Adira At Riverside Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Yonkers, New York.
- Location
- 120 Odell Avenue, Yonkers, New York 10701
- CMS Provider Number
- 335829
- Inspections on file
- 20
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Adira At Riverside Rehabilitation And Nursing during CMS and state inspections, most recent first.
Two residents with ventilator dependence, severe cognitive impairment, and multiple pressure ulcers did not receive wound care consistent with practitioner orders and accurate clinical information. For one resident, the wound nurse independently increased the frequency of wound treatments beyond the wound specialist’s daily order, implementing twice-daily and three-times-daily treatments in response to excessive drainage and purulent discharge without the practitioner’s knowledge. For another resident, progressive leukocytosis and an infected buttock ulcer were documented, IV antibiotics were started then discontinued before completion, and a discrepancy arose between the wound specialist’s documented order for Silvadene and the wound nurse’s documentation and transcription of Santyl instead. This resident’s condition worsened, with rising WBCs, severe anemia requiring hospital transfer, and a wound culture showing multiple organisms, while hospital staff were unable to obtain detailed information from facility nursing staff about the change in condition.
Two residents at high risk for pressure ulcers did not receive care consistent with professional standards. One ventilator-dependent resident with multiple facility-acquired stage 2 and 3 sacral and buttock ulcers had weeks of documented stagnant, draining wounds and an infected ulcer without evidence of care plan revision or treatment changes, and CNA records showed the resident remained in the same position in bed for extended periods. Another ventilator-dependent resident admitted with an unstageable sacral ulcer and identified as high risk for skin breakdown had a care plan calling for q2h turning, skin monitoring, and pressure-relieving devices, but there was no documentation of timely offloading device evaluation or follow-up wound consult, and CNA records initially lacked evidence of q2h repositioning; within a short time, this resident developed multiple new deep tissue injuries and a hip abrasion.
Two ventilator‑dependent residents with multiple pressure ulcers and complex medical needs did not have their total programs of care reviewed by an attending physician at required visits. For one resident, wound documentation and interviews showed discrepancies between the wound specialist’s recommended treatments and the pulmonologist’s signed orders, with no evidence that the physician reconciled or evaluated these differences despite ongoing purulent drainage and increased treatment frequency. For another resident, serial wound notes documented stagnant, draining sacral and buttock ulcers and labs showed progressively abnormal WBC, Hgb, and Hct values, while NPs ordered and adjusted antibiotics and topical treatments; however, the pulmonologist’s monthly note only mentioned pressure ulcers without addressing their unhealing status or abnormal labs. Interviews with the DON, NPs, medical director, pulmonologist, and administrator revealed conflicting understandings of who was the attending physician for ventilator‑dependent residents, and there was no clear physician oversight of the residents’ overall care, leading to the cited deficiency.
Surveyors found that wound care services did not meet professional standards when a wound nurse independently altered wound treatment orders for two residents with multiple pressure ulcers. For one resident with severe cognitive impairment and ventilator dependence, the nurse transcribed and implemented wound care at higher frequencies than ordered by the wound specialist, based on observed excessive drainage. For another resident with advanced neurologic impairment and facility-acquired pressure ulcers, the nurse documented and transcribed a change from Silvadene to Santyl ointment for a buttock ulcer that was not reflected in the wound specialist’s written order. The ADON reported limited recall of the nurse’s wound care competency and noted that nurses on the vent unit routinely provided more-than-daily dressing changes due to soiling, despite wound care being expected to follow specialist recommendations.
A resident with severe cognitive impairment, ventilator dependence, and multiple pressure ulcers, including an infected buttock ulcer on contact precautions, received wound care during which infection control practices were not followed. A nurse removed dressings from multiple wounds while the resident lay on a towel that became soaked with drainage, and no barrier or drop cloth was placed between the resident’s open wounds and the contaminated towel. When the nurse stepped away, a CNA allowed the resident to drop back so that sacral and buttock wounds directly contacted the soiled towel. The nurse later admitted forgetting to use a barrier, and the Assistant DON, who shared infection control responsibilities, reported not having observed the nurse’s wound care practices, despite an expectation that barriers be used to prevent wound contact with potentially soiled surfaces.
