Grand Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bronx, New York.
- Location
- 700 White Plains Road, Bronx, New York 10473
- CMS Provider Number
- 335744
- Inspections on file
- 42
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 29 (2 serious)
Citation history
Health deficiencies cited at Grand Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective system to reconcile and verify methadone doses supplied by external opioid treatment programs, resulting in multiple residents with opioid use disorder receiving methadone under conditions where physician orders did not match the dosages on clinic-labeled bottles. Despite existing policies for controlled substances and medication administration, there was no specific policy, procedure, or formal agreement governing methadone from outside clinics, and staff did not receive or use clinic documentation to confirm current dosages. Nurses reported relying mainly on resident names on bottles and did not routinely compare bottle dosages to physician orders, while physicians and the consultant pharmacist described processes in which methadone orders were entered or signed based on bottle labels without independent verification. These systemic gaps led to repeated discrepancies between ordered and labeled methadone doses for numerous residents.
The facility failed to ensure methadone was administered according to physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Policy required nurses to use the eMAR as the source for medication administration and to verify the five rights, but methadone bottles for several residents carried doses that did not match the physician orders entered in the electronic record, despite daily administration being documented. Nursing staff reported either not cross-checking bottle dosages against orders or relying solely on the bottle label or resident familiarity, and they often did not notice discrepancies. The attending physician, DON, and medical director described a process in which the methadone clinic determined doses, nurses transcribed bottle labels or clinic information into the electronic record, and physicians signed orders without independent verification or direct clinic documentation, contributing to inconsistent and inaccurate methadone dosing information.
The medical director failed to provide adequate oversight of methadone medication management, including the development and implementation of procedures to safely reconcile and verify methadone received from external opioid treatment programs. Facility policy assigned the medical director responsibility for oversight of medical care practices and clinical standards, yet the medical director did not know how methadone was delivered, relied on methadone clinic reports entered by nursing staff into the EMR, and electronically signed orders without reviewing the source documentation. An attending physician reported having residents on methadone maintenance but was unsure of each resident’s correct dosage and stated that nurses administered the dose on the methadone bottle even when it did not match the physician’s order, demonstrating a lack of coordinated, standardized processes for methadone prescribing and administration.
A resident with severe cognitive impairment was found unable to stand and was later diagnosed with a hip fracture of unknown origin. The facility did not report this injury of unknown source to the State Department of Health within the required timeframe, resulting in a delay of ten days before notification.
A resident with severe cognitive impairment and a history of falls was repeatedly observed without required fall prevention interventions, including floor mats and a bed in the lowest position, despite these being specified in the care plan. Staff interviews confirmed that these interventions were not consistently implemented.
The facility did not report allegations of staff borrowing money from residents and failing to repay within required timeframes, and failed to submit follow-up investigation reports within five business days. In each case, the initial or follow-up reporting was delayed, and investigations could not substantiate the allegations due to inconsistent statements or lack of evidence. Leadership interviews revealed a lack of awareness of reporting requirements.
A resident with significant medical needs reported being threatened by two CNAs, but the allegation was not immediately communicated to supervisory staff as required by facility policy. The Director of Recreation documented the report but failed to notify the DON or Administrator directly, resulting in a delayed investigation and lack of immediate protective measures.
The facility did not transfer the personal funds of two deceased residents to the probate jurisdiction within the required 30-day period, as confirmed by record review and staff interviews. The Payable Coordinator and Administrator acknowledged the delay but could not explain why the transfers were not completed on time.
A resident with multiple complex diagnoses exhibited restlessness, a stuffy nose, and a low-grade fever. Despite these changes, staff did not document notifying the physician or performing a follow-up assessment after administering acetaminophen. The resident later expired from cardiac arrest, and the physician was only notified post-mortem. This failure to follow assessment and notification protocols resulted in actual harm.
A resident with severe cognitive impairment and multiple medical conditions became restless and developed a low-grade fever. Staff documented the symptoms, notified the RN Supervisor, and administered Tylenol, but did not inform the resident's representative or physician of the change in condition, as required by policy. Interviews confirmed the family was not notified, and there was no evidence of reassessment after treatment.
The facility did not maintain required temperature levels, with all sampled resident rooms and common areas found below regulatory standards, some as low as 40 to 53°F. Multiple residents filed complaints and grievances about cold conditions, and maintenance logs documented ongoing heating issues. The Administrator and Medical Director were unaware of the extent of the problem, and the facility lacked proper maintenance contracts and failed to address vendor recommendations for boiler repairs, resulting in Immediate Jeopardy and Substandard Quality of Care.
The facility did not ensure safe and comfortable temperatures in resident rooms and common areas due to lack of heat, with all sampled areas below regulatory requirements. The Administrator was unaware of the issue, and there was no evidence of routine maintenance for boiler and PTAC units. The Director of Maintenance was unable to secure vendor services due to unpaid balances, and the Administrator denied receiving vendor communications about necessary repairs. These failures resulted in Immediate Jeopardy.
The facility failed to maintain its boiler system, resulting in malfunctioning heating equipment and temperatures in resident rooms and common areas falling below regulatory requirements. Despite multiple vendor proposals and reports of insufficient heat, the facility did not act to address the boiler deficiencies, and only a portion of the boilers were operational. Staff interviews revealed that maintenance requests were hindered by unpaid bills and lack of administrative approval, and the Administrator was unaware of the extent of the heating problem.
Two residents were involved in an altercation due to inadequate supervision, resulting in one resident sustaining head lacerations. Despite known behavioral issues, the facility failed to update care plans or ensure proper monitoring, leading to the incident.
A facility failed to review and revise comprehensive care plans for three residents after significant events. A resident's care plan for an indwelling catheter was not updated after an ER visit for urinary retention. Another resident's care plan for behavior and victimization was not revised after a physical abuse incident, lacking evidence of required monitoring. A third resident's care plan was not reviewed following a physical altercation. The DON acknowledged the oversight in care plan updates.
The facility failed to provide sufficient nursing staff, particularly CNAs, leading to delays in resident care, especially during evenings and weekends. Residents reported long wait times for assistance with personal care, and staffing schedules consistently showed fewer CNAs than required. Staff interviews confirmed the challenges in maintaining adequate care due to staffing shortages, with agency staff often not showing up for work.
The facility failed to conduct annual performance reviews for CNAs, as required by their policy. A review of personnel files showed no evidence of such reviews for five CNAs. Interviews revealed that the responsibility for these evaluations fell through the cracks due to personnel changes, leading to the deficiency noted by surveyors.
The facility failed to administer resources effectively, leading to repeated deficiencies in staffing, infection control, and care quality. The administration and Director of Nursing were aware of staffing issues but did not adequately address them, resulting in unmet resident needs and unmonitored previous citations. The Director of Nursing was unaware of specific care issues, including infection control and care plan updates.
The facility lacked an active governing body to implement management policies, leading to deficiencies in resident care. Inconsistent communication between the Administrator and Governing Body hindered effective management. Residents reported delayed call light responses and insufficient staffing, especially on weekends, with no prompt action or follow-up on their concerns.
The facility's QAPI program failed to identify and prioritize issues, resulting in widespread deficiencies in Nursing Services, Administration, and Infection Control. Repeated deficiencies from past surveys were noted, and the facility lacked documented evidence of corrective actions. Interviews revealed a lack of awareness and oversight by the Director of Nursing, Administrator, and Operator/Owner, contributing to the ongoing issues.
