Elderwood At Cheektowaga
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheektowaga, New York.
- Location
- 225 Bennett Road, Cheektowaga, New York 14227
- CMS Provider Number
- 335752
- Inspections on file
- 17
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Elderwood At Cheektowaga during CMS and state inspections, most recent first.
The facility failed to ensure residents were properly educated about the COVID-19 vaccine and that their consent or declination was accurately documented. One cognitively intact resident with multiple chronic conditions was recorded as having declined the COVID-19 vaccine without a signed or verbally documented declination and without any documented education on risks and benefits; in interview, this resident stated they wanted the vaccine and had never received education or signed a declination. Review of vaccination forms for 34 other residents who were marked as having declined the COVID-19 vaccine showed no signed declinations and no documentation that Vaccine Information Sheets or other education were provided. Staff and leadership interviews confirmed that education on risks/benefits and completion of consent/declination sections with signatures or verbal documentation were expected but were not carried out or recorded as required.
Two residents with dementia and documented cognitive impairment received COVID-19 and influenza vaccines based on verbal consents obtained directly from them by the Assistant DON/Infection Preventionist, despite activated Health Care Proxies and prior documentation that they lacked medical decision-making capacity. Facility policies and state and federal resident rights documents required informed consent and recognized the authority of health care agents when residents lack capacity. In both cases, the health care agents were not contacted for consent, were unaware the vaccines had been administered, and later stated they would have expected to be involved in these decisions, demonstrating a failure to honor residents’ rights to refuse treatment and to obtain consent from the appropriate representatives.
Three residents with cognitive and chronic medical conditions received influenza and/or COVID-19 vaccines from an outside pharmacist during a vaccine clinic, but the facility’s MAR and immunization records inaccurately documented that facility nurses administered these vaccines or left the administrator information incomplete. Facility policy required that immunizations be documented by the nurse who administered them and that vaccines given by non-facility staff be entered as outside-agency or historical immunizations in the EMR, rather than as standard MAR entries. An LPN reported signing the MAR for vaccines they did not administer, based on verification forms and resident reports, while another LPN stated they only entered orders and did not give any vaccines, despite being listed as the administering nurse. Leadership and nursing staff acknowledged that nurses should not document medications they did not administer or witness, yet the records continued to reflect inaccurate or incomplete documentation of who actually gave the vaccines.
A resident with an indwelling Foley catheter and a history of UTIs was repeatedly observed with the drainage bag positioned above bladder level and not wearing a leg bag as care planned. There were no provider orders for the catheter or its care, and the care plan contained outdated and inaccurate information about the resident's urinary devices. Staff interviews revealed lapses in updating care plans, obtaining orders, and following proper catheter care procedures.
A certified nurse aide was found to have verbally abused a resident by yelling and making inappropriate comments during care, as witnessed by another resident and confirmed by staff interviews. The resident, who was cognitively intact and had multiple medical conditions, reported feeling hurt and disappointed by the aide's actions. The incident was corroborated by witness statements and staff, who recognized the behavior as verbal and mental abuse.
A facility failed to ensure a Consultant Pharmacist reported irregularities in a resident's drug regimen review, leading to the prolonged use of an antibiotic without an end date. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Doxycycline Monohydrate since 2020. The pharmacist did not identify or report the excessive duration, and the DON was unaware of the antibiotic use. The deficiency was noted during a standard survey, indicating a lapse in medication management and antibiotic stewardship.
A resident with severe cognitive impairment and multiple diagnoses, including MRSA, was receiving Doxycycline Monohydrate for lifelong suppression without proper monitoring by the facility's Infection Preventionist or Antibiotic Stewardship Program. The facility's policy required tracking and reporting of antibiotic usage, but this was not done. Staff interviews revealed a lack of awareness and monitoring due to the antibiotic not appearing on the facility's dashboard, and there was no process to review the pharmacy's report.
