Heritage Green Rehab & Skilled Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenhurst, New York.
- Location
- 3023 Route 430, Greenhurst, New York 14742
- CMS Provider Number
- 335721
- Inspections on file
- 16
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Heritage Green Rehab & Skilled Nursing during CMS and state inspections, most recent first.
Surveyors found that the facility used the DON as a charge/staff nurse to meet minimal staffing levels even when the census was well above 60 residents. Staffing records showed the DON was scheduled as the second nurse on a unit and, at times, functioned as the only nurse on that unit, despite a written requirement for two nurses per shift. The DON and scheduler reported that the DON regularly filled in as a CNA, housekeeper, or medication nurse when staffing was short, and the scheduler was unaware that the DON should not function outside the DON role under these census conditions.
The facility did not maintain enough nursing staff to meet resident needs across shifts. Residents and families reported long call bell waits, delayed toileting, missed or late meals, and difficulty getting help with transfers and feeding. Staff described working with only one or two aides on a unit, staying late to finish duties, and being unable to complete all care tasks on time. Observations showed delayed tray passing and a resident waiting on the toilet for an extended period before staff returned with a mechanical lift.
Surveyors found that side rails were not properly assessed, documented, or maintained for three residents. One resident had loose quarter rails on the bed even though the care plan said no rails, another had loose rails that were on the care plan but had no documented routine maintenance, and a third had a quarter rail up despite a care plan showing no rails. Staff and leadership stated the rails should have been identified through assessments, care plan review, and maintenance checks, but documentation was missing or inconsistent.
A resident with CHF, HTN, and COPD had potassium chloride left on the bedside table instead of being directly observed as taken, while the MAR documented the medication as administered. The resident said staff brought the pills in the morning and they saved them for later, and staff interviews confirmed the medication was left in the room without an order for self-administration. The DON and RN manager stated meds were not to be left unattended and nurses were expected to stay until all meds were taken.
A resident with CHF, HTN, and COPD had potassium chloride pills left unsecured in a small container on the bedside table without an order to self-administer or keep meds at bedside. Staff observed the pills there over multiple days, and both the RN manager and DON stated meds were not to be left with residents without a physician order.
Cold and unappetizing meals were served on two unit test trays after tray line delays and inconsistent temperature monitoring. Residents reported cold food, lukewarm coffee, poor taste, and small portions, while surveyors observed reheating, item substitutions, and a shortage of clean plates that delayed service. On both trays, pork and stuffing were served below expected hot-holding temperatures and were described as lukewarm, cold, dry, or lacking flavor.
Survey results were not posted in a readily accessible location and the binder was stored behind the reception desk with other binders, making it unavailable for residents and visitors to easily review. The binder contained only the most recent CMS-2567 and did not include all complaint investigation results with POCs for the past 3 years. Several residents stated they did not know where to find the survey results and wanted to review them.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
A resident who had declined the COVID-19 vaccine was mistakenly administered the vaccine after an LPN failed to verify the resident's identity according to facility policy. The error was confirmed by staff interviews and documentation, revealing a violation of the resident's right to refuse treatment.
DON Inappropriately Used as Charge Nurse at High Census
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the facility’s average daily census exceeded 60 residents, as required by 10 NYCRR 415.13(b)(1). The DON job description stated that the DON was responsible for planning, directing, and coordinating nursing services, managing resident care 24 hours a day, seven days a week, and ensuring a sufficient number of qualified supervisory and supportive nursing personnel on each tour of duty. Census reports showed that during the review period the facility census ranged from 113 to 116 residents, and at survey entrance the census was 115 out of 135 beds. Despite this census level, daily staffing sheets from late January to mid-February documented that the DON was counted in the facility’s minimum staffing numbers for direct resident care. On specific evening shifts, the DON worked on a named unit from 6:00 PM to 10:00 PM as the second nurse, and on one of those dates, from 9:21 PM to 10:00 PM, the DON was the only nurse on the unit. The facility’s minimal staffing document required two nurses on that unit for the day and evening shifts, and the DON was used to meet those minimums. In interviews, the Facility Scheduler stated they were unaware that the DON was not supposed to act outside the DON role and acknowledged that the DON was used as staff when coverage could not be found, noting that the minimum staffing numbers were not ideal for completing work and providing good care. The DON reported not knowing the exact regulation, believing the practice was merely frowned upon, and stated they frequently acted as a CNA, housekeeper, or medication nurse while remaining available as DON. The Administrator confirmed that minimum staffing numbers were not the goal and that leadership was willing to help staff and residents when needed.
