Hudson Valley Rehabilitation & Extended Care Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland, New York.
- Location
- 260 Vineyard Ave, Rt 44/55, Highland, New York 12528
- CMS Provider Number
- 335399
- Inspections on file
- 15
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 47
Citation history
Health deficiencies cited at Hudson Valley Rehabilitation & Extended Care Ctr during CMS and state inspections, most recent first.
A unit was left without an LPN on the evening shift, while an RN supervisor was assigned to oversee the facility and cover two units at once. Staff and a resident representative reported there was no nurse on the unit, and the RN supervisor said they were running between units and could not document medications on one unit. The DON confirmed an LPN was a no call/no show and that pharmacy records showed medication administration was not documented for the entire unit.
Sufficient food service support personnel were not provided, as kitchen and unit refrigerator logs were incomplete and expired, undated, and unlabeled foods were found in pantry refrigerators. Staff reported ongoing kitchen short staffing, with nourishment snacks sometimes not prepared or delivered on time. A resident with dementia, COPD, heart disease, and hospice services had ordered fortified shakes and snacks, but the resident’s representative and staff reported the resident frequently missed AM and PM nourishments.
Food was not stored in accordance with professional standards because unlabeled, undated, and expired items were found in the kitchen refrigerators, dry pantry, and unit pantry refrigerators. Surveyors observed multiple food items, including resident foods, dairy items, and thickened waters, without proper dates or labels, and the FSD stated new dietary staff were still in training and that staff were responsible for discarding expired items.
Unsafe and Unclean Resident Environments: A resident’s room contained scattered garbage, linens, and a disconnected catheter bag with urine, while another resident had a dirty wheelchair, stained cushion, sticky bathroom floors, and a urine odor. A third resident’s bathroom had a large wall opening beneath the sink that exposed plumbing.
Hot food was not maintained at an appetizing temperature during meal delivery. A test tray of lasagna was 150 degrees at the tray line but was lukewarm at 120.5 degrees when sampled after delivery to the unit. A resident reported meals were delivered cold and that the only way to get a hot meal was to eat in the dining room. The FSD stated a new tray delivery system would help hold hot food temperatures during transport.
Infection control practices were not maintained during meal service when a CNA handled straw tops and food items with bare hands and did not perform hand hygiene between residents. Catheter collection bags for two residents with indwelling catheters were also observed hanging on bed rails or lying on the floor, despite care plans directing staff to keep the bags and tubing off the floor and maintain infection control practices.
Failure to Ask Permission Before Applying Clothing Protectors: A CNA placed clothing protectors on three residents during dining without first asking if they wanted them. The CNA said they always get one and acknowledged permission should have been asked. An LPN and the unit manager stated clothing protectors should be offered, not automatically applied, to preserve resident dignity and choice.
A resident with intact cognition and diagnoses including HTN, PVD, and CAD completed a MOLST indicating DNR/DNI, but the EMR orders and wristband did not all match the form. Surveyors observed conflicting wristbands and an order stating to check the blue arm band and that the resident wanted CPR, while the resident stated they did not want CPR and had clarified their wishes after returning from the hospital.
Missing Ombudsman Notifications and Bed Hold Policy Notices: The facility did not document sending transfer/discharge notices to the State LTC Ombudsman for several residents who were sent to the hospital, and it did not provide bed hold policy notices to resident representatives when residents were transferred or hospitalized. A resident with dementia and psychotic disturbance, a resident with dementia, HTN, and DM, and another resident with dementia, BPH, and HTN were all transferred without documented Ombudsman notification or bed hold policy notice; another hospitalized resident also did not receive a bed hold policy notice.
Care Plan Not Updated to Match Smoking Evaluation: A resident with dementia and tobacco use had a smoking care plan that allowed smoking with supervision and use of a smoking apron as needed, but a handwritten note on the smoking evaluation stated the resident must wear an apron at all times. The DON, an RN, and the LPN Manager each described that the care plan should have been updated to reflect the added intervention, but it was not.
Failure to provide required ADL assistance led to three residents not receiving needed personal hygiene support. Two residents who were dependent on staff for toileting and incontinence care were observed or reported to be double briefed, and staff acknowledged that double briefing was not allowed. Another resident with hemiplegia, dysphagia, and chronic gingivitis was observed on multiple occasions with poor oral hygiene, with the resident stating staff did not help brush their teeth despite a care plan for daily oral care.
Failure to Provide Resident-Directed Activities: A resident with Alzheimer's disease, anxiety, depression, and severely impaired cognition had documented preferences for music, group activities, fresh air, and religious services, but surveyors observed the resident sitting in the day room multiple times with no activities being provided. Records showed the resident did not attend activity programs during the review period, including music and Catholic Mass, and the DON and D of Activities described separate unit-based leisure efforts without a calendar or attendance documentation.
A resident with muscle weakness, hemiplegia, and paralytic gait was observed multiple times without the ordered right AFO in place. The care plan and physician order required the brace when out of bed and skin checks, but staff interviews confirmed the brace had not been worn for weeks to over a month even though staff were signing off on it. An RN manager and the rehab director stated the brace was required to prevent foot drop and address weakness.
A resident with psychosis, PTSD, and cognitive impairment was identified as needing supervision while smoking, but the smoking care plan was not updated after a blister was linked to smoking and a handwritten note referenced a cigarette extender. Later, staff observed the resident smoking without a cigarette extender or smoking apron, and interviews showed inconsistent understanding of the resident’s smoking plan and whether the extender was being used.
Oxygen was administered to a resident without a valid physician order. The resident had lung cancer, PE, and acute respiratory failure, and was receiving oxygen via NC after returning from the hospital. Surveyors observed the NC on the floor and later found the concentrator set at 0 L/min, while the EHR contained no order for oxygen during the period reviewed. An LPN could not locate an order, and the MD later stated there had been no previous order even though oxygen had been continued.
A resident with schizoaffective disorder, type 2 DM, and morbid obesity continued receiving Megestrol even after the consultant pharmacist recommended discontinuation and the MD agreed. The MAR showed ongoing administration, while the MD stated the NP reordered the medication and the DON could not produce the discontinuation order.
Failure to Address Refusals of Care and Hygiene Needs in a Resident With Dementia: A resident with dementia, bipolar disorder, and major depressive disorder was repeatedly observed in soiled clothing with poor hygiene, including dirty shoes, greasy hair, and a urine odor. Nursing notes documented repeated refusals of ADL care, staff said the resident often refused care and was reapproached, but there was no documented SW follow-up related to the refusals despite care plan interventions for social services involvement and behavioral concerns.
