN #10 | Registered Nurse | Interviewed about Resident #592 elopement and medication administration. |
| CNA #6 | Certified Nursing Assistant | Assigned to Resident #592 on day of elopement incident. |
| CNA #5 | Certified Nursing Assistant | Interviewed about monitoring residents in smoke room area. |
| Registered Nurse Manager | RNS #1 | Interviewed about Resident #592 behavior and care plan. |
| Security Guard #1 | Security Guard | On duty during Resident #592 elopement incident. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Oct 20, 2023
Visit Reason
Two standard health citations related to reporting of alleged violations and requirements before submitting a request with level 2 severity; isolated and pattern scopes; deficiencies corrected as of December 15, 2023.
Findings
Two standard health citations related to reporting of alleged violations and requirements before submitting a request with level 2 severity; isolated and pattern scopes; deficiencies corrected as of December 15, 2023.
Deficiencies (2)
Reporting of alleged violations — quality of care
Requirements before submitting a request for — quality of care
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Oct 20, 2023
Visit Reason
The visit was conducted as an abbreviated survey to investigate the facility's failure to timely report an alleged abuse incident involving Resident #1, as required by federal and state regulations.
Findings
The facility failed to report an alleged abuse incident involving a Behavioral Health Associate (BHA) grabbing a resident's phone and bumping the resident's forehead within the required two-hour timeframe to the New York State Department of Health. The incident was investigated internally, no visible injury or psychological harm was found, and the facility did not save the camera footage. The Director of Nursing and Administrator acknowledged the reporting requirement but did not report the incident due to lack of observed abuse on video.
Deficiencies (1)
Failure to timely report suspected abuse involving Resident #1 to the State Survey Agency as required by policy and law.
Report Facts
Residents reviewed for abuse: 5
Date of alleged incident: Apr 26, 2023
Date of survey completion: Oct 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Behavioral Health Associate #1 | Named in abuse allegation for grabbing resident's phone and bumping forehead | |
| Behavioral Health Associate #2 | Reported the abuse allegation involving BHA #1 and Resident #1 | |
| Assistant Director of Nursing | Assistant Director of Nursing | Wrote the Facility Occurrence Report documenting the abuse allegation |
| Director of Nursing | Director of Nursing | Conducted investigation and interview regarding the abuse allegation |
| Administrator | Administrator | Interviewed regarding knowledge and reporting of the abuse allegation |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as a recertification survey from 10/16/2023 to 10/23/2023, including complaint investigation NY00315981, to assess compliance with food safety and pest control standards.
Complaint Details
The inspection included complaint NY00315981 regarding pest control issues, which was substantiated by observations of live mice and multiple pest sightings documented in the facility.
Findings
The facility failed to ensure proper food handling and hygiene practices by dietary staff, leading to potential cross-contamination risks. Additionally, the facility did not maintain an effective pest control program, with live mice observed on two units and documented multiple pest sightings.
Deficiencies (2)
Dietary staff did not change contaminated gloves after disposing garbage and before handling soiled dishes, with no hand hygiene performed between glove changes, risking foodborne illness.
Facility did not maintain an effective pest control program; live mice were observed in resident rooms and hallways, with multiple documented pest sightings.
Report Facts
Dates of pest sightings: Multiple dates in 2023 including 6/28, 7/11, 7/18, 7/20, 7/22, 9/15, and 10/18
Number of mice caught: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Present during mouse sighting near nurses station and stated they would call the exterminator |
| Dietary Aide | Observed not changing gloves properly and handling food trays without hand hygiene | |
| Food Service Supervisor | FSS | Provided key for trash compactor and stated staff should wash hands after glove removal |
| Director of Environmental Services | Food Service Director | Noted dietary aide did not wash hands after handling trash and emphasized infection control |
| Infection Preventionist | Described hand washing program and importance of hand hygiene in infection control | |
| Assistant Director of Building Services | ADBS | Discussed pest control efforts and exterminator availability |
| Exterminating Technician | ET | Conducts pest management, performs rounds, and applies traps catching multiple mice |
| Administrator | Confirmed daily exterminator visits and efforts to seal the facility |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 13, 2023
Visit Reason
One standard health citation for reporting - national health safety network with level 2 severity; widespread scope; no correction noted.
Findings
One standard health citation for reporting - national health safety network with level 2 severity; widespread scope; no correction noted.
Deficiencies (1)
Reporting - national health safety network — quality of care
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 6, 2021
Visit Reason
The inspection was conducted as part of the recertification survey to assess compliance with regulatory requirements including resident rights, use of restraints, accuracy of assessments, care planning, and medication management.
Findings
The facility was found deficient in honoring resident bathing preferences, improper use of physical restraints (four side rails raised), inaccurate Minimum Data Set (MDS) assessments regarding oxygen use, untimely revision of care plans, and use of unnecessary psychotropic medication without documented behavioral justification.
Deficiencies (5)
Failure to promote and facilitate resident self-determination through support of resident choice, specifically not honoring bathing preferences for Resident #45.
Use of physical restraints in the form of four side rails raised on residents #222, #296, and #297 without proper care plan or orders.
Inaccurate MDS assessments failing to document oxygen use for residents #41 and #222.
Failure to revise comprehensive care plans in a timely manner after quarterly assessments for Resident #41.
Use of antipsychotic medication (Seroquel) for Resident #67 without documented behavioral symptoms or evidence supporting necessity.
Report Facts
Residents reviewed: 38
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Provided information about Resident #45's bathing and care. |
| RN #7 | Registered Nurse | Interviewed regarding Resident #45's shower care. |
| CNA #3 | Certified Nursing Assistant | Discussed side rail use for residents #222 and #296. |
| CNA #2 | Certified Nursing Assistant | Discussed side rail use and resident reactions. |
| LPN #1 | Licensed Practical Nurse | Provided information on side rail positioning and policy. |
| RN #1 | Registered Nurse Unit Manager | Discussed side rail policy and resident care. |
| DON | Director of Nursing | Provided policy and care plan information regarding restraints and care plan revisions. |
| MDS Assessor | Interviewed about errors in oxygen documentation on MDS. | |
| DCR | Director Clinical Reimbursement | Discussed responsibility for MDS accuracy. |
| AP | Attending Physician | Reviewed resident records and discussed psychotropic medication use. |
| MDP | Medical Doctor of Psychiatry | Initially ordered Seroquel for Resident #67; declined to comment on indication. |
| CNA #1 | Certified Nursing Assistant | Described Resident #67's responsiveness and behaviors. |
| RN #2 | Registered Nurse and Charge Nurse | Discussed Resident #67's behaviors and medication. |
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