The facility failed to maintain infection control practices during medication administration. An LPN did not sanitize the blood pressure machine and cuff after using them on multiple residents. Similarly, an RN did not sanitize the glucometer after finger stick blood sugar tests and failed to perform hand hygiene. Another LPN also neglected to sanitize the blood pressure equipment after use. Despite receiving education on these practices, staff did not adhere to the facility's policy requiring equipment cleaning between uses.
Two residents in an LTC facility did not receive regular showers as per their care plans, leading to a deficiency. One resident, with Cerebral Palsy and Depression, preferred showers at a later time, but this was not accommodated, resulting in missed showers. Another resident, with Non-Alzheimer's Dementia and Bipolar Disorder, also did not receive showers according to the schedule. Staff interviews revealed communication gaps and lack of awareness about the residents' preferences and care needs.
A resident with a history of healed pressure ulcers and a care plan for a pressure ulcer relieving device was found with a deflated air mattress on multiple occasions. Despite the resident's complaints of pain, the facility staff failed to address the issue, and there was no documentation of the use of pressure relieving devices. Interviews revealed a lack of awareness and communication among staff regarding the mattress issue.
A resident with behavioral issues, including stealing and involvement in altercations, did not receive necessary behavioral health care and services. The facility failed to evaluate intervention effectiveness, update care plans, and ensure consistent monitoring. Staff interviews revealed a lack of coordination and awareness in managing the resident's behavior.
The facility failed to store insulin pens properly, as observed during a survey. Insulin pens for four residents were stored together in a medication cart, contrary to the facility's policy requiring separate storage to ensure sanitation. A nurse admitted the oversight, while the DON stated there was no requirement for individual storage, indicating a lack of consistent policy implementation.
A resident with cerebral palsy and depression did not have their bathing preferences honored, as the facility failed to provide scheduled showers and instead gave bed baths without documented refusal. The resident preferred evening showers, but this was not communicated or reflected in their care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's preferences, contributing to the deficiency.
The facility failed to ensure accurate documentation in the MDS assessments for three residents, leading to discrepancies in their recorded statuses. A resident's discharge status was inaccurately documented, another's Schizophrenia diagnosis was omitted, and a third resident's behavioral symptoms were not recorded despite a physical altercation. The MDS Coordinator acknowledged these oversights, reflecting a failure to adhere to the facility's policy for comprehensive assessments.
The facility did not submit the required direct care staffing information for Quarter 3 of 2024 on time, as required by CMS. The Director of Human Resources and the Administrator were responsible for ensuring the submission, but an oversight led to the failure to meet the deadline.
The facility failed to maintain adequate staffing levels, leading to compromised resident care. Staffing schedules showed consistent shortages of LPNs and CNAs, particularly on weekends. Staff and residents reported delayed care, with Registered Nurse Supervisors covering LPN duties and residents experiencing delayed medication and inadequate incontinence care. The Assistant Administrator acknowledged the issue but was unclear on staffing adjustments, and the Director of Nursing did not provide further clarification.
The facility failed to properly dispose of garbage, with surveyors observing uncovered and overflowing dumpsters, scattered trash, and flies. Interviews revealed unclear responsibility for maintaining the garbage area, with the Director of Housekeeping and Administrator unaware of the issues.
The facility failed to provide consistent hot water for bathing and hygiene across all units, with water temperatures significantly below the required level and some areas lacking water flow. Residents reported being washed with cold water for months, and maintenance logs confirmed ongoing issues. Despite temporary measures like providing wipes, the deficiency persisted, indicating inadequate response.
The facility did not comply with food safety standards as kitchen staff were observed not wearing hairnets, contrary to the facility's policy. The policy requires all food service personnel to wear hairnets to maintain cleanliness. The issue was confirmed by the Cook and Food Service Director, and the Administrator acknowledged it as a new problem.
A resident with a diabetic foot ulcer did not receive the recommended wound treatment due to a lack of communication and documentation by the nursing staff. Despite recommendations from an Infectious Disease consultant and a podiatrist, there were no treatment orders documented, and the resident's care plan did not address the wound. Interviews revealed that the RN supervisor failed to notify the attending physician, and the LPN was unaware of the wound due to the absence of written orders.
A resident with a diabetic foot ulcer did not receive proper evaluation and treatment due to the facility's failure to ensure the attending physician reviewed and authenticated specialist recommendations. Despite consultations with an Infectious Disease specialist and a podiatrist, there was no documentation of the attending physician or nurse practitioner evaluating the wound or entering treatment orders. A communication lapse between the nurse practitioner and registered nurse contributed to this deficiency.
The facility did not post nurse staffing information daily from January to May 2024, particularly on weekends. The policy assigned the staffing coordinator to post schedules but did not specify nurse staffing data. Interviews revealed confusion over weekend posting responsibilities, with the Staffing Coordinator and RN Supervisor providing conflicting accounts. The DON confirmed daily posting requirements, and the Administrator considered it an isolated incident.
Two residents in the facility did not receive prescribed medications as per their care plans. One resident missed a dose of Lantus Insulin due to being asleep, and the physician was not notified. Another resident did not receive an antibiotic infusion for bacteremia as ordered upon hospital discharge. Despite multiple medication reviews, the antibiotic was not administered. These incidents indicate a failure in the facility's medication administration and communication processes.
The facility failed to provide quarterly financial statements to two residents, despite their cognitive ability and significant balances in their Personal Needs Accounts. Interviews revealed gaps in the process, with no proof of receipt or mailing of the statements.
The facility failed to ensure professional standards of quality for a resident with a PICC line. There was no documentation of the PICC in the resident's chart, nor evidence of dressing changes or site monitoring. Staff interviews revealed a lack of awareness and documentation regarding the PICC line.
A facility failed to document blood sugar levels for a diabetic resident as required by physician's orders. The issue was due to an error in the electronic medical record system, which did not allow nurses to enter the blood sugar results. The nursing staff performed the tests but could not document them, and the administration was unaware of the problem until the survey.
Failure to Reconcile and Verify Methadone Doses from External Opioid Treatment Programs
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain a system to accurately reconcile, verify, and oversee methadone medications received from external opioid treatment programs. Facility policies on controlled substance handling, medication administration, and consultant pharmacist services required accurate receipt, logging, and administration of controlled drugs, as well as verification of the five rights of medication administration using the electronic MAR and prescription labels. However, the facility had no policy or procedure specific to methadone received from opioid treatment programs and could not provide any documented agreement outlining coordination with those programs. Surveyors identified 10 residents, all diagnosed with opioid use disorder and various comorbidities such as endocarditis, heart failure, anemia, asthma, coronary artery disease, diabetes, hypertension, cerebral infarction, schizophrenia, benign prostatic hypertrophy, and viral hepatitis, whose methadone administration records showed discrepancies between physician orders and the dosages labeled on methadone bottles. In several cases, the physician’s order reflected a lower dose than the bottle label (for example, 60 mg ordered vs. 70 mg labeled, 115 mg ordered vs. 125 mg labeled, 80 mg ordered vs. 90 mg labeled, 120 mg ordered vs. 130 mg labeled, and 280 mg ordered vs. 295 mg labeled), while in other cases the physician’s order reflected a higher dose than the bottle label (for example, 40 mg ordered vs. 30 mg labeled, 95 mg ordered vs. 85 mg labeled, 30 mg ordered vs. 24 mg labeled, 20 mg ordered vs. 30 mg labeled, and 90 mg ordered vs. 80 mg labeled). Despite these discrepancies, the MARs documented administration of the physician-ordered doses, and controlled drug accountability records, when present, reflected the physician-ordered doses rather than the doses indicated on the clinic-supplied bottles. Interviews with nursing staff and medical providers revealed that methadone from the external clinics was handled without systematic reconciliation against physician orders or clinic documentation. Nurses reported that residents were escorted to methadone clinics, and the escort returned with labeled methadone bottles that were handed to the unit nurse, who logged only the number of bottles in the controlled drug record and stored them in a locked box. Nurses stated they did not receive paperwork from the clinics to verify dosage or changes, did not cross-check the dosage on the bottle against the physician’s order, and often relied only on the resident’s name on the bottle or familiarity with the resident. The attending physician stated that orders were entered by nurses based on the bottle labels and then signed, that they did not receive physical or electronic orders from the clinics, and that they were unsure of the correct methadone dosages but believed residents must receive the dosage indicated on the bottle and that the physician’s order and bottle label did not necessarily need to match. The consultant pharmacist reported that regimen reviews were limited to medications dispensed from the linked pharmacy and that there was no way to verify the correctness of methadone orders from the clinics. The Medical Director acknowledged not knowing the delivery process, stated that clinic reports were signed without review, and later characterized the situation as a system failure. The Administrator stated that nurses were responsible for reconciling physician orders with methadone regimens on the bottles and that attending physicians should have performed monthly record reviews to identify discrepancies. This combination of missing policies, lack of formal agreements, and staff practices resulted in methadone dosages that were inconsistent between physician orders and clinic-labeled bottles for multiple residents. The situation was determined to have caused no actual harm but posed a likelihood for serious harm that constituted Immediate Jeopardy to residents receiving methadone maintenance therapy.