Improper garbage and refuse disposal was observed in the facility waste area. The recycle dumpster lid was broken and could not fully close, allowing cardboard boxes to spill over, with boxes and litter on the ground around and under the dumpster. The compactor area also had food debris spilled down the door and pooled at the base, along with used gloves, cups, an empty milk carton, and an empty bag of instant potatoes scattered nearby. The FSD stated the dumpster lid was broken, and the Administrator stated there was no policy for garbage/recycling disposal.
Failure to provide ordered OT screening and evaluation was identified for two residents. One resident with dementia and moderate cognitive impairment had a physician order for OT screen, eval, and treat, but no OT screen, eval, or rehab care plan was found, and the resident was repeatedly observed in bed without receiving therapy services. Another resident with dementia, schizophrenia, diabetes, and mild contractures had an order for OT eval and treat for leaning to the right, but no OT eval note was found despite repeated observations of the resident leaning to the right in bed and in a Geri chair.
A resident with cognitive impairment and high care needs was involuntarily confined to their room by a CNA who wedged washcloths in the door, preventing exit for over two hours. The resident was later found by housekeeping staff in soiled conditions and appeared anxious to leave. The care plan requiring monitoring and protection was not followed, and staff interviews revealed a lack of awareness and documentation regarding the incident.
Two residents experienced abuse and neglect when one was involuntarily secluded in their room by a CNA and left in unsanitary conditions, while another was video recorded by staff during personal care and the video was posted on social media. In both cases, the incidents were not promptly reported to administration, the residents were not assessed by clinical staff after the events, and required notifications to law enforcement were not made.
Two residents experienced incidents of suspected abuse and privacy violations that were not reported to law enforcement or the Department of Health within required timeframes. In one case, a resident with severe cognitive impairment was barricaded in their room by a CNA, and in another, a resident with moderate cognitive impairment was videotaped by staff and the video was posted on social media. Facility leadership was not promptly informed, and mandated notifications were delayed.
Two residents did not receive care and treatment in accordance with professional standards, including missed documentation of daily wound care by an LPN and repeated omissions in CNA documentation of bowel movements for a resident with a history of constipation. The facility's required documentation and monitoring processes were not consistently followed, and there was no evidence that missed care or documentation was addressed or communicated as required.
The facility did not ensure its QAPI committee developed or implemented action plans for two serious incidents: one where a resident was barricaded in their room by a CNA and another where a resident was videorecorded and the video posted on social media. Despite the facility's policy requiring proactive quality improvement, these incidents were not discussed or addressed in QAPI meetings.
A resident with dementia and physical impairments was video recorded by two CNAs while washing their briefs at a sink, and the video—accompanied by mocking comments—was posted on social media. This action violated the facility's policy on resident dignity and privacy, as confirmed by staff interviews and documentation.
A resident with severe cognitive impairment was barricaded in their room by a CNA using washcloth wipes, and the facility did not ensure a thorough investigation. The resident was not assessed for injury by clinical staff after the incident, and not all staff present at the time were interviewed. Video footage used to identify the staff member involved was not saved or made available for review.
Two residents' MDS assessments did not accurately reflect their documented behaviors, including wandering and rejection of care, despite care plans and progress notes indicating these issues. The discrepancies were attributed to errors and misunderstandings by the MDS Coordinator regarding assessment criteria.
A resident on comfort care with severe cognitive and physical impairments did not receive scheduled Morphine doses within the required time frames, with several doses administered late or not documented as given. Nursing staff cited heavy med passes and medication availability issues, but there was no evidence of physician notification or proper documentation for missed or late doses, contrary to facility policy.
Staff did not consistently follow enhanced barrier precautions for two residents, including not wearing gowns during care for a resident with wounds and allowing another resident with a Foley catheter to walk around carrying their drainage bag without a leg bag. Staff interviews revealed gaps in communication and understanding of which residents required these precautions, despite facility policy and signage.
The facility failed to administer medications at the prescribed times for two residents, with LPNs administering medications late without notifying physicians. One LPN administered 13 medications at 12:30 PM instead of 9:00 AM, and another administered 10 medications at 10:05 AM instead of 9:00 AM. Staffing issues and communication breakdowns contributed to these deficiencies.
A facility failed to administer medications timely to residents in the Second Floor Dementia Unit, affecting 23 residents. LPNs were unable to complete medication passes within the required timeframe due to understaffing, leading to late administration of critical medications such as insulin and anticoagulants. The DON and Medical Director were unaware of the issue until the survey, and the Pharmacy Consultant's reviews did not include time-stamped records.
The facility failed to ensure timely medication administration and proper physician notification for 24 residents, including 19 with significant medications. The Medical Director was unaware of the delays until informed by the DON, and the Attending Physician did not believe the delays had adverse outcomes. Staffing issues were identified as the root cause.
The facility failed to provide sufficient nursing staff on the Second Floor Dementia Unit, resulting in late medication administration for 23 residents. A consistent pattern of late medication administration was observed from July to August 2024, with significant medications being administered outside the prescribed time frame. Interviews revealed that the medication nurse was often left to administer medications to 38 to 40 residents alone, and the facility administration did not adequately address the staffing shortfall.
The facility failed to address timely medication administration, leading to residents not receiving significant medications on time. Despite feedback from a Bureau of Narcotics representative and Resident Council complaints, the facility did not investigate or audit medication practices. Staffing challenges were cited as a contributing factor.
Insufficient nursing coverage and missing medication documentation on a unit
Penalty
Summary
The facility did not provide sufficient nursing staff on the 2 East unit during the 3:00 p.m. to 11:00 p.m. shift, and there was no documented evidence that medications were administered to 35 residents on that unit. The facility assessment dated 10/31/2025 identified the minimum staffing for 2 East on that shift as 2 LPNs and 1 RN Supervisor, but the staffing sheets for 2/8/2026 showed there was no LPN assigned for that shift. RN Supervisor #17 was assigned to supervise the facility and was also assigned to 2 East and 3 West. During interviews, the resident's designated representative and a CNA stated there was no nurse on the 2 East unit that evening. The Staffing Coordinator stated they were informed there was no LPN on 2 East and that attempts to reach the DON and Administration RN were unsuccessful. RN Supervisor #17 stated they were told around 4:00 p.m. that they would be supervising the facility and working as the nurse on both 2 East and 3 West, and that they were running between the two units and felt very overwhelmed. They stated they were able to get some documentation done on 3 West but were unable to document on 2 East. The DON stated LPN #31 was a no call no show for the shift and that RN Supervisor #17 came in at 3:00 p.m. and had the keys for 2 East and 3 West. The DON also stated a pharmacy printout showed medication administration was not documented for the entire 2 East unit, and that if RN Supervisor #17 did not sign that medications were administered, it was considered an omission. The Administrator stated they were not aware of the staffing issue until the next day and acknowledged that the situation was not ideal.