Insufficient Nursing Staff and Delayed Resident Care
Penalty
Summary
The facility did not ensure sufficient nursing staff were available on a 24-hour basis to meet resident needs and maintain resident well-being. The facility assessment and QAPI review documented a 134-bed facility with a secure dementia unit, a long-term care unit, and a short-term rehab unit, and identified staffing needs based on resident acuity, census, odors, complaints, call lights, and staff ability to complete assignments. The staffing plan called for specific minimum numbers of nurses and nurse aides on each shift, but the daily staffing sheets showed the Director of Nursing was counted toward direct care staffing numbers. The facility was also rated one star for staffing in the PBJ report and triggered for low staffing levels on weekends. Residents and family members described long waits for call lights, delayed toileting assistance, missed or delayed meals, and difficulty getting help with transfers and other basic care. One resident reported waiting almost three hours for a call light to be answered and often making their own bed because staff did not get to it in time. Another resident reported waiting over an hour to use the bathroom and then incontinent in their brief because staff said they did not have enough help. A resident council meeting included multiple residents who agreed there were not enough CNAs in the building, and one resident stated two staff were sometimes not used for mechanical lift transfers even though two were required. Family members also reported long call bell wait times and concerns that residents were not getting to the bathroom in time. Observations and staff interviews showed delays in routine care and meal service that were linked to limited staffing. During a dining observation, a meal cart was delivered but trays were not started for several minutes, and staff and family reported food often sat too long before being passed, resulting in cold meals. A resident was observed waiting on the toilet for 34 minutes before staff returned with a mechanical lift. Staff repeatedly stated they were working with only one or two aides on a unit, had to stay late to finish work and documentation, and could not always complete showers, toileting, feeding, or transfers on time. The DON, Administrator, and other leaders acknowledged the minimum staffing was not ideal and that long call bell wait times and staffing concerns were ongoing.
Bed Rails Installed or Left in Place Without Proper Assessment, Care Planning, or Maintenance Documentation
Penalty
Summary
The facility failed to assess all residents for the risk of entrapment from bed rails before installation and failed to provide documentation of routine preventive maintenance for bed rails for three residents reviewed. The report also found that quarter side rails were installed in error for two residents and were not reflected on the care plan. The facility policy required side rail safety assessments on admission, quarterly reassessment for residents using side rails, discussion of risks and benefits, informed consent, and maintenance review to ensure the bed and rail system passed an entrapment assessment. One resident had diagnoses including wedge fractures, difficulty walking, and cognitive communication deficit. Although the resident’s care plan and prior side rail assessments documented no side rails, observations on multiple days showed gray plastic side rails on both sides of the upper portion of the bed. Both rails were loose and wobbly. The resident stated they used the bed rails to get into bed at night and had not seen anyone check the side rails. The resident’s daughter stated the rails had been on the bed the whole time. The DON stated the resident should not have had the side rails and that someone should have noticed they were present even though they were not on the care plan. A second resident had diagnoses including Fournier gangrene, diabetes mellitus, and morbid obesity. The resident’s care plan documented two upper side rails, and the side rail assessment documented the resident had two upper side rails and discussed entrapment risks with the resident/family. However, observations showed two gray quarter side rails up on both sides of the bed, and both were loose and wobbly. The resident stated they used the side rails for bed mobility and that the rails had been there for three years without anyone checking to ensure they were secured. A CNA later observed the rails and stated they were loose. A third resident had diagnoses including dementia, pneumonia, and anxiety. The resident’s care plan documented no side rails, and the side rail assessment also documented no side rails. Despite this, observations showed one quarter side rail up on the left side of the bed while the resident was asleep. Maintenance provided logs and worksheets, but the records showed no documented routine preventive maintenance for the side rails and no current entrapment check documentation. Maintenance staff stated they visually checked side rails every six months but had no documentation of routine inspections, and the DON stated maintenance should have kept track of preventive maintenance documentation.
Medication Left at Bedside and Documented as Administered
Penalty
Summary
Services provided by the facility did not meet professional standards of quality for one resident when prescribed medications were not administered as ordered and were left unattended at the bedside. Resident #82 had diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease, and was documented as cognitively intact, alert, and oriented x3. The care plan stated medications were to be administered as ordered, and the physician ordered Potassium Chloride 20 milliequivalents once daily in the morning. During observation, two yellow pills identified as potassium were seen on the resident’s bedside table in a small clear plastic container. The resident stated the nurses brought the medication in the morning and that they put it aside to take later before bed. Intermittent observations over several days continued to show the same two pills on the bedside table. The Medication Administration Record documented the potassium as administered on multiple mornings, even though the pills remained visible in the resident’s room. Interviews with nursing staff showed that one LPN stated the resident had pills left in the room and that the nurse did not check back to confirm all medications were taken. Another LPN stated the resident preferred to take potassium after breakfast and that the pills were left in the room, with follow-up later to witness ingestion. The RN manager and DON stated nurses were expected to stay with residents until all medications were taken, that medications were not to be left at the bedside without a physician order, and that Resident #82 did not have an order to self-administer potassium.