Removal Plan
- The Director of Nursing reviewed all residents receiving methadone from an external opioid treatment program, confirmed residents with dosage discrepancies, and clinically assessed those residents with no signs/symptoms of toxicity or adverse reactions.
- The Director of Nursing contacted each methadone clinic to confirm the current prescribed methadone dose and frequency.
- The Director of Nursing contacted the Medical Director and obtained telephone orders to ensure the physician orders correspond with the doses on the methadone bottles.
- The Pharmacy Consultant completed a regimen review of residents prescribed methadone and confirmed discrepancies were corrected and no other discrepancies were identified.
- The facility created and implemented a new policy and procedure for methadone administration, order verification, reconciliation, and chain of custody, including use of a Reconciliation and Chain of Custody Receipt Form completed by the methadone clinic, reconciliation by the receiving licensed nurse against the facility physician order, escalation/verification steps for discrepancies, documentation in nursing progress notes, and retention of forms in a binder in the nursing office.
- All licensed nurses, attending physicians, the pharmacy consultant, and facility escorts received in-service training on the new policy.
Methadone Dosing Discrepancies and Failure to Verify Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure methadone was administered in accordance with physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Facility policy required that medication administration and documentation be timely and accurate, that the eMAR serve as the source for pouring and administering medications, and that licensed nurses verify the five rights by comparing the medication name, strength, route, and dosage schedule on the MAR against the prescription label. Despite this, a review of methadone administration records for 23 residents on methadone identified 10 residents whose methadone bottles were labeled with doses that did not match the physician’s orders entered in the electronic medical record. For these 10 residents, the physician’s orders and bottle labels showed consistent discrepancies in methadone dosages, although the eMARs documented administration of the ordered doses. Examples included residents with diagnoses such as endocarditis, heart failure, anemia, asthma, coronary artery disease, schizophrenia, viral hepatitis, and opioid use disorder. One resident had a physician’s order for 60 mg daily while the bottle was labeled 70 mg; another had an order for 115 mg while the bottle was labeled 125 mg; another had an order for 80 mg with a bottle labeled 90 mg. Additional residents had orders for 40 mg with a bottle labeled 30 mg, 95 mg with a bottle labeled 85 mg, 30 mg with a bottle labeled 24 mg, 20 mg with a bottle labeled 30 mg, 120 mg with a bottle labeled 130 mg, 280 mg with a bottle labeled 295 mg, and 90 mg with a bottle labeled 80 mg. All of these residents had methadone orders documented in the eMAR and received daily methadone doses as charted, but the labeled bottle doses did not match the physician orders. Interviews with nursing staff and medical leadership revealed systemic process failures and inconsistent practices in verifying methadone doses. An LPN stated that when administering methadone, they checked the physician’s order in the electronic record and then administered methadone labeled with the resident’s name, but did not cross-check the dosage on the bottle against the physician’s order and had not noticed discrepancies. An RN reported only checking the resident’s name on the bottle and not the physician’s order or dosage, explaining that they were familiar with the residents, despite acknowledging they were supposed to ensure the bottle dosage matched the order. Other RNs stated they followed the dosage on the bottle without comparing it to the physician’s order and had not noticed differences. Interviews with the attending physician, DON, and medical director further described a lack of clear communication and documentation processes between the facility and the methadone clinic. The attending physician stated that the methadone clinic prescribed the dosage and frequency, that they did not receive physical or electronic orders from the clinic, and that nurses entered orders into the electronic record from the bottle labels, which the physician then signed without knowing the intended methadone dose for each resident. The attending physician also stated that the physician’s order and the bottle dosage did not necessarily need to match for nurses to administer the medication. The DON reported that residents went to the methadone clinic to pick up medication, returned it to the unit nurse, and that the nurse called the attending physician with the dosage and entered the order, with no receipt or paperwork from the clinic. The medical director stated that the clinic sent a report with dosages and frequencies, that nurses entered this into the electronic record, and that they signed orders without reviewing the report, later characterizing the situation as a system failure due to lack of established processes and communication.
Failure of Medical Director Oversight for Methadone Medication Management
Penalty
Summary
The deficiency involves the failure of the medical director to collaborate with the facility to develop and implement procedures for the safe and accurate provision of methadone medications received from external opioid treatment programs. The facility’s policy on Physician Visits and Physician Delegation stated that the medical director’s role is to provide oversight of medical care practices, regulatory compliance programs, and clinical standards. Despite this, the medical director did not ensure that current standards of practice were followed for reconciling, verifying, and overseeing methadone medications from methadone clinics. Surveyor interviews revealed that an attending physician acknowledged having residents on methadone maintenance programs but stated they were unsure of the methadone dosage each resident was supposed to receive and that nurses were to administer the dosage indicated on the methadone bottle, even if it did not match the physician’s order. The medical director stated they did not know the process by which methadone was delivered to the facility and that the methadone dosage was determined by the methadone clinic, which sent a report to the facility. The medical director reported that nurses entered this information into the EMR as physician orders, which the medical director electronically signed without reviewing the clinic report, and that their only responsibility was to assess residents and renew orders. In a follow-up interview, the medical director characterized the lack of established processes and communication between the facility and the methadone clinic as a system failure.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving injury of unknown source were reported immediately, as required by policy and regulation. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia and diabetes, was found unable to stand on their left leg and was transferred to the hospital, where a closed left hip fracture was diagnosed. The resident was unable to explain how the injury occurred, and there was no documentation of a fall or traumatic event. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the New York State Department of Health until ten days after the change in the resident's condition was observed. Record review and interviews revealed that the delay in reporting was due to a lack of immediate notification to the Director of Nursing by the nursing supervisor. The Director of Nursing only became aware of the fracture after the resident was readmitted from the hospital and subsequently reported the injury. The facility's investigation did not find evidence of abuse, mistreatment, or neglect, and there was no documentation that the fracture was pathological. However, the failure to report the injury of unknown source within the required timeframe constituted a deficiency.