Incomplete food service staffing and missed nourishment delivery
Penalty
Summary
The facility did not provide sufficient support personnel to safely and effectively carry out food and nutrition services. During the recertification and abbreviated survey, surveyors observed incomplete refrigerator temperature log documentation in the kitchen and on the units, including missing entries for the nourishment refrigerator, dairy walk-in, produce walk-in, and ice cream freezer. Surveyors also found expired, undated, and unlabeled food items in the 3W and 3E unit pantry refrigerators, including resident food, fruit, salad, cream cheese, celery sticks, and other stored items that were not properly labeled or dated. The Food Service Director stated the facility had staffing issues, including four new dietary staff in training, and later stated two dietary employees were terminated and the kitchen was again short staffed. The Director also stated there had not been a full kitchen staff for a while and that the Administrator was aware of the staffing issues. The report further documented that nourishment snacks for the units were sometimes not prepared or delivered on time because of understaffing, and that this occurred about once a week, with weekends being worse. Resident #15 had diagnoses including unspecified heart disease, dementia with anxiety and psychotic disturbance, and COPD, and had severe cognitive impairment, was independent with eating, and received hospice services. The resident had orders for fortified shakes three times daily and soft sandwiches without crust, and the care plan included additional fluids and 2:00 PM tuna or egg salad. The resident’s representative reported the resident frequently did not receive 9:00 AM and/or 2:00 PM nutritional supplements/snacks, and staff interviews confirmed that there were days when these nourishments were not delivered from the kitchen. Staff also stated that when this occurred, the kitchen was notified, but sometimes the nourishment still was not sent.
Food Storage and Labeling Deficiencies
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards for food service safety because unlabeled and undated foods were found in the kitchen and unit pantry refrigerators, and expired foods were found in the kitchen, unit pantry refrigerators, and dry pantry. The facility policy dated 06/19/2025 stated refrigerator temperatures and checks must be monitored and documented, and staff were responsible for ensuring safe storage and proper labeling. During the initial kitchen tour, surveyors observed 1/2 roll of uncut bologna, a storage container of peaches, individual portions of pineapple, jello, butterscotch pudding, applesauce, egg salad, cottage cheese, and prune juice that were unlabeled and undated. Surveyors also found a storage container of fruit cocktail dated 02/12/2026 and a case of individual cups of honey thickened waters that were expired. The Food Service Director stated food items were usually dated when stocking, but new aides and a cook had just been hired and were in training. On a later observation, the Unit 3W refrigerator pantry contained resident food in a paper bag dated 02/17/2026, resident food in a plastic take-out bag that was undated, a grocery store fruit platter that was undated, a grocery store salad that was undated and unlabeled, and a large coffee creamer that was undated. The Unit 3E refrigerator pantry contained an expired cup of celery sticks dated 02/202/2026 and an unlabeled, undated opened brick of cream cheese. The Food Service Director stated new staff were still receiving training on tasks related to unit pantries and later stated dietary staff had a lot of responsibility and the facility was continually training new employees due to high staff turnover.
Unsafe and Unclean Resident Environments
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for three residents reviewed for environmental concerns. One resident was observed in a room with garbage and linens scattered on the floor, empty water bottles on furniture, and a disconnected catheter bag containing urine hanging on the bed rail. On later observations, the same resident’s room continued to have pillows and sheets on the floor, paper, garbage, empty water bottles, plastic wrappers, a full garbage can, and dirt stains on the floor. A second resident was observed with a wheelchair that had dust and dirt on the frame and a cushion with brown stains, along with a bathroom that had sticky floors and a urine odor. Additional observations noted a faint urine smell, stained bed linens, old cups and plastic wrappers on the bedside table, scattered dirt on the floor, and brown dry spots between the entry and the bed. A third resident’s bathroom had an approximately 20-inch by 10-inch opening in the wall beneath the sink, exposing the plumbing after wall tiles and sheetrock had been removed.
Hot Food Served at Unsafe Temperature
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature. During the recertification survey, a test tray showed lasagna being served to residents on the 3 W unit at 120.5 degrees Fahrenheit. The report states that food safety requires consistent temperature control from the time food leaves the kitchen through transport and distribution. A resident stated that food was delivered to the unit cold and that the only way to get a hot meal was to eat in the dining room. On observation, the Food Service Director said lunch tray line started at 11:30 AM, and the lasagna tested at 150 degrees Fahrenheit at that time. The lunch trays arrived to unit 3W at 12:24 PM, CNAs delivered meals to residents in rooms at 12:26 PM and to residents in the 3W dining room at 12:37 PM, and when the tray was sampled at 12:41 PM it was lukewarm at 120.5 degrees Fahrenheit. The Food Service Director stated that a new tray delivery system would be helpful in holding hot food temperatures from the tray line until residents received their meals.
Infection Control Lapses During Meal Service and Catheter Care
Penalty
Summary
Infection prevention and control practices were not maintained during meal service and catheter care observations. During lunch tray delivery and tray set-up, a CNA handled the tops of straws with bare hands, touched fork prongs with bare hands, placed straws into milk containers, and buttered a resident’s roll with bare hands without performing hand hygiene between residents. The CNA stated they were aware hand hygiene should have been performed between residents and that they should not have touched straws or food items without gloves or hand hygiene, but said they were in a hurry and did not perform hand hygiene. An LPN stated staff should use hand sanitizer or hand wipes between residents during meal distribution, and a unit manager stated aides should sanitize hands between residents and should not touch straw tops or resident food items without gloves and proper hand hygiene. Catheter collection bags were also observed in improper positions for two residents with indwelling catheters. One resident with diagnoses including obstructive uropathy, benign prostatic hyperplasia, and dementia was dependent on staff for toileting hygiene and had a catheter collection bag hanging on the bed rail, with the bottom portion resting on the floor during one observation. On another observation, the same resident’s bag was again hanging on the bed rail and touching the floor. A second resident with diagnoses including obstructive and reflux uropathy, urinary tract infection, and acute kidney failure was moderately cognitively impaired, required maximal assistance for toileting hygiene, and had a catheter collection bag lying on the floor between the bedside table and bed frame. The resident’s care plan directed staff to maintain infection control practices and ensure the collection bag and tubing were not touching the floor or floor mat, and staff interviews confirmed the bag should not be touching the floor.