A resident with severe cognitive impairment and multiple comorbidities sustained a head injury after falling from bed when a CNA turned the resident away from themselves during in-bed care, contrary to facility policy. The CNA did not call for assistance and was unable to prevent the fall, resulting in the resident being transferred to the hospital with a laceration, hematoma, and further complications identified on imaging.
A resident at high risk for pressure ulcers developed an unstageable ulcer due to the facility's failure to update care plans and implement necessary interventions. Despite the resident's left heel redness being identified, staff did not ensure proper off-loading, turning, and repositioning. Observations showed the resident's heels were not elevated, and there was inadequate documentation and communication regarding care. This led to the deterioration of the resident's skin integrity, resulting in actual harm.
The facility was found to have insufficient nursing staff, resulting in delayed responses to call bells and residents being unable to get out of bed when desired. Residents reported these issues during interviews and a Resident Council meeting, with specific instances of long waits for bathroom assistance and missed therapy sessions. Staffing sheets showed understaffing on 19 out of 31 days, and staff confirmed frequent double shifts to cover absences.
The facility did not conduct annual performance reviews for CNAs, as required. Eight CNAs, employed for over a year, lacked documented evaluations. Staff responsible for these evaluations could not explain the oversight, as confirmed through interviews and record reviews.
A resident with pneumonia, chronic respiratory failure, and dementia was not promptly reported to their representative about a pneumonia diagnosis and antibiotic treatment initiation. The facility's policy required such notifications, but there was no evidence of compliance. Interviews indicated that nurses were responsible for family notifications, yet the expected communication did not occur.
A resident with severe cognitive impairment and a history of pressure injuries developed a pressure injury on the left heel, but the care plan was not updated with necessary interventions. Despite being at high risk, the resident's heels were not off-loaded or elevated, and they were not repositioned regularly. Staff interviews confirmed that the wound progressed to an unstageable state, and preventative measures were not implemented promptly.
The facility failed to provide necessary care and equipment for residents with limited range of motion, as three residents were observed without their prescribed hand rolls. Despite care plans and physician orders, staff interviews revealed a lack of awareness and communication, leading to the residents not receiving the intended interventions to prevent contractures and maintain skin integrity.
A resident with chronic respiratory failure was observed receiving oxygen therapy at a higher flow rate than prescribed. Despite physician orders for 2-3 liters per minute, the resident was receiving 4 to 4.5 liters per minute. Staff documented adherence to the prescribed rate, but a nurse later adjusted the flow to the correct rate, unable to explain the initial discrepancy.
The facility failed to maintain food safety standards, with expired sandwiches found in the refrigerator and on lunch trays, and residents' personal food stored beyond the allowed limit. Additionally, the first-floor ice machine was unclean, with black slime observed inside. The Assistant Food Service Director and Director of Housekeeping acknowledged these issues, highlighting lapses in adherence to food safety protocols and cleaning schedules.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in infection tracking, Legionella water management, staff vaccination education, and implementation of Enhanced Barrier Precautions for residents. The Infection Preventionist did not track infections in real-time, and the Water Management Plan had not been updated since 2016. Staff were not educated about pneumonia vaccination, and necessary precautions for residents were not properly implemented.
A facility failed to document offering and educating a resident on pneumococcal immunization, as required by policy. The resident, with respiratory failure and ventilator dependence, had no record of being offered or declining the vaccine. Interviews revealed disorganization in tracking vaccine information, with the Infection Preventionist lacking tools to monitor vaccine status and the DON acknowledging the need for better tracking.
The facility failed to document and educate a resident and a staff member on COVID-19 vaccination, lacking records for a ventilator-dependent resident and a staff member. Interviews revealed systemic issues in tracking vaccination records, with staff not being approached about their vaccine status or offered boosters.