Failure to Provide Required Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident identified as being at risk for falls received adequate supervision and assistive devices as outlined in their care plan. Specifically, the resident, who had diagnoses including schizoaffective disorder, dementia, and anxiety disorder, was assessed as having severely impaired cognition and significant functional limitations. The resident's care plan required the bed to be maintained in the lowest position and the use of bilateral floor mats to prevent falls. Despite these interventions being documented, multiple observations showed the resident's bed was in the highest position and no floor mats were present. These observations occurred on more than one occasion, and staff confirmed that floor mats were not in use in the resident's room. The resident had a documented history of multiple falls, with incidents occurring both on and off the floor mats, and was known to be non-compliant and to get up independently. The facility's policies required individualized fall prevention interventions and regular monitoring by nursing supervisors to ensure compliance with care plans. However, interviews with staff, including a CNA and the DON, revealed that the required interventions were not consistently implemented, resulting in the resident being left without the necessary fall prevention measures as specified in their care plan.
Failure to Timely Report and Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting and follow-up of alleged misappropriation of resident property to the State Survey Agency as required by regulations. In three cases involving residents with intact cognition and various medical diagnoses, allegations were made that staff members borrowed money from residents and did not repay it. The facility did not report one of these allegations to the New York State Department of Health within the required 24-hour timeframe, and in all cases, failed to submit the required Follow-Up Investigation Reports within five business days of the incidents. For one resident with depression and opioid abuse, an allegation was made that a patient care assistant borrowed money several months prior and did not repay it. The initial report to the state was delayed, and the follow-up investigation report was also submitted late. The facility's investigation could not substantiate the allegation due to inconsistent statements and lack of corroborating evidence. Another resident with cerebral palsy, anxiety disorder, and hypertension reported a similar incident involving a certified nursing assistant. While the initial report was timely, the follow-up investigation report was again submitted late, with the investigation unable to confirm the allegation due to lack of witnesses and denial by the staff member involved. Interviews with facility leadership revealed a lack of awareness regarding the specific reporting timelines for both initial and follow-up reports. The Director of Nursing and the Administrator both indicated they were either unaware of the requirements or the late submissions, and delays were attributed to the need for additional information and difficulty contacting involved staff. Facility policy and state guidance both require immediate reporting and timely completion of investigations, which were not followed in these cases.
Failure to Immediately Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple medical conditions, including Multiple Sclerosis, Hemiplegia, and Adjustment Disorder. The resident, who had intact cognition and required assistance with activities of daily living, reported to the Director of Recreation and a nursing supervisor that two Certified Nursing Assistants had threatened to slap them if they pressed the call bell again. The Director of Recreation documented the allegation but did not immediately report it to the appropriate supervisory staff, citing a lack of specific details such as the staff member's name or the date of the incident. Instead, the written statement was placed in the mailboxes of the Social Worker and, purportedly, the Director of Nursing, but was not directly communicated to them. As a result, the Social Worker and Director of Nursing were not made aware of the allegation until several days later, delaying the initiation of an internal investigation. The facility's policy required immediate reporting and prompt initiation of investigations into abuse allegations, but this process was not followed. There was no documented evidence that an investigation was started until days after the initial report, and no immediate measures were put in place to protect the resident from further potential abuse.
Failure to Timely Transfer Deceased Residents' Personal Funds
Penalty
Summary
The facility failed to transfer the personal funds of two deceased residents to the probate jurisdiction administering their estates within the required 30-day period. According to the facility's admission agreement, refunds for the balance in a resident's personal account, after deducting any amounts owed to the facility, are to be made to the resident after discharge or, in the case of death, to the probate jurisdiction or by a New York small estate affidavit, unless otherwise claimed by the Department of Social Services. Record review showed that for two residents who had expired, there was no disbursement of their remaining funds or final accounting sent to the Public Administrator within the required timeframe. Interviews with facility staff revealed that the Payable Coordinator is responsible for reviewing monthly reports to identify residents who have been discharged or have expired and who have a balance left in their accounts. The Payable Coordinator acknowledged that the funds for the two deceased residents were not transferred within 30 days but could not provide an explanation for the delay. The Administrator confirmed the process for transferring funds after a resident's death but also indicated that the required transfer did not occur within the specified period for these cases.
Failure to Assess and Notify Physician After Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a comprehensive clinical assessment was performed to identify changes in a resident's condition and did not provide treatment and care in accordance with professional standards. The resident, who had a history of severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, traumatic brain injury with epilepsy, and incontinence, was observed with symptoms including a stuffy nose, low-grade fever of 100.5°F, and restlessness. Despite these changes, there was no documented evidence that the medical doctor was notified of the resident's elevated temperature and restlessness. Additionally, after acetaminophen was administered for the fever, there was no documentation of a follow-up assessment to evaluate the resident's response to the medication. Multiple staff interviews confirmed that the resident appeared weaker and was experiencing changes in condition, but the required notifications and assessments were not consistently documented or performed. The medical doctor was only informed after the resident had expired due to cardiac arrest secondary to coronary artery disease. The facility's policy required timely identification, documentation, and response to significant changes in a resident's condition, but these procedures were not followed, resulting in actual harm to the resident.
Failure to Notify Representative and Physician of Resident Condition Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's designated representative and physician of significant changes in the resident's condition. The resident, who was severely cognitively impaired and had multiple diagnoses including epilepsy, non-Alzheimer's dementia, depression with schizophrenia, traumatic brain injury, and incontinence, exhibited restlessness and developed a low-grade fever of 100.5°F. Certified Nursing Assistant observed the resident appearing weaker and reported this to the LPN, who documented the symptoms and administered Tylenol. The Registered Nurse Supervisor was notified and attempted to contact the medical doctor without success. However, there was no documentation that the resident's representative or family was informed of these changes, as required by facility policy and state regulation. Interviews with staff confirmed that the family was not notified because the resident was not perceived to be in distress, and there was no evidence of reassessment after Tylenol administration. The Director of Nursing acknowledged that both the physician and family should have been notified when the resident exhibited fever and restlessness. The lack of notification and documentation constituted a failure to comply with the facility's policy and regulatory requirements for informing representatives of significant changes in a resident's condition.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels throughout the building, as required by federal and state regulations. Observations during the survey revealed that all sampled resident rooms, corridors, and stairwells on five resident floors had temperatures below the required range, with some areas as low as 40 to 53 degrees Fahrenheit. Multiple complaints and grievances were filed by residents regarding the loss of heat over a period of time, and maintenance logbooks documented ongoing heating issues in 23 resident rooms. Despite these reports, there was no documented evidence that the facility had identified or addressed unsafe room temperatures. The Administrator was unaware of the loss of heat or that room temperatures had dropped below regulatory standards, and stated that the PTAC units were not necessary because the boiler was supposed to provide heat. However, maintenance records and vendor invoices indicated that the boiler system was not functioning properly, with only 5 of 13 boilers operational at one point, and that the facility had not maintained an active service contract for preventive maintenance. Vendor communications documented repeated recommendations and proposals for repairs and maintenance that were not addressed by the facility. Staff interviews confirmed that the heating issues were discussed in meetings and that activities staff were called in to distribute hot drinks due to the cold conditions. The Medical Director was not aware of the heat-related issues, and temperature logs maintained by the facility were incomplete, lacking specific room or corridor information. The facility's failure to maintain adequate heating resulted in Immediate Jeopardy and Substandard Quality of Care, affecting all residents in the building.
Removal Plan
- Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs revealed temperatures within acceptable ranges.
- Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas.
- The Administrator provided a vendor contract to provide annual maintenance to boilers, and for the maintenance of Packaged Terminal Air Conditioner units.
- The facility completed staff training on identifying and addressing temperature related issues, procedures for reporting issues, deploying emergency measures, and ensuring resident comfort. All staff received the in-service.
- Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the temperature.
- The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues.