Failure to Ask Permission Before Applying Clothing Protectors
Penalty
Summary
The facility did not ensure that residents were treated in a manner that maintained dignity and respect during dining when Certified Nurse Aide #7 placed clothing protectors on Resident #47, Resident #55, and Resident #90 without first asking permission. During observation on 02/24/2026 at 12:00 p.m., the CNA was seen applying the clothing protectors to all three residents without offering them a choice or obtaining their consent before doing so. During interview, Certified Nurse Aide #7 stated they did not ask the residents because they always get a clothing protector, and acknowledged they should have asked before applying them. Licensed Practical Nurse #6 stated clothing protectors should be offered rather than automatically placed, and Licensed Practical Nurse Unit Manager #4 stated all residents should be asked if they would like a clothing protector before it is applied. The facility policy titled Dignity and Resident Rights stated residents are to be treated with dignity and respect and involved in decisions affecting their lives.
Advance Directive Orders and Wristband Did Not Match Resident Wishes
Penalty
Summary
The facility did not ensure that one resident’s right to formulate an advance directive was documented in a way that prevented the resident’s wishes from being followed. Resident #136, who had diagnoses including hypertension, peripheral vascular disease, and coronary artery disease, had intact cognition on the admission MDS. The resident completed a MOLST form stating Do Not Resuscitate and Do Not Intubate, but the physician orders in the electronic medical record and the resident’s wrist band did not all match the form. The record showed a physician order for Do Not Resuscitate and another order stating to check the blue arm band and that the resident wanted CPR. During observation, the resident was first seen wearing a blue wristband, and later a white wristband was observed after the resident stated staff had given them a new wristband. The resident told surveyors they did not want CPR and said there had been confusion when they returned from the hospital, but they clarified their wishes with staff. The RN unit manager stated the resident recently returned from the hospital and changed their wishes to Do Not Resuscitate and Do Not Intubate, and that the orders and wristband should have been changed when the MOLST was signed. The DON stated advance directives should be reviewed on admission and that the corresponding wristband and orders should be corrected immediately when a resident’s wishes change.
Missing Ombudsman Notifications and Bed Hold Policy Notices
Penalty
Summary
The facility did not ensure that a copy of the notice of transfer or discharge was sent to the State Long Term Care Ombudsman for four residents reviewed for hospitalization, and it also did not provide a bed hold policy to resident representatives when residents were transferred or hospitalized. The facility policies titled Transfer and Discharge and Bed Hold policy stated that transfer or discharge notices must be provided to the resident, resident representative, and ombudsman at the same time, and that residents and their representatives are to receive written and verbal notice of bed hold policies upon admission and again at transfer. Resident #15, who had unspecified dementia with anxiety and psychotic disturbance, was sent to the hospital for altered mental status and there was no documented evidence that the Ombudsman was notified or that a bed hold policy was provided to the resident or representative. Resident #2, who had non-Alzheimer dementia, hypertension, and diabetes mellitus, was transferred to the emergency room after an unwitnessed fall, and there was no documented evidence of Ombudsman notification or bed hold policy provision. Resident #84, who had dementia, benign prostatic hyperplasia, and hypertension, was sent to the hospital for trouble breathing, and there was no documented evidence that the Ombudsman was notified or that a bed hold policy was provided. Resident #132 was hospitalized and a bed hold policy was not provided.
Care Plan Not Updated to Match Smoking Evaluation
Penalty
Summary
Comprehensive Care Plans were not reviewed and revised as needed to reflect changing resident needs for one resident reviewed for accidents. Resident #15 had diagnoses including unspecified dementia, and a significant change MDS dated 12/08/2025 documented severe cognitive impairment and tobacco use. The resident’s smoking care plan dated 03/28/2025 included interventions to allow smoking in the designated area with supervision as needed, check clothing regularly for signs of unsafe smoking, and provide a smoking apron as needed. A smoking evaluation kept at the front desk contained a handwritten note indicating that Resident #15 must wear an apron at all times, but this intervention was not added to the care plan. The DON stated the care plan should have been updated immediately to reflect the new intervention and that assessments and care plans should match. Administration RN #8 stated they wrote the note on the smoking evaluation and that the LPN Manager would have been responsible for updating the care plan, while the LPN Manager stated they did not recall receiving a report that the resident must wear an apron at all times.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for three residents reviewed for ADLs. The deficiency involved double briefing for two residents and poor oral hygiene for one resident, contrary to the facility’s ADL policy, which stated that CNAs shall provide assistance, setup, supervision, or complete care as required for toileting, incontinence care, hygiene, and grooming tasks. One resident with heart disease, dementia, anxiety with psychotic disturbance, and COPD had severe cognitive impairment, required substantial to maximal assistance with dressing and hygiene, and was intermittently incontinent of bladder and frequently incontinent of bowel. The resident’s representative stated they observed the resident double briefed during a visit and reported that a CNA said the resident was a heavy wetter and that a pull-up brief was used over a standard brief because the standard brief tended to fall. Staff later acknowledged the resident had been double briefed, that the CNA was counseled, and that double briefing was against facility policy. A second resident with dementia, urinary retention, and UTI was dependent on staff for all ADLs and always incontinent of bowel and bladder. During morning care, the resident was observed wearing two wet adult briefs. Staff stated they were unaware why the resident was double briefed, and nursing staff confirmed that double briefing was not allowed and that the resident was care planned for checks and changes every two to four hours. A third resident with hemiplegia, dysphagia, and chronic gingivitis was dependent on staff for all ADLs and was care planned to receive daily oral hygiene, but on multiple observations the resident’s teeth were coated in white buildup around the gums and the resident stated no one helped brush their teeth.
Failure to Provide Resident-Directed Activities
Penalty
Summary
The facility did not ensure an ongoing program supported residents in their choice of activities based on comprehensive assessment, care plan, and preferences for one resident with dementia. Resident #90 had diagnoses including Alzheimer's Disease, Anxiety, and Depression. The activity care plan documented that the resident was frequently confused, needed help getting from place to place, and preferred reading, music, animals, news, group activities, fresh air, and religious activities. The significant change MDS documented severely impaired cognition and activity preferences that included listening to music, being around groups of people, going outside for fresh air, and participating in religious activities. Survey observations and record review showed Resident #90 was repeatedly sitting in the 2 East day room without activities being provided. On one observation, the resident was sitting at a table while not facing the television, with no music playing and no activities being offered. Attendance records showed the resident was not involved in any activity on or off the unit during the reviewed period, and the music program attendance sheet documented the resident was not in attendance. The activities calendar listed Catholic Mass in the large activity room, but the resident was observed remaining on the unit. The Director of Activities stated music programs and one-to-one visits were being used for residents with dementia, while the DON stated a nursing quality-of-life program using Geri-aides was run by nursing, but there was no calendar or attendance sheets for that program.