A facility failed to review and renew a resident's Medical Orders for Life-Sustaining Treatment (MOLST) as required, leading to a discrepancy between the resident's current wishes and documented orders. Despite the resident's moderate cognitive impairment and history of serious medical conditions, their MOLST form had not been updated since a specified date. Interviews with staff revealed a lack of consistent review, highlighting the importance of aligning medical orders with residents' current wishes.
The facility failed to properly label and manage medications in the Unit 4 storage room. Observations revealed undated and outdated Tubersol vials and expired over-the-counter medications. Staff interviews highlighted lapses in adherence to labeling and expiration protocols, with responsibilities shared among LPNs, the Pharmacy Technician, and the Shipping/Receiving Manager. The DON and Administrator emphasized the need for proper labeling and removal of expired medications.
A facility failed to notify a resident and their family of a room change and a positive COVID-19 test. The resident's room was changed without notification, and the family was unaware of the COVID-19 diagnosis until visiting. Staff interviews confirmed the lack of documentation and communication.
A resident with cognitive impairments and dependent on staff for toileting was left exposed during incontinent care by a CNA, compromising their privacy and dignity. Despite the facility's policies on respecting residents' rights, the CNA left the resident uncovered and visible to the hallway, and staff interviews confirmed the lapse in maintaining privacy.
A resident with dementia and hemiparesis experienced a delay in receiving a lumbar x-ray after a fall, due to communication and documentation failures. Although x-rays for the elbow and sacral regions were completed, the lumbar x-ray was delayed because the order was not entered into the electronic medical record, and the Unit Clerk was not informed through the usual process. Staff interviews highlighted inconsistencies in the ordering and documentation process, leading to the deficiency.
Failure to Provide and Document COVID-19 Vaccine Education, Consent, and Declination
Penalty
Summary
The deficiency involves the facility’s failure to ensure that when COVID-19 vaccine was available, each resident was properly offered the vaccine, educated on its risks and benefits, and had their decision and education accurately documented in the medical record, as required by facility policy and regulation. The facility’s COVID-19 Vaccine Policy stated that residents who decline vaccination would provide a written affirmation indicating they were offered and declined the vaccine, that vaccination fact sheets would be made available prior to administration, and that informed consent (written or verbal) would be obtained from all individuals being vaccinated. However, the policy did not specify the minimum documentation requirements for the medical record, and in practice, the facility did not consistently obtain or record signed declinations or evidence of education. For one resident reviewed in detail, Resident #3, who had diagnoses including psoriatic arthritis, COPD, and depression and was documented as cognitively intact, the Vaccination Review: Consent/Declination SNF Resident Form showed verbal consent for influenza and a documented decision to decline the COVID-19 vaccine. The declination statement on the form was not signed, and there was no documentation of verbal declination. There was also no evidence in the record that this resident received education regarding the risks and benefits of the COVID-19 vaccine. In interview, Resident #3 stated they wanted to receive the COVID-19 vaccine, reported never receiving written or verbal education about it, and stated they had not signed a declination. An Immunization Audit Report later documented that this resident refused the COVID-19 vaccine on a specific date and that no education was provided. Further review of 34 additional resident Vaccination Review: Consent/Declination forms for residents indicated to have declined the COVID-19 vaccine revealed there were no signed declinations and no documentation that Vaccine Information Sheets or other education on risks, benefits, and potential side effects had been provided to the residents or their representatives. Staff interviews confirmed that when residents declined vaccinations, the declination section of the form should have been completed with a signature or verbal declination notation and that education on risks and benefits should have been provided and documented. The Assistant DON/Infection Preventionist acknowledged responsibility for providing vaccination education but had no evidence that such education was completed, and a former unit manager stated they did not provide vaccination education or obtain consents/declinations for a prior influenza/COVID-19 clinic. Leadership interviews further confirmed expectations that both consent and declination statements be signed when applicable and that risks versus benefits be reviewed prior to obtaining decisions, which did not occur as required in these cases.