Failure to Provide Ordered and Accurately Managed Wound Care for Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents with pressure ulcers received treatment and care according to practitioner orders and accurate clinical information. For one resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and multiple pressure ulcers (three present on admission and one facility-acquired), the facility’s wound care nurse independently increased the frequency of wound treatments beyond what the wound care physician assistant had ordered. The wound PA had ordered daily and PRN treatments to multiple pressure ulcers, but the wound nurse transcribed and implemented orders for twice-daily and three-times-daily treatments, documenting and carrying them out over several days. The wound nurse reported that the change was made due to excessive drainage and purulent discharge from a buttock wound and that the resident had experienced excessive drainage for at least a week, but the PA stated they had not recommended more than once-daily treatment and were not aware of the excessive drainage. For another ventilator-dependent resident with severe cognitive impairment and facility-acquired stage 2 and 3 pressure ulcers, the facility did not accurately transcribe wound specialist recommendations and did not thoroughly review and address signs of worsening infection. Laboratory results showed a progressively increasing white blood cell count over several dates, and a nurse practitioner documented an infected right buttock ulcer and ordered IV Zosyn and follow-up by the wound care team. The antibiotic was discontinued before completion after a negative urinalysis, and later a wound PA documented an order for Silvadene to the right buttock ulcer, while the wound nurse’s note from the same day documented that the PA changed the treatment to Santyl ointment. The physician order transcribed by the wound nurse reflected Santyl rather than Silvadene. Subsequent lab results for this resident showed a further increase in white blood cell count, and the resident required transfer to the hospital for severe anemia and a blood transfusion. Hospital records documented a markedly elevated white blood cell count and a wound culture positive for multiple organisms, including Klebsiella pneumoniae, Proteus mirabilis, Acinetobacter, yeast, and staphylococcus species, and the resident was started on IV antibiotics. The hospital attempted, but was unsuccessful, in obtaining more information from facility nursing staff regarding the resident’s change in condition prior to hospitalization. Interviews with the wound nurse, DON, nurse practitioner, and pulmonologist showed that wound assessments, documentation of wound characteristics, and responsibility for monitoring and responding to changes in wound status were fragmented, with the wound nurse stating they did not document wound assessments and the DON stating nursing staff were responsible for daily wound documentation and referral of changes to the physician.
Failure to Revise Wound Care and Implement Pressure Ulcer Prevention for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment and preventive care consistent with professional standards for two residents with significant skin integrity needs. One resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and total dependence for ADLs had multiple facility-acquired stage 2 and 3 pressure ulcers to the sacrum and buttocks. Despite wound care notes over several weeks documenting that these ulcers were stagnant and producing moderate serous to serosanguinous drainage, there was no documented revision of the resident’s treatment plan to address the lack of healing or the ongoing drainage. A nurse practitioner documented that the right buttock ulcer was infected, yet subsequent wound notes continued to describe stagnant wounds with moderate serosanguinous drainage and no changes in measurements, characteristics, or treatment orders for the sacral and buttock ulcers. For this same resident, the facility’s documentation showed additional concerns with basic pressure relief and monitoring. The CNA accountability record for the month indicated the resident remained in the same position in bed for six or more hours on 15 of 25 days, despite the resident’s immobility and known pressure ulcers. The wound care nurse reported that they performed daily treatments and transcribed wound specialist orders into physician orders, but stated they did not document wound assessments until after the wound specialist had assessed the wounds. The DON, however, stated that nursing staff were responsible for documenting wound characteristics daily during treatment administration and referring any changes to the physician. There was no documented evidence that the wound care provider addressed the infected right buttock ulcer or reviewed and adjusted the care plan in response to the nonhealing, draining pressure ulcers. When the resident was transferred to the hospital for severe anemia, the hospital documented a large sacral ulcer with purulent drainage and a wound culture showing multiple organisms, and the sanguinous discharge from the sacral ulcer was described as highly suspicious as the source of the resident’s infection and anemia. The second resident was admitted with acute respiratory failure requiring ventilator support, a history of cerebrovascular accident, severe cognitive impairment, total dependence for ADLs, and an unstageable sacral pressure injury. Admission assessments and the MDS identified the resident as high risk for pressure ulcers, and the care plan called for skin risk assessment, preventive skin care, monitoring for changes each shift, keeping skin clean and dry, incontinent care every two hours, turning and repositioning every two hours, and providing appropriate pressure-relieving devices per PT/OT recommendations. A wound note documented an unstageable sacral ulcer and ordered Medi-honey with a follow-up wound consult in one week. However, there was no documented evidence that the resident was evaluated for offloading devices to prevent further breakdown, and no documentation that the wound care specialist saw