Failure to Apply Ordered Right Ankle-Foot Orthosis
Penalty
Summary
The facility did not ensure that a resident with limited ROM and mobility received the ordered right ankle-foot orthosis to maintain function. Resident #44 had diagnoses including muscle weakness, hemiplegia of the right dominant side, and paralytic gait, and had a physician order dated 5/23/2024 directing staff to apply the right ankle-foot orthosis in the morning, remove it in the evening, and have nursing assess skin integrity. The resident’s care plans also directed staff to use the right foot brace when out of bed and to apply stockinette to protect the skin from the brace. During observations on 02/24/2026, 02/25/2026, and 02/26/2026, Resident #44 was seated in the second-floor dayroom without the right ankle-foot orthosis in place. Staff interviews confirmed the brace had not been worn for weeks to over one month, despite the order and care plan. An LPN stated staff had been signing off on the brace even though the resident had not been wearing it, and an RN unit manager stated the resident was required to wear the brace per the physician’s order and care plan. The RN unit manager and the Director of Rehabilitation both stated the brace was needed to prevent foot drop and that without it, muscle weakness would occur and foot drop would worsen.
Smoking Supervision and Care Plan Not Kept Consistent
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices were consistent with Resident #103’s smoking needs. Resident #103 had diagnoses including unspecified psychosis, left femur fracture, and PTSD, and was identified in care planning as a dependent smoker with poor safety awareness and a history of non-compliance with smoking policies. The smoking care plan dated 04/03/2025 documented that the resident needed supervision while smoking, but also noted the resident often smoked cigarettes down to the butt and refused staff intervention to replace them. A later quarterly assessment documented that the resident had poor safety awareness and may smoke with supervision only, with staff to light the cigarettes. After a 05/19/2025 care plan note documented that the resident had an intact blister on the left hand second digit related to smoking, a handwritten 05/21/2025 note referenced the use of a cigarette extender. However, there was no documented evidence in the care plan addressing the cigarette extender. Subsequent assessments continued to state that the resident may smoke with supervision only, and an annual assessment packet dated 02/06/2026 again documented poor safety awareness and supervision only. A picture identification sheet dated 02/18/2026 listed no supervision requirement below the resident’s picture, while the annual MDS dated 02/13/2026 documented moderate cognitive impairment and current tobacco use. During observation on 02/25/2026, the resident was brought to the smoking area with a cigarette in the mouth in the lobby, and a Geri Aide lit the cigarette. No cigarette extender or smoking apron was offered or worn. Interviews with staff showed conflicting understanding of the resident’s smoking plan and whether a cigarette extender was in use. The DON stated care plan interventions, notes, and smoking assessments were expected to match and be updated when changes occurred, while the LPN manager stated there were no care plan interventions addressing monitoring the resident smoking down to the butt or use of a cigarette extender.
Oxygen Administered Without Physician Order
Penalty
Summary
Resident #5 was administered oxygen without a valid physician order from 01/29/2026 through 02/19/2026. The resident’s diagnoses included lung cancer, pulmonary embolism, and acute respiratory failure. The significant change MDS dated 12/19/2025 documented moderate cognitive impairment and shortness of breath when lying flat. A nursing progress note dated 01/29/2026 documented that the resident returned from the hospital and was admitted back into the facility while receiving oxygen at 2 liters per minute via nasal cannula, and a note dated 02/03/2026 documented an oxygen saturation of 91% while receiving oxygen at 2 liters per minute. During observation on 02/19/2026, the resident’s nasal cannula was found on the floor while the oxygen concentrator was running, and later the oxygen was observed flowing at 0 liters per minute. The electronic health record contained no documented physician order for oxygen administration during the period from 01/29/2026 to 02/19/2026. During interview, the LPN stated the resident was receiving oxygen at 2 liters per minute but could not locate an order, and the RN unit manager stated they would contact the medical doctor regarding an order for oxygen administration. The medical doctor later stated the resident had been receiving oxygen when they returned to the facility, that the oxygen was continued, and that there had been no previous physician order for the oxygen.
Megestrol Continued Despite Pharmacist Recommendation to Discontinue
Penalty
Summary
Medical supervision was not ensured for one resident reviewed for drug regimen review. The resident had diagnoses including schizoaffective disorder, type 2 diabetes mellitus, and morbid obesity, with a documented weight of 413 to 415 pounds and intact cognition. The consultant pharmacist’s medication regimen review identified long-term use of Megestrol beyond 30 days and recommended discontinuation or clarification of the indication if the medication continued. The response to the review documented to discontinue Megace and noted no GLP-1 medication until the resident was monitored off Megace. Despite the recommendation and the physician’s agreement to discontinue the medication, the resident continued to receive Megestrol. The record showed a physician renewal order for Megestrol 400 mg/10 ml once daily, and the MAR documented repeated administration of the medication in December 2025, January 2026, and February 2026. During interviews, the Medical Director stated the pharmacist’s recommendation to discontinue Megestrol had been reviewed and agreed with, and that an order was given to discontinue it, but the Nurse Practitioner reordered the medication. The DON was unable to produce the discontinuation order, and the consultant pharmacist stated the recommendation had not been addressed during the following month.
Failure to Address Refusals of Care and Hygiene Needs in a Resident With Dementia
Penalty
Summary
The facility did not ensure that a resident with dementia and other psychiatric diagnoses received appropriate treatment and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being. Resident #28 had diagnoses including bipolar disorder, dementia, and major depressive disorder, and care plans documented compromised status, resistance to participation in ADLs, and a history of refusal of assistance with ADLs. The care plans also included interventions for social services referral and follow-up related to discharge planning, family support, non-compliance, cognitive changes, and behavioral concerns, but there was no documented evidence of social work progress notes related to the refusals of care or follow-up after the care plan meeting. The resident was repeatedly observed with poor hygiene and soiled clothing over consecutive days, including stained shirts, dirty pants, dirty shoes, greasy and uncombed hair, and a urine odor. Nursing progress notes documented multiple refusals of care, and staff interviews confirmed that the resident often refused care, was reapproached, and that refusals were reported to nursing. The psychological consultation noted impaired social judgment, episodic verbal aggression, frequent noncompliance with hygiene practice, and adjustment challenges. During interview, the Director of Social Work stated they had not been notified of any issues with refusals of care for the resident, despite the documented refusals and observed hygiene concerns.