Failure to Maintain Safe Temperatures and Boiler Maintenance
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in residents' rooms and common areas, as required by State and Federal regulations. Six resident grievances were filed over several days regarding lack of heat, and observations confirmed that temperatures in all sampled rooms, corridors, and stairwells were below required ranges. The Administrator was not aware of the loss of heat in the building during this period. Additionally, there was no documented evidence that the boiler room equipment and Packaged Terminal Air Conditioner (PTAC) units were routinely maintained. The PTAC units were found to be incorrectly connected and not providing heat, and the boilers were not functioning adequately due to lack of maintenance. The Director of Maintenance reported that attempts to have the boilers serviced were unsuccessful because the vendor refused to come due to overdue unpaid balances, and all requests for materials or services required prior approval from the Administrator. The vendor confirmed that the boilers had significant issues from lack of maintenance and were operating at only 40% capacity, with proposals for repairs sent to both the Administrator and Director of Maintenance. Despite this, the Administrator denied receiving any such communications. These failures resulted in Immediate Jeopardy due to the likelihood of more than minimal harm to all residents.
Removal Plan
- The Administrator is conducting meetings with department heads to review any issues.
- Staff have been in-serviced, a policy was created on how agency staff will also be in-serviced.
- Morning meetings attended by all department heads are being conducted.
- Resident council meeting was rescheduled.
- The Administrator provided documentation of regular rounds.
- A binder of Vendor Documents was created and placed at the Security Desk by the elevators.
- Emergency Preparedness plan for loss of heating was revised and discussed at the QAPI meeting, the Administrator is the Acting Director of Maintenance.
Failure to Maintain Boiler System Results in Inadequate Heating
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically neglecting routine maintenance of the boiler system. The annual service contract for the boilers had expired, and the facility did not have a current contract in place. Multiple proposals and quotes from vendors to address identified boiler deficiencies and to provide ongoing maintenance were not acted upon by the facility. Invoices and service records showed repeated reports of insufficient heat and hot water, with only a fraction of the boilers functioning at any given time. The lack of maintenance led to the heating system malfunctioning, resulting in inadequate heating throughout the building. Observations during the survey revealed that temperatures in resident rooms, corridors, and stairwells were below the required state and federal ranges, with some areas measured as low as 40 degrees Fahrenheit. Resident rooms closest to the stairwells had the lowest temperatures. There was no documented evidence that the facility staff were inspecting or maintaining the heating system equipment, including the boilers and Packaged Terminal Air Conditioner (PTAC) units. The Director of Maintenance confirmed that the PTAC units were not blowing hot air due to incorrect connections and that the Administrator had been made aware of the issue. Interviews with the Director of Maintenance, the Administrator, and the boiler vendor revealed that the vendor had stopped servicing the facility due to unpaid bills, and that the Director of Maintenance was not permitted to order services or materials without prior approval from the Administrator. The Administrator was unaware of the extent of the heating issues and the low temperatures in resident rooms. The vendor reported that the boilers were operating at only about 40% capacity due to lack of maintenance, which contributed to the insufficient heat and hot water throughout the building.
Removal Plan
- Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs revealed temperatures within acceptable ranges.
- Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas.
- The Administrator provided a vendor contract for annual boiler maintenance and the maintenance of Packaged Terminal Air Conditioner units.
- The facility completed staff training on identifying and addressing temperature-related issues, procedures for reporting problems, deploying emergency measures, and ensuring resident comfort. 100% of staff received the in-service.
- A Quality Assurance meeting was held to discuss the findings of the Immediate Jeopardy. Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the thermometers.
- The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by an incident involving two residents. Resident #118, who had a history of stealing and involvement in physical altercations, was not adequately supervised or monitored despite staff awareness of their behavior. On August 2, 2024, Resident #118 snatched a $20 bill from Resident #151's hand in an elevator, leading to Resident #151 hitting Resident #118 on the head with a cane. This altercation resulted in Resident #118 sustaining head lacerations that required emergency medical intervention, including 14 staples. The facility's policy on Abuse Prohibition and Prevention, which was reviewed in May 2023, mandates a zero-tolerance approach to abuse and requires the provision of a safe environment for all residents. However, the facility's investigation into the incident revealed that there was cause to believe resident abuse had occurred. Despite the policy's requirements, there was no documented evidence that the care plans for either resident were reviewed or updated following the incident. Resident #151 had a care plan for victimization, but it lacked evidence of evaluation or revision after the altercation. Similarly, Resident #118's care plan, which included interventions for behavior monitoring and safety, was not updated, and there was no evidence of the required close observation or 1:1 monitoring. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, highlighted a lack of consistent monitoring and supervision of Resident #118, particularly when they left their assigned unit. Staff members were aware of Resident #118's behavior issues, such as stealing and wandering to other units, but there was no clear protocol for monitoring the resident's movements or ensuring their safety. The Director of Social Services acknowledged the altercation but indicated that the responsibility for monitoring and intervention lay with the nursing department. The Director of Nursing confirmed awareness of Resident #118's behavioral issues but did not provide a clear response on how the resident was monitored when leaving their unit.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised periodically and after each assessment, including both comprehensive and quarterly review assessments. This deficiency was evident in the cases of three residents. Resident #84's care plan for an indwelling catheter was not reviewed and revised after returning from an emergency room visit due to urinary retention and pain at the catheter insertion site. Additionally, the care plan was not updated after quarterly assessments and the annual assessment. Resident #118's care plan interventions for behavior and victimization were not reviewed and evaluated after a resident-to-resident physical abuse incident. The care plan lacked updates following the incident where Resident #118 was hit in the head by another resident. Furthermore, there was no documented evidence of close observation or 1:1 monitoring as stated in the care plan interventions. Resident #151's care plan interventions were not reviewed and evaluated following a resident-to-resident physical altercation. The care plan for victimization was not updated after the incident, and there was no evidence of the interventions being reviewed. The Director of Nursing acknowledged that the nurse supervisor is responsible for updating the care plans, but the oversight was not addressed.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents, as evidenced by observations, record reviews, and interviews conducted during the Recertification and Abbreviated Survey. Several residents reported a shortage of Certified Nursing Assistants (CNAs), particularly during evenings and weekends, leading to delays in assistance with toileting, bathing, and personal care. The facility's staffing schedules from July to November 2024 consistently showed fewer CNAs than required, with some shifts having only one CNA for units with up to 45 residents. Interviews with residents revealed significant delays in response times to call bells, with some residents waiting up to four hours for assistance. Residents expressed frustration over the lack of timely help, which sometimes resulted in missed showers and inadequate personal care. Staff interviews corroborated these findings, with CNAs and nurses acknowledging the staffing shortages and the resulting challenges in providing adequate care. The facility's staffing plan indicated a need for 4 CNAs per unit during day and evening shifts and 3 during night shifts. However, actual staffing often fell short of these numbers, with agency staff frequently not showing up for work. The Director of Nursing and the Administrator acknowledged the staffing issues, citing challenges in hiring and retaining staff, particularly due to better pay offered by staffing agencies. Despite efforts to improve staffing, the facility continued to struggle with maintaining adequate levels of care.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews for Certified Nursing Assistants (CNAs) were conducted at least once every 12 months, as required by their policy. This deficiency was identified during a Recertification Survey conducted from November 13 to November 21, 2024. The facility's policy, dated June 2024, mandates annual performance reviews for nurse aides, but a review of personnel files for five CNAs showed no documented evidence of such reviews. Interviews with the Director of Human Resources and the Director of Nursing revealed that the CNAs were hired years ago, and no performance reviews could be located in their files. The Director of Nursing could not explain the absence of these reviews. The Administrator acknowledged that the Nursing Department is responsible for conducting these evaluations and attributed the oversight to personnel changes within the facility, which led to the responsibility of performance reviews being neglected. The facility's assessment tool, dated October 2024, indicated that performance reviews should provide structured feedback and identify areas for improvement, but it did not specify the frequency of these reviews. This lack of adherence to policy and oversight resulted in the deficiency noted by the surveyors.