Failure to Obtain Proper Consent for COVID-19 and Influenza Vaccinations
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to refuse treatment and to obtain proper consent for immunizations, specifically COVID-19 and influenza vaccines, for two residents reviewed for immunizations. Facility policies for COVID-19 and influenza vaccination required that residents and/or resident representatives receive vaccine information sheets, be educated on risks and benefits, and that informed consent (written or verbal) be obtained prior to administration, with vaccination remaining voluntary. New York State regulations and federal resident rights documents cited in the report state that residents have the right to refuse medication and treatment after being fully informed, and that legal guardians or health care proxies have the right to make important decisions on the resident’s behalf when the resident lacks capacity. Resident #1 had diagnoses including Alzheimer’s disease, vascular dementia, and a prior stroke, with the MDS documenting moderate cognitive impairment. The resident’s care plan showed multiple advance directives, including a MOLST, Health Care Proxy, and Power of Attorney, with a goal that the resident’s wishes be honored. A Determination of Incapacity for Medical Decision-Making documented that the resident lacked capacity and that the Health Care Proxy/Agent had been informed of this determination by two medical providers. Despite this, a Vaccination Review: Consent/Declination form recorded that the Assistant Director of Nursing/Infection Preventionist obtained verbal consent directly from the resident for influenza and COVID-19 vaccines, and the vaccines were administered. The Immunization Audit Report also showed prior refusals of other immunizations by the family/resident, and the order summary confirmed active Health Care Proxy status and vaccine orders. The resident’s Agent/Surrogate later stated they were responsible for medical decisions, were not asked for consent, were only notified after the vaccines were given, and would have declined them. The previous Unit Manager stated that Resident #1 lacked capacity, had documentation of incapacity, and that the spouse should have been called; they further stated that the Assistant DON/Infection Preventionist went room to room obtaining verbal consents from residents without verifying capacity, resulting in vaccinations against the Health Care Proxy’s wishes. Resident #2 had diagnoses including dementia, encephalopathy, and COPD, with the MDS documenting severe cognitive impairment. The care plan described the resident as moderately impaired in decision making and referenced a cognitive level tool indicating Level 4 (moderately impaired). There was no initial documentation of capacity determination or advance directives in the care plan, but later orders showed that a Health Care Proxy was activated with an effective date prior to the vaccination clinic. The Vaccination Review: Consent/Declination form documented that the Assistant DON/Infection Preventionist obtained verbal consent from the resident for influenza and COVID-19 vaccines, and the vaccines were administered. The Immunization Audit Report and order summary confirmed the vaccines were given and that a Health Care Proxy order was in place. The Social Worker stated that a BIMS score under 12 indicated lack of capacity, that Resident #2 did not have the ability to make decisions, and that the Health Care Agent made decisions and should have been notified for vaccinations. The Assistant DON/Infection Preventionist stated they obtained consents verbally from residents and by phone from proxies, that it was not legal to vaccinate without proper consent, and acknowledged they did not document family consent for Resident #2 and should have done so. Resident #2’s Health Care Agent reported that vaccination consent was not discussed with them, they were unaware the vaccines were given, and that the resident would not have understood what they were consenting to. The DON, Administrator, and Medical Director all stated that capacity should be assessed (e.g., via BIMS and capacity forms), that if a resident lacks capacity the responsible party or Health Care Proxy must make decisions, and that residents who lack capacity should not receive vaccinations without proxy consent. These facts collectively demonstrate that the facility failed to ensure residents’ rights to refuse treatment and to obtain appropriate consent from authorized representatives before administering vaccines to two cognitively impaired residents.