Improper Garbage and Refuse Disposal
Penalty
Summary
Improper disposal of garbage and refuse was identified in the facility’s waste area during the recertification survey. The recycle dumpster lid was broken on the right side and could not be completely closed, allowing cardboard boxes to spill over the top. Boxes and other litter were observed on the ground around the dumpster and trapped underneath it. The waste management company arrived during the observation to empty the dumpster, and the broken lid was confirmed after the dumpster was emptied. At the same time, the compactor area had food debris spilled down the front of the door and puddled at the base of the compactor on the ground. Used gloves, cups, an empty milk carton, and an empty bag of instant potatoes were also observed on the ground around the compactor extending toward the recycle dumpster. The Food Service Director stated the recycle dumpster lid was broken and never fully closed because the right side of the lid was missing, and the Administrator stated there was no policy for garbage/recycling disposal, noting only that the facility had a schedule for the waste management company to pick up and keep the area clean.
Failure to Provide Ordered OT Screening and Evaluation
Penalty
Summary
Provide or get specialized rehabilitative services as required for a resident was not ensured for two residents reviewed for rehabilitation services. The facility policy titled Rehab Evaluation stated the evaluation must occur following admission with physician orders for evaluation and should be performed within 48 hours of the physician order. For one resident with unspecified dementia, moderate cognitive impairment, and assistance needs for bathing, dressing, and transfers, a physician order dated 12/27/2025 documented occupational therapy screen, evaluation and treat, but no occupational therapy screen, evaluation, or rehabilitation care plan was found in the electronic medical record. The resident was observed in bed on multiple occasions, and the resident representative stated the resident had not received therapy services since admission and spent most of the time lying in bed. For a second resident with unspecified dementia, schizophrenia, diabetes, and mild contractures, the annual MDS documented intact cognition, dependence on staff for all cares, and use of a mechanical lift for transfers. A physician order dated 12/11/2025 documented occupational therapy evaluate and treat for leaning to the right in bed and in the Geri chair, but no occupational therapy evaluation or progress note was found for that order. The resident was observed leaning to the right while in bed and in the Geri chair on multiple occasions. The Director of Rehabilitation stated they were not sure why the evaluation had not occurred, and the occupational therapist stated they did not see the order and did not complete it due to a heavy workload and prioritizing managed care residents.
Resident Involuntarily Confined to Room by Staff
Penalty
Summary
A deficiency occurred when a certified nurse aide confined a resident to their room by wedging disposable washcloths in the doorframe, preventing the resident from exiting. The incident was captured on surveillance video, which showed the aide following the resident to their room, closing the door, and placing the washcloths to block the door. The resident, who had diagnoses including Alzheimer's disease, Parkinsonism, and bipolar disorder, and was assessed as requiring maximal assistance with toileting, was left alone in the room for over two hours without the ability to leave or call for help. The resident was discovered by housekeeping staff, who found the door difficult to open due to the washcloths. Upon entering, they observed the resident unclothed except for a pair of pants pulled over their chest, with urine and feces present on the floor, beds, garbage can, and nightstand. The resident appeared anxious to leave the room, quickly exiting once the door was opened. The care plan for this resident indicated a risk for victimization and required monitoring for anxiety and protection from abuse, but these interventions were not followed at the time of the incident. Interviews with staff revealed that the nurse aide responsible for the seclusion did not deny the act and claimed to have been trained in this manner. Other staff members, including nursing and housekeeping, were unaware of the incident until after it was discovered. There was no physician's order for seclusion, and the event was not reported to law enforcement. Documentation of follow-up assessments by social work was lacking, and the incident was not discussed in the facility's Quality Assurance and Performance Improvement meeting.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
Two residents were not protected from abuse, resulting in significant deficiencies. In the first incident, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and Parkinsonism, was involuntarily secluded in their room by a Certified Nurse Aide (CNA). The CNA placed washcloth wipes in the door frame, preventing the resident from exiting for approximately three hours. The resident was later found by housekeeping staff in an unsanitary state, unclothed, with urine and feces present in the room. The CNA responsible did not alert anyone to the resident's condition or their actions, and the incident was not immediately reported to facility administration. In the second incident, another resident with moderate cognitive impairment and a history of dementia was video recorded by facility staff while washing their incontinence brief in their room. The video was posted on a social media platform by one of the CNAs involved. Multiple staff members were present during the recording, but the incident was not reported to administration in a timely manner. The video was later discovered by other staff members outside of work, who then reported it to the administration. The facility's abuse policy specifically prohibits such recordings and the use of social media in a manner that demeans or humiliates residents. In both cases, there was no documented evidence that the affected residents were assessed by a Registered Nurse, Physician, or Nurse Practitioner following the incidents. Additionally, the incidents were not reported to local law enforcement as required. The facility's policies on abuse and mental abuse related to unauthorized recordings were not followed, and staff failed to protect residents from abuse, neglect, and mistreatment as outlined in their care plans.
Failure to Timely Report and Notify Authorities of Suspected Abuse and Privacy Violations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, and did not report the results of investigations to the proper authorities for two residents. In the first incident, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and Parkinsonism, was barricaded in their room by a Certified Nurse Aide who placed washcloth wipes in the door frame, preventing the resident from exiting. The resident was discovered by housekeeping staff, but the facility Administrator was not informed until the following day. The incident was not reported to local law enforcement and was only reported to the New York State Department of Health eight days after the event occurred. In the second incident, another resident with moderate cognitive impairment and a history of dementia and cerebral infarction was videotaped by facility staff while washing their briefs at a sink. The video was posted on a social media platform by one of the Certified Nurse Aides involved. The Director of Nursing became aware of the incident two days after it occurred, and the Administrator was not informed until three days after the event. There was no documented evidence that the incident was reported to local law enforcement, and the report to the Department of Health was delayed. The facility's abuse policy required staff to report any incidents of abuse to administration or the Director of Nursing immediately, within one hour. However, in both cases, there were significant delays in notifying facility leadership and external authorities. The incidents were not reported to law enforcement as required, and notifications to the Department of Health were not made within the mandated timeframe.