the resident again within a week as planned. Within days of admission, nursing documentation showed the resident initially awake and responsive during perineal care and wound dressing, but later that same day another nurse documented a new abrasion to the left hip and multiple deep tissue injuries to both heels, both ankles, and the right hip. Physician orders were then written for a wound consult for these deep tissue injuries, bilateral heel boots, and topical treatments. Review of CNA accountability records for the admission month showed no documented turning and repositioning assistance in accordance with the care plan, with documentation of every-two-hour turning and positioning not appearing until later in the following month. Staff interviews revealed that CNAs relied on accountability records to determine which residents required turning and repositioning and had no place to document observed skin changes themselves, depending instead on licensed nurses to act on their verbal reports. The ADON later stated they had investigated the resident’s facility-acquired deep tissue injuries and concluded they were unavoidable, and also reported they could not recall the last time the wound care nurse had a wound care competency, while the facility lacked an inservice coordinator and relied on the wound care vendor for wound care education.
Failure to Ensure Physician Review of Total Care for Ventilator‑Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the attending physician reviewed each ventilator‑dependent resident’s total program of care, including medications, treatments, wound care, and abnormal laboratory results, at required visits. For one ventilator‑dependent resident with chronic respiratory failure, cerebral infarction, and multiple pressure ulcers (including one facility‑acquired), the face sheet identified a pulmonologist as the attending physician. A wound note dated 03/27/2026 ordered daily and PRN treatments to multiple ulcers, while physician orders signed by the pulmonologist on the same date specified different treatment frequencies (twice daily for some wounds and three times daily for others). The treatment administration record showed staff followed the pulmonologist’s orders, but there was no documented evidence that the pulmonologist, as attending physician of record, reviewed or reconciled the discrepancies between the wound specialist’s recommendations and the physician’s own treatment orders. Interviews and wound documentation for this resident showed ongoing wound problems that were not addressed by the attending physician. The wound care nurse reported that the resident had multiple wounds, including a right buttock wound with purulent discharge and signs of infection, and that the wound care specialist verbally recommended treatment orders during weekly wound rounds, which the nurse transcribed into physician orders and used to update the care plan. The nurse also stated that, due to excessive drainage, wound treatments had been increased from twice daily to three times daily for at least a week. However, the wound physician assistant stated they had not recommended treatments more than once daily and indicated they would have recommended hospitalization if they had known the resident required wound care more than once daily for excessive drainage. Subsequent medical notes contained no evaluation or discussion by the attending physician of these wound care changes or the wound team’s recommendations. For a second ventilator‑dependent resident with chronic respiratory failure, hypoxic ischemic encephalopathy, and multiple unhealed, facility‑acquired stage 2 and 3 pressure ulcers, the face sheet also listed the pulmonologist as the attending physician. This resident had stagnant, unhealing sacral and buttock ulcers with ongoing serosanguinous drainage documented in multiple wound notes. Laboratory results over time showed progressively abnormal values, including elevated WBC counts and low hemoglobin and hematocrit. Nurse practitioner notes documented an infected right buttock ulcer, initiation of IV Zosyn, and subsequent discontinuation of the antibiotic before completion, as well as additional wound treatment orders (Santyl and Silvadene). Despite these findings and repeated wound notes describing stagnant, draining ulcers, there was no documented evidence that the pulmonologist, as attending physician of record, reviewed or addressed the increasingly abnormal lab values or the ongoing reports of stagnant, draining, unhealing pressure ulcers. The pulmonologist’s monthly progress note referenced the presence of pressure ulcers but did not address their unhealing status or recent lab results. Interviews with facility leadership and clinicians revealed confusion and inconsistency regarding who was actually serving as attending physician for ventilator‑dependent residents. The DON stated that nursing staff were responsible for documenting wound characteristics daily and referring any changes to the medical doctor. A nurse practitioner reported that three NPs sometimes covered episodic concerns on the ventilator unit and that wound care specialists were responsible for evaluating wounds, addressing stagnant unhealing wounds, and ordering treatments. The medical director stated that the pulmonologist was assigned as attending physician for ventilator‑dependent residents and that facility clinicians, including the medical director and pulmonologist, were responsible for ensuring wound care specialists addressed the care plan and that orders were carried out. In contrast, the pulmonologist stated they were only responsible for respiratory care, were not the attending physician for any residents, and were not responsible for non‑respiratory treatments. The administrator similarly stated the pulmonologist was not the attending physician for ventilator‑dependent residents and was unaware of why the pulmonologist was listed as attending on the residents’ face sheets. This lack of clarity and failure to ensure that an attending physician reviewed and coordinated the residents’ total care programs led to the cited deficiency under 10 NYCRR 415.15(b)(2)(iii).