Inadequate Administration and Staffing Deficiencies
Penalty
Summary
The facility was found to be inadequately administered, failing to use its resources effectively and efficiently to ensure the highest practicable well-being of its residents. The administration did not maintain sufficient staffing levels to meet residents' needs, and there was a lack of monitoring and enhancement of care quality, as evidenced by repeated deficiencies from previous surveys. These deficiencies included issues with activities of daily living, medication storage, infection control, and performance evaluations for nursing assistants. The administration was aware of the staffing issues but did not provide evidence of efforts to retain staff or monitor previous citations to prevent recurrence. The Director of Nursing was also aware of the staffing issues but did not understand the extent of their impact on resident care and services. During interviews, the Director of Nursing admitted to being unaware of several issues, including infection control problems, deflated mattresses, and outdated care plans. The Director of Nursing also could not explain how residents with behavioral issues were supervised when off the unit. The Administrator acknowledged the repeated staffing deficiency and mentioned contracting staffing agencies to fill positions, but was unaware of the newly identified issues, considering them isolated incidents.
Lack of Active Governing Body and Inadequate Resident Care
Penalty
Summary
The facility was found to lack an active governing body responsible for establishing and implementing management policies, as evidenced by multiple deficiencies identified during the Recertification and Complaint Survey. There was inconsistent communication between the facility Administrator and the Governing Body, which hindered effective management and regulatory compliance. The facility's policy on Quality Assurance and Performance Improvement (QAPI) indicated that the Governing Body is accountable for the program, including identifying and prioritizing problems and ensuring corrective actions are effective. However, the Operator/Owner of the facility admitted to attending QAPI meetings only once a year, relying on the Administrator to submit monthly reports, which suggests a lack of active oversight. During a Special Resident's Council Meeting, residents reported that call lights were not answered promptly, especially on weekends, and they were often left in bed due to insufficient staffing. These concerns were previously raised in an August 2024 Resident Council meeting, where issues such as staff using cell phones, poor customer service, and room cleanliness were also noted. The residents expressed that the facility did not act promptly on their concerns, and there was no follow-up from the staff, indicating a failure in addressing and resolving resident issues effectively.
Inadequate QAPI Program and Oversight Lead to Widespread Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems and opportunities for improvement. This was evident during the Recertification and Complaint Survey, where widespread deficiencies were noted in Nursing Services, Administration, and Infection Control. The facility also had repeated deficiencies from previous surveys, indicating a lack of effective corrective action. The QAPI plan, last revised in May 2023, was intended to guide the facility in improving the quality of care and resident life, but the facility could not provide documented evidence of systems and reports for identifying, reporting, investigating, analyzing, and correcting these deficiencies. Interviews with facility staff revealed a lack of awareness and oversight regarding the deficiencies. The Director of Nursing was unaware of the infection control issue, attributing it to an isolated incident and new staff. The Administrator acknowledged awareness of staffing issues but claimed other issues were isolated and not previously known. The Operator/Owner attended QAPI meetings only once a year and relied on the Administrator for compliance, indicating insufficient oversight by the governing body. This lack of effective governance and oversight contributed to the facility's failure to address and rectify ongoing deficiencies.
Infection Control Deficiency in Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed during the recertification survey. Specifically, Licensed Practical Nurse #4 did not sanitize the blood pressure machine and cuff after using them on Residents #69, #47, and #92. This oversight occurred despite the facility's policy requiring equipment shared between residents to be cleaned and disinfected after each use to prevent cross-contamination. Licensed Practical Nurse #4 acknowledged forgetting to sanitize the equipment after each use. Similarly, Registered Nurse #5 did not sanitize the glucometer after using it for finger stick blood sugar tests on Residents #412 and #87. The nurse also failed to perform hand hygiene after removing gloves and before leaving the residents' rooms. Although Registered Nurse #5 was aware of the requirement to clean the glucometer after each use, they did not adhere to this practice during the observed instances. Additionally, Licensed Practical Nurse #1 did not sanitize the blood pressure machine and cuff after using them on Residents #7 and #74. Despite having received education on the necessity of cleaning the equipment after each use, Licensed Practical Nurse #1 admitted to missing this step. The Director of Nursing and Infection Prevention Nurse confirmed that licensed nurses had received in-service education on cleaning equipment between resident usage.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services and assistance to maintain grooming and personal hygiene. This deficiency was identified during a Recertification and Complaint Survey, where it was found that two residents, Resident #48 and Resident #169, were not provided regular showers according to their care plans. The facility's policy required that residents be offered showers as specified in their care plans, but this was not adhered to for these residents. Resident #48, diagnosed with Cerebral Palsy and Depression, required substantial assistance for showering and had a care plan specifying showers twice a week. However, records showed that Resident #48 received only bed baths on certain dates and not the scheduled showers. Interviews revealed that Resident #48 preferred showers at a later time, but this preference was not accommodated, and there was a lack of communication among staff regarding the resident's preferences and care needs. Resident #169, with diagnoses including Non-Alzheimer's Dementia and Bipolar Disorder, was also dependent on staff for bathing. The care plan specified showers twice a week, but records indicated that showers were not consistently provided according to the schedule. Staff interviews highlighted a lack of awareness and communication regarding the resident's shower schedule, contributing to the failure to provide the necessary care. The Director of Nursing acknowledged the issue but could not explain why the residents did not receive showers as per their care plans.
Failure to Maintain Pressure Relief Mattress for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure ulcers received care consistent with professional standards to prevent pressure ulcers. This deficiency was identified for a resident with a history of healed pressure ulcers who had a care plan for using a pressure ulcer relieving device when in bed. The resident was observed with a deflated air mattress on three occasions, which was not addressed by the facility staff despite the resident's complaints of pain and discomfort. The facility's policy required regular inspection and maintenance of mattresses, including specialized pressure relief mattresses. However, there was no documentation of the use of pressure relieving devices for the resident, and the maintenance log did not record any entries regarding the deflated mattress. Interviews with staff revealed a lack of awareness and communication regarding the mattress issue, with the primary Certified Nursing Assistant unaware of the deflation, and the Maintenance Director stating that the maintenance department does not oversee mattresses. The Wound Care Nurse was only notified of the issue after the surveyor's observation, and a leak was found in the mattress.