Failure to Provide and Document Required Care and Treatment
Penalty
Summary
Two residents were identified as not receiving treatment and care in accordance with professional standards of practice. One resident, who had diagnoses including dementia, multiple sclerosis, and peripheral artery disease, was bedridden and had severe cognitive and physical impairments. This resident had a physician's order for daily wound care to the left below the knee area, including cleansing and application of topical ointment with a silicone dressing. Review of the treatment administration record for March 2025 showed that the treatment was not signed as completed by the LPN on three separate days. There was no documentation explaining the missed treatments or any notification to the physician regarding these omissions. During interviews, the LPN stated they may have forgotten to document the treatment in the electronic medical record, but could not confirm whether the treatment was actually completed or not. Another resident, with a history of schizophrenia, dysphagia, and constipation, was also found to have deficiencies in care. This resident was at high risk for constipation and required regular monitoring and documentation of bowel movements by certified nurse aides (CNAs) every shift, as outlined in the care plan. However, review of CNA accountability records for February and March 2025 revealed numerous omissions in documentation regarding the resident's bowel movement activity. In February, there were 25 occasions without documentation, and in March, 19 occasions were noted. Interviews with CNAs and the DON confirmed that documentation was expected to be completed every shift, and that blank boxes indicated either an omission or oversight. The facility's policy required accurate, timely, and complete documentation by CNAs in the electronic medical record to support high-quality resident care. The DON stated that nurses and supervisors were responsible for checking and ensuring documentation was completed, and that reports of undocumented tasks were distributed to unit managers for follow-up. Despite these processes, the records showed repeated failures to document required care and monitoring for both residents, with no evidence that omissions were addressed or communicated as required.
Failure to Address Reportable Incidents in QAPI Committee
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address identified quality of care deficiencies. Specifically, there was no documented evidence that the QAPI committee convened to discuss, develop, or prioritize actionable plans for two reportable incidents involving residents. One incident involved a resident with Alzheimer's disease, Parkinsonism, and Bipolar Disorder who was barricaded in their room by a Certified Nurse Aide, with the resident being found approximately three hours later by a housekeeper. Another incident involved a resident with Dementia, Cerebral Infarction, and Peripheral Vascular Disease who was videorecorded by staff while washing their briefs, and the video was posted on social media by a Certified Nurse Aide. Review of the facility's QAPI meeting agendas over several months revealed that neither incident was discussed, and there were no documented action plans to address these events. Although the facility's policy emphasized proactive identification and resolution of performance issues to enhance resident safety and quality of care, the QAPI committee did not address these specific incidents as required. The lack of documented discussion and action plans in the QAPI meetings constituted a failure to follow the facility's own quality improvement procedures.
Resident Dignity Violated by Staff Video Recording and Social Media Posting
Penalty
Summary
A deficiency occurred when a resident with dementia, cerebral infarction, and peripheral vascular disease, who required assistance with activities of daily living, was video recorded by two Certified Nurse Aides while washing their briefs at a sink. One of the aides posted the video on social media platforms, including TikTok and Instagram, where the resident was mocked. The facility's policy required all residents to be treated with dignity and respect, including privacy during personal care and protection from abuse or demeaning behavior. However, the actions of the staff violated these requirements, as the resident's privacy and dignity were not maintained during the incident. Multiple staff members became aware of the video through social media and reported it to facility administration. Interviews confirmed that the video depicted the resident from below the neck while they were engaged in personal care, and that mocking comments were made by staff in the recording. The incident was documented in employee statements and a nursing home investigative report, confirming that the resident was subjected to undignified treatment and exposure on social media, contrary to facility policy and regulatory requirements.
Failure to Thoroughly Investigate Alleged Abuse and Assess Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment, Alzheimer's disease, Parkinsonism, and bipolar disorder. On the date of the incident, a certified nurse aide barricaded the resident in their room by stuffing washcloth wipes in the door, preventing it from opening. The incident was discovered by housekeeping staff, who found the resident inside the room, calm and watching television. The resident was then cared for and brought to the dayroom. The facility's investigative summary noted that video footage was reviewed to identify the staff member involved, but the footage was not saved or made available for surveyor review. There was no documented evidence that the resident was assessed for injury by a registered nurse, physician, or nurse practitioner following the incident. Additionally, not all staff present on the unit at the time of the incident were interviewed, as the administrator relied on video footage to determine who to interview and stated it was not facility policy to interview all staff. The administrator also indicated that video footage is not routinely saved and was unable to provide it to surveyors, citing a lack of knowledge on how to copy the footage.
Inaccurate Resident Assessments Documented
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status and behaviors of two out of three residents reviewed. For one resident with diagnoses including Alzheimer's disease, Parkinsonism, and Bipolar disorder, the quarterly Minimum Data Set (MDS) assessment did not document wandering behavior, despite the resident being a known wanderer, wearing a wander guard, and having a care plan addressing wandering. The MDS Coordinator acknowledged that the omission was likely an error due to a misunderstanding of the criteria for coding wandering behavior. Another resident, with diagnoses such as Peripheral Vascular Disease, Diabetes Mellitus, and Delusional disorder, was care planned for rejecting medications and care, with documented refusals in progress notes. However, the comprehensive MDS assessment did not reflect this behavior, as the MDS Coordinator stated that no outbursts were observed during the look-back period. Both cases demonstrate that the assessments did not align with the residents' documented behaviors and care plans, as required by facility policy and regulatory guidelines.
Failure to Administer Scheduled Narcotic Medication Timely and Document Appropriately
Penalty
Summary
A deficiency was identified when a resident on comfort care, with diagnoses including dementia, multiple sclerosis, and peripheral artery disease, did not receive prescribed narcotic pain medication (Morphine) according to the scheduled times. The medication was ordered to be administered three times daily at specific times, but review of the Medication Administration Records for April and May 2025 revealed multiple instances where doses were given outside the regulated window of one hour before or after the scheduled time. Additionally, there was no documented evidence that three scheduled doses were administered on certain dates, and no documentation was found indicating that the physician was notified of these omissions or late administrations. The facility's Medication Administration policy requires medications to be administered as prescribed and within the specified time frame, observing the six rights of medication administration. Despite this, the records showed that doses were frequently late, sometimes by several hours, and in some cases, not signed out on the narcotic log sheet. Interviews with nursing staff revealed that heavy medication passes and unfamiliarity with the facility contributed to the delays. Staff also indicated that when medications were administered late or omitted, they were supposed to notify a supervisor and document the event, but there was no evidence of such notifications or documentation in this case. Further interviews highlighted additional issues, such as the unavailability of Morphine in the facility at times, which led to delays in administration. Staff reported that when medications were unavailable, they would contact the pharmacy and notify the physician, but again, there was no documentation to support that these steps were taken for the missed or late doses. The lack of adherence to medication administration schedules and failure to document or communicate deviations from prescribed orders constituted the basis for the deficiency.