Failure to Follow Wound Specialist Orders and Professional Standards in Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that services met professional standards of quality for residents with pressure ulcers when wound treatment orders were not followed as prescribed by wound care practitioners. For one resident with chronic respiratory failure, ventilator dependence, severe cognitive impairment, and multiple pressure ulcers (three present on admission and one facility-acquired), the wound care physician assistant ordered daily and as-needed treatments to ulcers on the right mid-back, sacrum, right medial buttock, right lateral buttock, and left lateral leg. However, the wound care nurse transcribed these orders as more frequent than prescribed, documenting treatments to the mid-back and left lateral leg twice daily and to the sacral and buttock ulcers three times daily. Treatment records show that staff administered wound care at these increased frequencies until the resident’s subsequent hospitalization. The wound care nurse stated they independently changed the frequency of treatments due to observing excessive drainage and purulent discharge, while the wound care physician assistant stated they had not recommended treatment more than once daily and would have recommended hospitalization if they had known the resident required wound care more than once daily. For another resident with chronic respiratory failure, ventilator dependence, hypoxic ischemic encephalopathy, and facility-acquired stage 2 and 3 pressure ulcers, the wound care physician assistant documented an order for Silvadene to a right buttock ulcer. On the same date, the wound care nurse documented that the wound care physician assistant had evaluated the resident and changed the treatment to Santyl ointment, and then transcribed a physician order reflecting Santyl instead of Silvadene. This change in treatment product was not supported by the wound care physician assistant’s written order. The assistant director of nursing, who oversaw the wound care program, reported they could not recall the last time the wound care nurse had a wound care competency and stated that residents with pressure ulcers were being treated more than once daily because dressings became soiled with incontinence, while also acknowledging that treatments should follow wound care specialist recommendations and be provided more than once daily only as needed.
Inadequate Infection Control During Wound Care Leading to Cross-Contamination Risk
Penalty
Summary
The deficiency involves a failure to maintain infection prevention and control standards during wound care for a ventilator‑dependent resident with multiple pressure ulcers, including an infected right buttock ulcer on contact precautions. The resident had chronic respiratory failure with ventilator dependence, cerebral infarction, severe cognitive impairment, and was totally dependent on staff for activities of daily living. Physician orders documented contact precautions for the infected right buttock wound and specific topical treatments for multiple wounds on the buttocks, sacrum, mid‑back, and left lateral leg. The wound care nurse acknowledged that the right buttock wound had purulent discharge and showed signs of infection, making infection control important to prevent the resident’s other wounds from becoming infected. During an observed wound care procedure, the resident was positioned on their left side while a CNA assisted with positioning and the wound care nurse removed dressings from the right lateral and medial buttock, mid‑back, and sacrum. A towel under the resident became soaked with dark red drainage from the soiled dressings, and no barrier or drop cloth was placed between the resident’s open wounds and the towel. When the wound care nurse stepped away to change gloves and obtain more supplies, the CNA allowed the resident to drop slightly onto their back, causing the sacral and buttock wounds to come into direct contact with the towel saturated with drainage. The wound care nurse later stated that a drop cloth barrier should have been used but was forgotten, and the Assistant DON, who also had infection control responsibilities, reported they had not observed the wound care nurse’s treatment practices, despite the expectation that residents with open wounds be provided with barriers to prevent contact with potentially soiled objects.