Inaccurate Documentation of Third-Party Vaccine Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical record documentation regarding vaccine administration for three residents. Facility policies required that residents receive immunizations from a licensed facility nurse per physician orders, that administration be documented on the Medication Administration Record (MAR), and that vaccines given by non-facility staff be entered as historical documentation in the electronic medical record’s immunization module. Policies also required that medications never be out of the sight of the nurse administering them and that nurses document administration on the MAR immediately after giving the medication, observing the five rights of medication administration. For one resident with Alzheimer’s disease, vascular dementia, and a history of stroke, the MAR for a specified month documented that an LPN administered both a COVID-19 vaccine and an influenza vaccine on a particular date. The Immunization Audit Report showed both vaccines as completed on that date, with incomplete documentation of the COVID-19 vaccine location and administrator, and the influenza vaccine recorded as given in the left deltoid by the Assistant Director of Nursing/Infection Preventionist. For a second resident with dementia, encephalopathy, and COPD, the MAR documented that another LPN administered both COVID-19 and influenza vaccines on the same date, and the Immunization Audit Report showed both as completed, but with incomplete information on the injection site and who administered them. For a third resident with psoriatic arthritis, COPD, and depression, the MAR documented that the same LPN administered an influenza vaccine on that date, and the Immunization Audit Report showed the influenza vaccine as completed in the left deltoid with the administrator field incomplete; this resident was documented as having refused the COVID-19 vaccine. Interviews established that an outside clinic/pharmacist, not facility nurses, actually administered the influenza and COVID-19 vaccines during a Flu/COVID clinic. The Assistant Director of Nursing/Infection Preventionist stated that the pharmacist administered the vaccines and that the correct order type in the electronic medical record should have been “Outside agency Medication/Vaccine Administration,” not a standard MAR medication order. One LPN reported that the outside agency did not have MAR access and that, after verifying which vaccines residents received, they signed the MAR, even though they generally do not sign for medications they did not administer and did not witness one resident’s vaccinations. Another LPN stated they did not administer any vaccines that day and were only entering orders, despite being listed on the MAR as the administering nurse. Other nursing staff and leadership stated that nurses should not document administration of medications they did not give or did not witness, and the Administrator confirmed that nurses should not sign for medications they did not prepare or administer. Despite this, the MAR and immunization records reflected facility nurses as the administering staff or left the administrator field incomplete, while the vaccines were actually given by a third party, resulting in inaccurate medical record documentation.
Deficient Catheter Care and Documentation
Penalty
Summary
A deficiency was identified regarding the care and management of an indwelling Foley catheter for one resident. The resident, who had a history of severe intellectual disabilities, hydronephrosis, urinary retention, and recurrent urinary tract infections, was observed multiple times with the urinary drainage bag positioned above the level of the bladder while seated in a wheelchair. The bag was attached to the wheelchair armrest, contrary to facility policy and standard practice, which require the drainage bag to be kept below bladder level to prevent backflow of urine. Additionally, the resident was not wearing a urinary collection leg bag as specified in the care plan when out of bed. Record review revealed that there were no provider orders in place for the indwelling Foley catheter, including orders for its care or for scheduled catheter changes, despite hospital discharge instructions specifying monthly changes. The resident's comprehensive care plan and Kardex contained inaccuracies, such as references to a suprapubic catheter and nephrostomy tube that the resident did not have. The care plan was not updated to reflect the resident's current urinary status or device needs, and staff interviews confirmed a lack of awareness and follow-through regarding the required catheter care and documentation. Staff interviews further indicated that responsibilities for updating care plans, obtaining provider orders, and ensuring accurate documentation were not consistently fulfilled. Nursing staff and aides were unclear about the correct use of leg bags and the proper placement of drainage bags, and there was a lack of communication regarding changes in the resident's condition and device requirements. The facility's failure to ensure appropriate catheter care, accurate care planning, and proper provider orders led to the identified deficiency.
Verbal Abuse of Resident by Certified Nurse Aide
Penalty
Summary
A deficiency occurred when a certified nurse aide verbally abused a resident during the early morning hours. The aide was witnessed by another resident yelling at the resident, stating that the world did not revolve around them and that they were not special, while also expressing frustration about having other residents to care for. The resident who was the subject of the yelling had diagnoses including congestive heart failure, hypertension, and diabetes mellitus, and was documented as cognitively intact, alert, and oriented. The incident was corroborated by the resident's roommate, who observed the aide's loud and boisterous tone and described the aide as verbally nasty and overcorrecting during care. Multiple interviews with other residents and staff confirmed concerns about the aide's behavior. One resident expressed fear of the aide and described the aide as wanting residents to adapt to their routine. Another resident described the aide's attitude as unpleasant. Staff interviews, including those with an LPN, RN Unit Manager, social worker, and the Director of Nursing, all acknowledged that yelling at residents constituted verbal and mental abuse and was inappropriate. The resident affected by the incident reported feeling disappointed and hurt by the aide's actions. The facility's policies and state regulations require protection of residents from all forms of abuse, including verbal and mental abuse. The investigation confirmed that the aide's conduct was intentional, verbally abusive, and in violation of resident rights. The incident was documented and verified through resident statements, witness accounts, and staff interviews, establishing that the resident was not protected from verbal abuse as required.