Unsecured Medication Left at Bedside Without Order
Penalty
Summary
Drugs and biologicals were not securely stored for one resident. Resident #82, who had diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease, was cognitively intact and documented as alert and oriented x3. The resident’s care plan stated medications were to be administered as ordered, but it did not document that the resident preferred or was able to self-administer medications. Physician orders reviewed for the relevant period did not include an order for self-administration or for medications to be left at the bedside. During observation, two yellow potassium chloride pills were seen in a small clear plastic container with a lid on the resident’s bedside table, and the resident stated the nurses brought the medication in the morning and the resident put it aside to take later before bed. The pills remained on the bedside table during repeated observations over several days. An LPN identified the pills as potassium chloride, another LPN stated the resident preferred to take the medication after breakfast and kept it in a container on the bedside table, and the RN manager and DON stated medications were not to be left with residents without a physician order and that Resident #82 did not have an order to self-administer medications.
Cold and Unappetizing Meals Served During Tray Line Delays
Penalty
Summary
Food and drink were not palatable and were not served at a safe and appetizing temperature for two of three unit test trays observed, involving residents on the Park Unit and Lake Unit. Facility policies stated that hot foods were to be heated to at least 165 degrees Fahrenheit and held at 140 degrees Fahrenheit or higher until service, and that trays were to be served promptly. During resident interviews, multiple residents stated the food was cold, lacked taste, and was often served with insufficient portions; one resident said the coffee was always cold, another said breakfast was especially cold, and another described the food as terrible and not decent. During a continuous observation of the kitchen lunch tray line, surveyors saw multiple delays, including gravy needing to be reheated, a vegetable item running out and being substituted, and clean plates running out mid-service, which delayed carts leaving the kitchen. On the Park Unit, the lunch test tray arrived at 12:52 PM and all trays were passed by 12:54 PM, but the pork measured 89.5 degrees Fahrenheit and tasted cold and dry, and the stuffing measured 122.9 degrees Fahrenheit and tasted lukewarm. The Director of Food Service stated the pork had been 172 degrees Fahrenheit at the start of tray line and should have been at least 120 degrees Fahrenheit when the cart reached the unit, and noted that new staff learning different positions contributed to the delay. On the Lake Unit, the lunch test tray cart arrived at 1:00 PM and trays were passed by 1:08 PM, but the pork with gravy measured 112.9 degrees Fahrenheit and the stuffing with gravy measured 110 degrees Fahrenheit; both were described as lukewarm and lacking flavor. The Director of Food Service stated both items should have been served at 120 degrees Fahrenheit or higher and acknowledged difficulty maintaining temperature for pureed foods once plated. Additional interviews confirmed that staff did not take mid-tray-line temperatures, that trays often sat for extended periods before being passed on the units, and that the facility had been receiving complaints about cold food and was auditing test trays more frequently because of those complaints.
Survey Results Not Readily Accessible
Penalty
Summary
The facility did not ensure that the results of the most recent health surveys were posted in a place readily accessible to residents, family members, and legal representatives. During the survey, the facility’s past survey results were found in a binder stored behind the reception desk with other binders, and the binder was not visible or labeled in a way that made it easy to identify. Social Worker #1 stated the survey results were not in a place readily accessible to residents and visitors without having to ask for them, and the Administrator also stated the binder was not in an easily accessible location when stored behind the reception desk with other binders. The binder contained the CMS-2567 from the 02/01/2024 recertification survey, but it did not contain all complaint investigation results with plans of correction for the past three years. The Administrator stated the facility had a complaint survey requiring a plan of correction after the last recertification survey, but those results were not in the binder. During the resident council meeting, Residents #1, #43, #60, #79, and #85 stated they were unsure whether the facility posted past survey results or where to find them, and they were interested in reviewing them.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
COVID-19 Vaccine Administered Without Consent Due to Resident Misidentification
Penalty
Summary
A resident with diagnoses including dementia, depression, and hypertension, who was assessed as cognitively intact, was administered the COVID-19 vaccine despite having signed a declination form indicating refusal of the vaccine. Facility policy required that consent or declination for the COVID-19 vaccination be obtained and documented within seven days of admission, and that residents or their responsible parties have the right to refuse any vaccination at any time, with all education and refusals documented in the medical record. The resident's signed declination was present in the record, and the COVID-19 vaccine was nonetheless administered. The incident occurred when an LPN failed to verify the resident's identity by not checking the wristband prior to administering the vaccine, as required by the facility's medication administration policy. Documentation in the medical record confirmed the administration of the vaccine and a subsequent medication error report noted the failure to follow resident rights and proper identification procedures. Interviews with facility staff, including the LPN, the infection preventionist RN, and the Director of Nursing, confirmed that the vaccine was given in error and that this action violated the resident's right to refuse treatment.
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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