Failure to Prevent Bed Fall Due to Improper Turning Technique
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for bed mobility and had multiple comorbidities including cerebrovascular disease and severe cognitive impairment, sustained a fall from bed resulting in a head injury. The facility's fall prevention policy required individualized care planning and proper technique for turning and positioning residents in bed, including turning residents toward the caregiver and maintaining close proximity during movement. Despite these protocols, the resident was turned away from the Certified Nurse Aide (CNA) during in-bed care, and the CNA was not positioned on the side to which the resident was being turned. During the incident, the CNA turned the resident to the right side, away from themselves, while changing the resident's diaper and chux. The CNA then reached for clean linen placed at the foot of the bed, during which time the resident unexpectedly rolled and fell off the bed. The CNA attempted to prevent the fall but was unsuccessful. There were no side rails or grab bars on the bed, and the CNA did not call for additional assistance when turning the resident away from themselves, contrary to facility policy and supervisor instruction. Following the fall, the resident was found on the floor with a laceration and hematoma on the forehead, bruising on the hand, and an abrasion on the knee. The resident was alert and oriented, but due to the head injury, was transferred to the hospital where imaging revealed a subarachnoid hemorrhage and subdural hematoma. Interviews with staff confirmed that the CNA did not follow proper turning technique and did not seek help when required, directly contributing to the accident hazard and resulting injury.
Failure to Prevent Pressure Ulcer Development and Deterioration
Penalty
Summary
The facility failed to provide adequate care to prevent the development and deterioration of pressure ulcers for a resident identified as high risk. Resident #24, who had a history of pressure injuries and was assessed as high risk for pressure ulcers, was found to have redness on the left heel on 08/24/2024. Despite this, the resident's care plan was not promptly updated with necessary interventions to prevent further deterioration. The facility's policy required actions such as updating the care plan, implementing nursing interventions, and ensuring proper positioning and incontinence care, but these were not adequately followed. Observations and interviews revealed that the resident's heels were not off-loaded or elevated, and the resident was not repositioned every two hours as required. The resident was frequently observed with their heels resting directly on the footrest of a geriatric chair, and there was no documented evidence of turning and positioning between 8:00 AM and 8:00 PM. The facility staff, including Registered Nurse #26 and Certified Nursing Assistant #28, failed to implement or report necessary interventions, and there was a lack of communication and documentation regarding the resident's condition and care. By 08/29/2024, the resident's left heel had progressed to an unstageable ulcer with necrosis, indicating a significant decline in skin integrity. The facility's failure to implement timely and appropriate interventions, such as off-loading, turning, and repositioning, contributed to the deterioration of the resident's condition. Interviews with facility staff, including the Director of Nursing and the Medical Director, highlighted a lack of awareness and adherence to the facility's pressure ulcer prevention protocols, resulting in actual harm to the resident.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts, as observed during a recertification survey. Multiple residents reported during interviews and a Resident Council Group meeting that the facility was short-staffed at times, leading to delays in call bell responses and residents not being able to get out of bed when desired. Specific instances included a resident waiting two hours for bathroom assistance and missing therapy sessions due to delayed assistance. Another resident reported being left in bed all day due to staffing shortages, particularly on weekends. The facility's staffing sheets from 7/25/24 to 8/25/24 revealed that the facility was understaffed on 19 out of 31 days, with direct care nursing staff below the minimum levels documented in the Facility Assessment. Interviews with staff members, including Certified Nurse Aides and the Staffing Coordinator, confirmed the use of double shifts and staffing agencies to cover regular staff absences. Despite these measures, staff reported challenges in providing timely care, with some aides working double shifts multiple times per week. The Director of Nursing claimed adequate staffing, supplemented by non-direct care helpers, but the deficiency in direct care staffing was evident.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received performance reviews at least once every 12 months, as required. During the recertification survey conducted from August 26 to August 30, 2024, it was found that eight randomly selected CNAs did not have documented performance reviews within the past year. These CNAs had been employed at the facility for over a year, with hire dates ranging from 2002 to 2021. Interviews with staff revealed that the Registered Nurse Unit Supervisor responsible for the 3-11 shift and the Staffing Coordinator, who was tasked with tracking the evaluations, could not provide an explanation for the oversight. The lack of performance evaluations was confirmed through staff interviews and a review of facility records.