Failure to Report Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist reported irregularities in the drug regimen review for a resident who was prescribed and administered an antibiotic for an excessive duration. The Consultant Pharmacist did not identify or report the prolonged use of Doxycycline Monohydrate, which had been prescribed since November 2020 without an end date. The facility's policy required the pharmacist to assess medication regimens monthly for appropriateness and to report any irregularities, including excessive duration and inadequate indications for use. However, there was no evidence of recommendations made to the provider regarding the continued use of the antibiotic from November 2022 through May 2024. The resident involved had diagnoses including osteomyelitis, pressure ulcers, and schizophrenia, and was documented to have severe cognitive impairment. The comprehensive care plan did not reflect the long-term use of antibiotics, and the Director of Nursing was unaware of the resident's antibiotic use. Interviews with the Pharmacy Consultant and the Chief Nursing Officer revealed a lack of communication and failure to identify and report the irregularities, which was expected as part of the pharmacist's role. The deficiency was identified during a standard survey, highlighting a failure in the facility's medication management and antibiotic stewardship program.
Failure to Monitor Antibiotic Use in Resident with MRSA
Penalty
Summary
The facility failed to ensure that its infection control program included protocols and a system to monitor antibiotic use, as evidenced by the case of a resident who had been receiving Doxycycline Monohydrate for lifelong suppression of Methicillin-Resistant Staphylococcus Aureus (MRSA) since 11/22/20. The resident, who had severe cognitive impairment and multiple diagnoses including osteomyelitis and pressure ulcers, was not monitored or tracked by the Infection Preventionist or the Antibiotic Stewardship Program. The facility's policy required that antibiotic usage be tracked and reported to the Infection Prevention and Control Committee, but this was not done for the resident in question. Interviews with facility staff revealed a lack of awareness and monitoring of the resident's antibiotic use. The Pharmacy Consultant stated that an Antimicrobial Days of Therapy Report was generated monthly and sent to the Administrator, who was expected to share it with relevant staff. However, the Registered Nurse/Infection Preventionist and the Director of Nursing were unaware of the resident's prophylactic antibiotic use, as it did not appear on the facility's monitoring dashboard. The Chief Nursing Officer acknowledged that there was no process in place to review the pharmacy's report, which contributed to the oversight in monitoring the resident's antibiotic use.
Failure to Review and Renew Advanced Directives
Penalty
Summary
The facility failed to ensure that the system for managing advanced directives was implemented in accordance with the residents' wishes, specifically for one resident. The Medical Orders for Life-Sustaining Treatment (MOLST) form for this resident had not been reviewed or renewed since a specified date, despite the facility's policy requiring such reviews at least every 60 days or upon changes in orders. This oversight was identified during a standard survey, which included observations, interviews, and record reviews. The resident in question had a history of cognitive communication deficit, hemiplegia, hemiparesis following a stroke, and type 2 diabetes mellitus. Despite having moderate cognitive impairment, the resident was understood to have expressed a desire for their advance directives to be honored throughout their stay. However, during an interview, the resident expressed a wish to receive CPR, indicating a potential discrepancy between their current wishes and the documented MOLST orders, which included a DNR order and other limitations on medical interventions. Interviews with facility staff, including a Physician Assistant, Social Worker, Registered Nurse Unit Manager, and the Director of Nursing, revealed a lack of consistent review and renewal of the MOLST forms. The staff acknowledged the importance of regularly reviewing these orders to ensure they align with the residents' current wishes and to prevent any medical interventions that might contradict those wishes. The deficiency was further highlighted by the absence of evidence in the social services progress notes that the resident's advanced directives had been reviewed during a specified period.