Failure to Provide Adequate Behavioral Health Care and Monitoring
Penalty
Summary
The facility failed to ensure that Resident #118 received necessary behavioral health care and services, as evidenced by multiple incidents of behavioral symptoms such as stealing from other residents and involvement in resident-to-resident altercations. The facility did not evaluate the effectiveness of interventions to address the resident's behavior, lacked an individualized approach in the care plan, and failed to monitor and supervise the resident adequately. The care plan for victimization/aggressive behavior was not updated following an altercation on 08/02/2024, and there was no documented evidence of close observation or 1:1 monitoring as required by the care plan. Resident #118 was admitted with diagnoses including violent behavior, unspecified mood disorder, and Parkinson's disease, which contributed to moderate cognitive impairment and required supervision with most activities of daily living. Despite these needs, the facility's care plans were not effectively implemented or updated to address the resident's ongoing behavioral issues. The care plans included interventions such as identifying triggers, room changes, and psychiatric evaluations, but these were not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and coordination in monitoring Resident #118's behavior. Certified Nursing Assistants and Licensed Practical Nurses acknowledged the resident's behavior issues but did not consistently monitor or redirect the resident when they left their unit. The Director of Social Services and the Director of Nursing were aware of the resident's behavior but did not ensure that appropriate interventions were in place or that care plans were updated. This lack of coordination and documentation contributed to the facility's failure to provide necessary behavioral health care and services to Resident #118.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that all medications and biologicals were stored safely, specifically concerning the storage of insulin pens. During a recertification survey, it was observed that insulin pens belonging to four different residents were stored together in a compartment in the top drawer of a medication cart on the 5th floor. This storage method did not comply with the facility's policy, which requires medications to be stored in accordance with manufacturer's specifications and professional standards to ensure proper sanitation. A registered nurse administering medications acknowledged the oversight, stating that the insulin pens should have been stored separately in individual plastic bags but were not due to being busy. However, the Director of Nursing contradicted this by stating there was no requirement to store insulin pens in individual plastic bags. This discrepancy highlights a lack of consistent understanding and implementation of the facility's medication storage policy.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination by not supporting their bathing preferences. Resident #48, who has cerebral palsy and depression, was assessed as cognitively intact and required substantial assistance for bathing. The resident expressed a preference for showering, which was documented as somewhat important in their assessment. However, the facility did not document the resident's bathing preferences in their care plan, and the resident's scheduled showers were not consistently provided. Instead, the resident received bed baths on several occasions without evidence of refusal or preference for this alternative. Interviews with staff revealed a lack of awareness and communication regarding the resident's preferences. Certified Nursing Assistants reported that the resident sometimes refused showers due to the early schedule, preferring evening showers instead. However, this preference was not communicated to or acknowledged by the nursing staff, and the resident's care plan was not updated to reflect this change. The Director of Nursing confirmed that the shower schedule could be adjusted based on resident preferences, but this was not done for Resident #48, leading to the deficiency.
Inaccurate Documentation in MDS Assessments
Penalty
Summary
The facility failed to ensure accurate documentation in the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their recorded statuses. Resident #462's discharge status was inaccurately documented as being discharged to a short-term general hospital, while the nursing progress notes indicated the resident was discharged to the community. The MDS Coordinator acknowledged this oversight during an interview. Resident #311's diagnosis of Schizophrenia was omitted from the quarterly MDS assessment, despite being documented in the Hospital and Community Patient Review Instrument and a psychiatric evaluation. The MDS Coordinator expressed caution in coding Schizophrenia due to a memorandum from the Centers for Medicare and Medicaid Services, although the new psychiatrist did not diagnose Schizophrenia. Resident #118's behavioral symptoms were not documented in the MDS assessment, despite an incident where the resident was involved in a physical altercation after grabbing money from another resident. The Director of Nursing confirmed that the MDS Coordinator was responsible for the accuracy of the assessment. These inaccuracies in the MDS assessments reflect a failure to adhere to the facility's policy, which mandates a standardized and comprehensive assessment process to ensure proper care delivery and resident-centered care planning.
Failure to Submit Direct Care Staffing Data Timely
Penalty
Summary
The facility failed to submit the required direct care staffing information for Quarter 3 of 2024 in a timely manner, as mandated by the Centers for Medicare and Medicaid Services (CMS). According to the CMS Electronic Staffing Data Submission Payroll-Based Journal, facilities are required to submit direct care staffing information, including agency and contract staff, based on payroll and other auditable data. This data must be submitted quarterly and received by the end of the 45th calendar day after the last day of each fiscal quarter to be considered timely. However, the facility did not submit the necessary data for the period from April 1 to June 30, 2024, by the specified deadline. During interviews conducted as part of the Recertification Survey, the Director of Human Resources stated that they are responsible for ensuring all time management records of staff are completed and sent to the Administrator for submission. The Administrator, who is responsible for submitting the Payroll Based Journal, acknowledged awareness of the deadline but could not explain the failure to submit the data, attributing it to an oversight. This oversight resulted in non-compliance with the CMS requirements for timely submission of staffing data.
Staffing Shortages Compromise Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, compromising their safety and well-being. The facility's staffing levels were consistently below the minimum levels assessed as necessary to provide adequate care. The staffing policy outlined the required number of licensed nurses and nurse aides, but the actual staffing schedules for April, May, and June 2024 showed repeated shortages, particularly on weekends. Interviews with staff and residents confirmed these deficiencies, with reports of inadequate staffing leading to delayed care and unmet needs. On specific dates, the facility experienced significant shortages of both Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs). For instance, on June 9, 2024, there were only 15 CNAs on the day shift against a required 20, and similar shortages were noted on other days. Staff interviews revealed that Registered Nurse Supervisors often had to perform the duties of LPNs due to these shortages. Additionally, the facility's Assistant Administrator, who also served as the Assistant Director of Nursing, acknowledged the staffing issues but was unclear on how adjustments were made according to the staffing policy. Residents reported negative impacts due to the staffing shortages, such as delayed medication administration and inadequate incontinence care. One resident mentioned waiting longer for medication on weekends and staying in bed due to insufficient staff to assist with transfers. Another resident expressed concerns about the lack of nurse aides, leading to delays in receiving care. The facility's Director of Nursing did not provide further clarification on the staffing procedure, indicating a lack of effective communication and management in addressing the staffing deficiencies.
Improper Garbage Disposal and Lack of Responsibility
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a Recertification Survey. The surveyors noted that the dumpster outside the facility was not covered, and various types of garbage were scattered on the ground around it. Items such as broken food service carts, an air conditioning unit, and wooden pallets were found lying next to the dumpster. Additionally, an overflowing garbage bin contained furniture, laundry containers, and computers, while an uncovered recycling bin had clear plastic bags with exposed cans and cardboard boxes. Flies were observed around the dumpster, indicating a lack of proper containment. Interviews with facility staff revealed a lack of clarity regarding responsibility for maintaining the garbage disposal area. The Director of Housekeeping stated that garbage pickup was scheduled for specific days and believed there was no need to cover bins containing non-perishable items. They also mentioned that the kitchen staff shared responsibility for maintaining the garbage bins. The Administrator was unaware of the garbage disposal issues and stated that the dumpster should not contain perishables, and lids should always be closed. It was unclear who was responsible for maintaining the garbage disposal area, contributing to the deficiency.
Inadequate Hot Water Supply in Facility
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the lack of consistent hot water supply across all six units observed during the recertification survey. The issue persisted from April through June, with maintenance logs indicating multiple entries of hot water supply problems. Observations revealed water temperatures significantly below the required 110 degrees Fahrenheit, with some shower rooms having no water flow or pressure. Residents reported being without hot water for months, and some were washed with cold water, highlighting the facility's failure to address the ongoing issue effectively. Interviews with staff and residents further confirmed the deficiency. The Maintenance Director acknowledged ongoing boiler repairs, while the Director of Nursing mentioned providing wipes to residents as a temporary measure. Despite these efforts, the Administrator claimed no resident complaints were received, contradicting resident statements during the Resident Council Meeting. The facility's inability to provide a policy on loss of hot water and the recurrence of the issue indicate a lack of adequate response to the deficiency.