Failure to Notify Resident's Representative of Health Status Change
Penalty
Summary
The facility failed to promptly notify a resident's representative of a significant change in the resident's health status. Specifically, the designated representative of a resident with diagnoses including pneumonia, chronic respiratory failure, and dementia was not informed when the resident developed pneumonia and was started on an antibiotic treatment. The resident's Quarterly Minimum Data Set indicated severely impaired cognition and complete dependence on staff for daily activities, underscoring the importance of family notification. The facility's policy required prompt notification of the resident's representative in the event of a change in condition. However, there was no documented evidence that the representative was informed about the pneumonia diagnosis and the initiation of Cefuroxime treatment. Interviews with the Director of Nursing and a Registered Nurse revealed that it was the nurses' responsibility to notify families, and the expectation was that families would be promptly informed of any changes, especially given the resident's dementia diagnosis. Despite this expectation, the notification did not occur in this instance.
Failure to Update Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner to reflect the resident's changing needs and current status. Specifically, Resident #24, who had diagnoses including type 2 diabetes, Alzheimer's disease, and a history of pressure injuries, acquired a pressure injury on the left heel. Despite the resident's high risk for pressure ulcers, as indicated by a Braden Scale score of 11, the care plan was not updated with goals and interventions to promote wound healing. Observations and records revealed that Resident #24's care plan did not include interventions for the left heel redness and to prevent further deterioration of the heel's skin integrity. The resident was frequently observed with their heels resting directly on the footrest of a geriatric chair, without off-loading or elevation, and was not turned or repositioned during extended periods. The family member of Resident #24 reported noticing the heel redness and requested staff intervention, but was not aware of any measures being implemented except for a wound consult scheduled for a later date. Interviews with staff, including a Registered Nurse and Nurse Practitioner, confirmed that the left heel wound had progressed to an unstageable state. The staff acknowledged that preventative measures such as heel off-loading, turning, repositioning, and the use of heel boots should have been implemented immediately upon noticing the heel redness. The Director of Nursing and Medical Director also stated that interventions should have been initiated promptly based on nursing judgment and orders, including off-loading, turning, repositioning, and the use of supportive devices.
Failure to Implement Hand Roll Care Plans for Residents
Penalty
Summary
The facility failed to ensure that residents with limited range of motion and mobility received the necessary care and equipment to maintain or improve their function. Three residents, all with severe cognitive impairments and dependent on staff for daily activities, were care planned to use hand rolls to prevent contractures and maintain skin integrity. However, observations revealed that these residents were frequently without their prescribed hand rolls, indicating a lapse in the implementation of their care plans. For Resident #24, the care plan included bilateral Posey hand rolls, but observations over several days showed the resident without them. Interviews with staff revealed a lack of awareness and communication regarding the hand rolls, with no order placed in the electronic medical record. The family member expressed concerns about the resident's clenched hands and lack of hand rolls, which they had never seen in use. Resident #54 had a physician order for bilateral Posey hand rolls, but observations showed the resident without them, and the Treatment Administration Record lacked documentation of their use. Staff interviews indicated that the resident had refused the hand rolls, but this was not communicated to the nursing staff or documented. Similarly, Resident #91 was observed without the prescribed right hand roll, and staff interviews confirmed that the responsibility for ensuring the use of the hand roll was not adequately managed by the nursing staff.
Failure to Follow Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident received necessary respiratory care in accordance with the physician's orders. Resident #308, who had diagnoses including chronic respiratory failure with hypoxia, shortness of breath, and pneumonia, was observed receiving oxygen therapy at a higher flow rate than prescribed. The physician's order dated 8/21/24 specified continuous oxygen at 2-3 liters per minute via nasal canula, but observations on 8/26/24 and 8/27/24 revealed that the resident was receiving 4 to 4.5 liters per minute. The Treatment Administration Records from 8/20/24 to 8/27/24 indicated that staff documented the administration of oxygen at the prescribed rate of 2-3 liters per minute every shift. However, during an observation on 8/27/24, a registered nurse adjusted the oxygen concentrator from 4.5 liters to 2 liters per minute after reviewing the order and acknowledging the discrepancy. The nurse was unable to explain why the order was not being followed, indicating a lapse in adherence to the prescribed respiratory care plan.