Medication Labeling and Expiration Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, specifically in the Unit 4 medication storage room. During an observation, it was found that the refrigerator contained four opened multi-dose vials of Tubersol solution, three of which were undated, and one was outdated. Additionally, the medication storage room cabinet contained expired over-the-counter medications, including liquid Acetaminophen, Sorbitol Solution, and Multi-Vite Liquid. The facility's policy required that only authorized personnel access the medication rooms, and the manufacturer's instructions for Tubersol solution specified that opened vials should be discarded after 30 days. Interviews with staff revealed a lack of adherence to labeling and expiration protocols. A Licensed Practical Nurse admitted to not labeling a new bottle of Tubersol when opened. The Shipping/Receiving Manager stated they were responsible for stocking over-the-counter medications but not refrigerator medications, which were the responsibility of the Pharmacy Technician. The Pharmacy Consultant emphasized the importance of dating multi-dose vials and discarding them after 28 days. The Pharmacy Technician and the Unit Manager both acknowledged the responsibility of nurses to check for expired or unlabeled medications. The Director of Nursing and the Administrator reiterated the expectation that all medication rooms and carts should be free of expired medications and that open vials should be labeled and dated.
Failure to Notify Resident and Family of Room Change and COVID-19 Diagnosis
Penalty
Summary
The facility failed to notify a resident and their responsible party of significant changes, including a room change and a positive COVID-19 test result. Specifically, the resident's room was changed on 11/30/23 without notifying the resident or their family member, as required by the facility's policy. Interviews with the social worker and the Director of Social Work confirmed that there was no documentation of notification, and the family member stated they were not informed of the room change. Additionally, the resident tested positive for COVID-19 on 12/17/23, but there was no evidence that the responsible party was notified. The family member discovered the resident's condition upon visiting the facility and expressed dissatisfaction with the lack of communication. Interviews with nursing staff and the Director of Nursing revealed that the unit manager should have notified the family immediately about the change in condition, but there was no documentation of such notification in the resident's records.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during personal care, as observed during a complaint investigation. The incident involved a resident with diagnoses including congestive heart failure, ischemic cardiomyopathy, and osteoarthritis, who was dependent on staff for toileting hygiene. During an observation, a Certified Nursing Assistant (CNA) initiated incontinent care for the resident but left the resident exposed and uncovered, visible to the hallway, when exiting the room. The resident expressed discomfort about being left exposed, and the CNA returned with another CNA to complete the care but again left the resident uncovered with the door open. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that all nursing staff were responsible for ensuring personal privacy during care to maintain residents' dignity. The CNAs involved acknowledged the failure to cover the resident and close the door, which compromised the resident's dignity and privacy. The facility's policies emphasized the importance of respecting residents' rights to privacy and dignity, which were not adhered to in this instance.
Delay in Radiology Services for Resident After Fall
Penalty
Summary
The facility failed to provide timely radiology services for a resident who required a lumbar x-ray following an unwitnessed fall. The resident, who had a history of dementia, hemiparesis, and repeated falls, was found on the floor complaining of lower back and elbow pain. Although x-rays for the elbow and sacral regions were ordered and completed, the lumbar x-ray was not performed until several days later, resulting in a delay in treatment. The deficiency was primarily due to a breakdown in communication and documentation processes. Registered Nurse #1 did not enter the x-ray orders into the electronic medical record, and the Unit Clerk was not informed of the new orders through the usual method of writing them in a designated book. This miscommunication led to the omission of the lumbar x-ray from the initial radiology request, despite the Nurse Practitioner having ordered it. Interviews with staff, including the Unit Clerk, Registered Nurse #1, the Nurse Practitioner, and the Director of Nursing, revealed inconsistencies in the process of ordering and documenting x-rays. The Director of Nursing acknowledged the communication breakdown, and the Medical Doctor confirmed that all x-rays should have been completed as ordered. The failure to obtain the lumbar x-ray promptly was identified as a deficiency in meeting the resident's needs.
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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