Non-Compliance with Food Safety Standards
Penalty
Summary
The facility failed to ensure that food was prepared in accordance with professional standards for food service safety, as observed during the Recertification Survey. Specifically, kitchen staff were seen not wearing hairnets in the kitchen, which is a violation of the facility's policy. The policy, last reviewed in February 2024, mandates that all food service personnel maintain high standards of personal cleanliness and wear hairnets or coverings that cover all hair while working. On two separate occasions, dietary workers were observed without hair coverings in the kitchen areas. Interviews with the Cook and the Food Service Director confirmed that it is mandatory for kitchen staff to wear hairnets and beard protectors. The Administrator acknowledged that the Food Service Director is responsible for ensuring compliance with this policy and stated that this was a new issue for the facility.
Failure to Provide Recommended Foot Care for Diabetic Ulcer
Penalty
Summary
The facility failed to provide appropriate foot care and treatment for a resident with a diabetic foot ulcer, as per professional standards of practice. The resident, who had diagnoses of Diabetes Mellitus with Foot Ulcer and Peripheral Vascular Disease, did not receive the recommended wound treatment from both an Infectious Disease consultant and a podiatrist. The resident was observed with a yellow-stained and soiled gauze dressing on their left foot, indicating a lack of proper wound care. The deficiency was further highlighted by the absence of a comprehensive care plan and appropriate interventions to address the resident's foot wound. Despite recommendations for a topical antibiotic ointment and hydrogel dressing, there were no documented treatment orders in the resident's records. The nursing staff failed to document and communicate the necessary treatment orders to the attending physician, resulting in the resident not receiving the prescribed care. Interviews with the nursing staff and medical personnel revealed a breakdown in communication and responsibility. The Registered Nurse supervisor did not notify the attending physician of the consultation recommendations, and the Licensed Practical Nurse was unaware of the resident's wound due to the lack of written orders. The Director of Nursing and Medical Director both indicated that the responsibility for following up on consultation recommendations was not adequately fulfilled, leading to the deficiency in care.
Failure to Review and Authenticate Treatment Recommendations for Diabetic Ulcer
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and authenticated treatment recommendations for a resident with a diabetic foot ulcer. The resident, who had diagnoses of Diabetes Mellitus with Foot Ulcer and Peripheral Vascular Disease, was seen by an Infectious Disease consultant and a podiatrist. However, there was no documented evidence that the attending physician or nurse practitioner evaluated the resident's wound or reviewed the treatment recommendations provided by these specialists. This lack of documentation spanned from early April to early June, during which time no treatment orders were entered for the resident's wound. The facility's policies required the attending physician to authenticate orders from consulting physicians, but this was not adhered to in the case of the resident's diabetic ulcer. Interviews with the nurse practitioner and attending physician revealed a communication breakdown, as the nurse practitioner was not informed of the consultation recommendations by the registered nurse, preventing the entry of necessary treatment orders. Consequently, the resident's wound care was not properly managed according to the recommendations provided by the specialists.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily, as required, during the period from January 2024 through May 2024. The facility's policy, effective August 2023, assigned the responsibility of posting the daily schedule to the staffing coordinator but did not explicitly include the posting of nurse staffing data. A review revealed that there were no postings available for Saturdays and Sundays during the specified period. Interviews conducted during the survey indicated a lack of clarity regarding responsibility for weekend postings. The Staffing Coordinator stated that the Registered Nurse Supervisor was responsible for posting on weekends, while Registered Nurse #4, the weekend supervisor, stated they were not given this responsibility. The Director of Nursing confirmed that nurse staffing information must be posted daily and that Registered Nurse Supervisors were responsible for weekend postings. The Administrator mentioned that the posting board had been moved to a noticeable location and considered the issue an isolated incident.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified during a complaint survey for two residents. The first resident, diagnosed with Diabetes Mellitus, did not receive their prescribed Lantus Insulin at the scheduled time because they were asleep. There was no documentation indicating that the physician was notified of the missed dose, which is a requirement when a medication is missed or refused. Interviews with the resident and staff revealed that the nurse responsible for the oversight no longer worked at the facility, and the Director of Nursing was unaware of the incident. The second resident, who was admitted with hospital discharge orders for an antibiotic intravenous infusion for bacteremia, did not receive the prescribed antibiotic. The hospital discharge summary included a prescription for a 4-week course of antibiotics, but the facility's records showed no evidence that the antibiotic was ordered or administered. Despite multiple reviews and reconciliations of medications by the nurse practitioner and physician, the antibiotic was not included in the orders or administered. Interviews with the nursing staff and the Director of Nursing indicated that the discharge medication orders were typically reviewed and reconciled, but in this case, the antibiotic was overlooked. These deficiencies highlight a failure in the facility's medication administration process, where critical medications were not administered as prescribed, and there was a lack of communication and documentation regarding missed doses. The facility did not adhere to the required protocols for notifying physicians of missed medications, which is essential for maintaining the residents' health and safety.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to ensure that individual financial records were made available to residents and/or their representatives through quarterly statements and upon request. This deficiency was identified during a recertification survey conducted from 12/18/23 to 12/22/23. Specifically, there was no documented evidence that quarterly statements were provided to two residents, Resident #72 and Resident #131, out of 35 residents reviewed for Personal Funds. Both residents were cognitively intact and had significant balances in their Personal Needs Accounts (PNA) over the reviewed periods, but neither received the required quarterly financial statements. Interviews with the residents and staff revealed gaps in the process of distributing these statements. Resident #131 confirmed they had not received any financial statements and expressed a desire to receive them. The Human Resources/Payroll Manager indicated that the Account Receivables Department was responsible for preparing the statements, which were then given to the Director of Social Work to distribute. However, the Director of Social Work admitted that while statements were supposed to be provided quarterly, there was no system in place to obtain proof of receipt or mailing. The Administrator also confirmed that statements were given based on the residents' cognitive status but did not provide evidence of compliance with the policy.
Failure to Document and Monitor PICC Line for Resident
Penalty
Summary
The facility failed to ensure that the services provided met professional standards of quality for Resident #205, who was observed with a Peripherally Inserted Central Catheter (PICC) in their right arm on two occasions. There was no documentation in the resident's chart about the presence of the PICC, nor was there any evidence that the PICC dressing was changed or that the site was monitored for infection. The facility's policy required weekly flushing and dressing changes for PICC lines, but these were not documented for Resident #205. Additionally, the Comprehensive Care Plan (CCP) for antibiotic therapy did not indicate the name and route of administration for the antibiotic, and the physician's orders did not document the type of intravenous access or include orders for PICC dressing changes, flushing, or monitoring for infection. Interviews with staff revealed a lack of awareness and documentation regarding Resident #205's PICC line. The Assistant Director of Nursing, who completed the resident's admission assessment, could not recall if the resident had a PICC. The charge nurse on the unit acknowledged the presence of the PICC but admitted to not documenting it. The Nurse Practitioner stated that the Medical Doctor would document any intravenous access, and Registered Nurses were responsible for putting in orders for PICC care. The Director of Nursing confirmed that the facility had a protocol for PICC lines, which included orders for flushing, dressing changes, and monitoring the site, but could not explain why these orders were not in place for Resident #205.
Failure to Document Blood Sugar Levels for Diabetic Resident
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically for a resident with Diabetes Mellitus. The resident had a physician's order to perform fingerstick blood tests twice daily and notify the physician if the blood sugar levels were outside the specified range. However, the blood sugar results were not documented in the electronic Medication Administration Record (eMAR) from the time the order was given until the survey date. The last recorded blood sugar result was on 10/16/23, despite the order being dated 11/06/23. Interviews with the nursing staff and administration revealed that the nurses were performing the fingerstick tests but were unable to document the results due to an error in the electronic medical record system. The error occurred because the order was entered without enabling the documentation feature for blood sugar levels. The Director of Nursing and the Assistant Director of Nursing were unaware of this issue until it was brought to their attention during the survey.
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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