Deficiencies in Food Storage and Ice Machine Cleanliness
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the survey, expired peanut butter and jelly sandwiches were found in the walk-in refrigerator and on prepared lunch trays. Additionally, expired egg salad sandwiches were also observed on the trays. The Assistant Food Service Director acknowledged that the lunch meal trays were prepared the day before and suggested that staff mistakenly left the expired sandwiches on the truck. The Director of Food Service was unaware of why the expired sandwiches were present but emphasized the importance of adhering to use-by dates for infection control and illness prevention. Furthermore, the facility did not adhere to its policy regarding the storage of residents' personal food. Food items in the resident pantry refrigerator were observed beyond the three-day limit, and an undated ice cream cake was found in the freezer. A Licensed Practical Nurse stated that the refrigerator should be checked daily by Certified Nursing Assistants, but this had not been done for some time. Additionally, the first-floor resident ice machine was found to be unclean, with black slime observed inside the machine. The Director of Housekeeping stated that the Housekeeping Department was responsible for cleaning the ice machines and was unaware of the issue, although the last cleaning was documented. They acknowledged the importance of keeping the ice machines clean to prevent contamination.
Inadequate Infection Control and Prevention Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during a recertification survey. The infection surveillance plan was not properly implemented, with no documentation available for infection onset dates, signs and symptoms, lab tests/results, isolation, and outbreak potential for July and August 2024. The Infection Preventionist admitted to not tracking infections in real-time, which hindered the identification and prevention of infection patterns. Additionally, the Water Management Plan for Legionella had not been reviewed or updated since December 2016, despite the Director of Maintenance acknowledging the requirement for annual reviews. Furthermore, the facility did not ensure that staff members were educated about the risks and benefits of the pneumonia vaccination, nor was there documentation of the vaccine being offered or declined. The Infection Preventionist admitted to not routinely offering the vaccine, and the Director of Nursing expressed concern over the disorganization in vaccine tracking. Enhanced Barrier Precautions were not properly implemented for four residents, as observed by the absence of doffing pails and supply carts outside their rooms, which the Infection Preventionist acknowledged should have been in place.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey, where it was found that there was no documented evidence that a resident with diagnoses of respiratory failure, seizures, and who was ventilator dependent, was offered, declined, or educated on the pneumococcal immunization. The facility's policy required that all new admissions be assessed for the need for the vaccine and that education be documented, but this was not followed for the resident in question. Interviews with the Infection Preventionist and the Director of Nursing revealed a lack of organization and accountability in tracking vaccine information. The Infection Preventionist admitted to not having a tool to track resident information and vaccine status, and there was no record of declinations from residents or their representatives. The Director of Nursing acknowledged the disorganization and the need for better tracking of vaccine status, indicating a systemic issue in the facility's vaccination program management.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to ensure that all residents and staff were properly screened, educated, and offered the COVID-19 vaccine, as evidenced by the lack of documented immunization records for one resident and one staff member. Specifically, Resident #91, who had diagnoses of respiratory failure, seizures, and was ventilator-dependent, did not have documented evidence of receiving education, being offered the vaccine, or declining it. Additionally, there was no documentation of the COVID-19 vaccination status for Staff #37. Interviews with facility staff revealed systemic issues in maintaining and tracking vaccination records. The Infection Preventionist admitted to not having records of staff or residents who were offered, declined, or were educated on COVID vaccines, and did not follow up with staff who had not provided their vaccine history. The Registered Nurse Supervisor indicated that vaccine information for new admissions was passed down to the next supervisor without a proper tracking system. Furthermore, a Respiratory Therapist and two Certified Nurses Aides reported not being approached about their vaccine status or offered booster vaccines during their time at the facility.
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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