Failure to Consistently Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
During an abbreviated survey, the facility failed to ensure that enhanced barrier precautions were consistently followed by staff for two out of three residents reviewed for infection control. In one instance, two Certified Nurse Aides provided care to a resident with wounds requiring dressing changes, who was on enhanced barrier precautions, without donning gowns as required by facility policy. The resident confirmed that staff sometimes wore gowns and sometimes did not. Both aides stated they were unaware the resident was on enhanced barrier precautions, citing lack of report and information. The enhanced barrier sign was present outside the room, but staff did not recognize or follow the protocol until it was pointed out during the survey. In another case, a resident with an indwelling Foley catheter and severe cognitive impairment was observed walking from their room to the nurse's station carrying their drainage bag by hand, without a leg bag in place. Staff interviews revealed that the resident routinely carried the drainage bag and had not been observed with a leg bag, despite staff awareness that a leg bag should be used during the day. The LPN and Certified Nurse Aide involved indicated that the resident did not comply with the use of a leg bag, and the care plan noted the resident was encouraged to use one. The facility's infection control policy, last revised in April 2024, requires enhanced barrier precautions, including targeted gown and glove use, for residents at increased risk for multidrug-resistant organisms. The policy applies to all employees providing care. However, the survey found lapses in communication and adherence to these protocols, as staff were either not informed or did not follow the required precautions during high-contact care activities for residents on enhanced barrier precautions.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to adhere to accepted standards of practice for medication administration, specifically regarding the timing of medication delivery. On two separate occasions, Licensed Practical Nurses (LPNs) administered medications to residents significantly later than the prescribed time without notifying the attending physician. For instance, one LPN attempted to administer 13 medications to a resident at 12:30 PM, although the medications were ordered for 9:00 AM. The LPN did not notify the physician about the delay, citing a lack of time as the reason for not doing so. Another incident involved an LPN administering 10 medications to a resident at 10:05 AM, despite the medications being scheduled for 9:00 AM. Again, the physician was not notified of the late administration. The facility's policy requires medications to be administered within one hour before or after the scheduled time, and any deviations should be communicated to the physician. However, this protocol was not followed, leading to a deficiency in medication administration practices. The report also highlights systemic issues within the facility, such as understaffing and communication breakdowns among nursing staff. On one occasion, an LPN was responsible for administering medications to 38 to 40 residents without assistance, making it impossible to adhere to the prescribed medication schedule. The Director of Nursing acknowledged these challenges but did not take immediate corrective actions to address the staffing and communication issues, contributing to the ongoing deficiencies in medication administration.
Medication Administration Deficiency in Dementia Unit
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, particularly in the Second Floor Dementia Unit, where medications were not administered timely to 23 out of 40 residents reviewed. The medications involved included antianxiety, antidiabetic (insulin), anticoagulant, antihypertensive, antipsychotic, anti-Parkinson's, and antiseizure drugs. The facility's policy required medications to be administered within one hour before or after the scheduled time, but this was not adhered to, leading to late administration of medications from 07/01/2024 to 08/13/2024. Licensed Practical Nurse (LPN) #3 was observed administering medications alone to approximately 38 residents on the Second Floor Dementia Unit, which was beyond their capacity to complete within the required timeframe. LPN #3 admitted to regularly administering medications late due to the lack of assistance and the impracticality of calling for help or notifying physicians. Similarly, LPN #4, who was the Unit Manager, was also tasked with medication administration, which interfered with their primary responsibilities of treatment and care plan management. Both LPNs acknowledged the late administration of medications, as indicated by the yellow alerts on the Electronic Medical Record dashboard. The Director of Nursing (DON) and the Medical Director were unaware of the extent of the medication administration issues until the survey. The DON admitted to not reviewing detailed reports that would show the timing of medication administration and relied on the dashboard for documentation. The Medical Director confirmed that no acute issues were reported among the residents, but acknowledged the potential risks associated with late administration of time-sensitive medications such as insulin, anticoagulants, and antipsychotics. The Pharmacy Consultant also stated that their reviews did not include time-stamped administration records, indicating a gap in oversight.
Late Medication Administration and Lack of Physician Notification
Penalty
Summary
The facility failed to ensure that Resident Primary Care Physicians comprehensively reviewed the residents' total program of care, including medications and treatments, for 24 out of 40 residents reviewed. A review of the medication administration detailed report revealed that residents received their medications late, including 19 residents with significant medications such as antianxiety, antidiabetic (insulin), anticoagulant, antihypertensive, antipsychotic, anti-Parkinson's, and antiseizure drugs. There was no documented evidence that facility staff communicated these delays to the residents' Primary Care Physicians or the Medical Director, which could directly impact the residents' health outcomes. The Medical Director was unaware of the consistent late medication administration until informed by the Director of Nursing during the survey. The Attending Physician stated they had been notified of late medication administration but did not believe it occurred often or had adverse outcomes. The facility's Administrator identified staffing as the root cause of the issue. The facility's policies require the medical staff to ensure the quality of medical care and for the Consultant Pharmacist to perform monthly drug regimen reviews, identifying and reporting medication irregularities for review and action by the attending physician.
Insufficient Nursing Staff Leads to Late Medication Administration
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the care needs of residents on the Second Floor Dementia Unit, as observed during an abbreviated survey. Specifically, on the morning of August 13, 2024, there was no additional medication nurse available to administer medications on the north side of the unit, resulting in 23 residents receiving their 9 AM medications late. This issue was not isolated to a single day, as a review of the Medication Administration History Detailed Report from July 1, 2024, to August 13, 2024, revealed a consistent pattern of late medication administration on the second floor. The facility's daily shift schedule and interviews with the Director of Nursing confirmed that only one medication nurse was assigned to pass medications to all 40 residents on the second-floor dementia unit. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed and within the scheduled time frame. However, the review of resident physician orders and medication administration records for 40 residents from August 12 to August 13, 2024, showed that 24 residents received their medications late, with no documentation of physician notification. Among these, 19 residents had significant medications, such as antianxiety, antidiabetic, anticoagulant, antihypertensive, antipsychotic, anti-Parkinson's, and antiseizure medications, administered outside the prescribed time frame. Interviews with nursing staff revealed that when short-staffed, the medication nurse had to administer medications to 38 to 40 residents alone, making it impossible to complete the task within the required time frame. Interviews with facility administration, including the Director of Nursing and the Administrator, indicated awareness of the staffing issues on the second floor. The Director of Nursing acknowledged that the medication nurse had been handling the medication pass for 40 residents alone for some time, and the Administrator noted that there was no policy for mandating personnel, particularly agency staff. The facility's staffing coordinator and nursing supervisors attempted to cover open shifts, but the staffing levels remained inadequate to ensure timely medication administration. The facility administration did not identify the need to ensure sufficient staff for medication administration to meet prescribers' orders on the Second Floor Dementia Unit.
Deficiency in Timely Medication Administration
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies related to medication administration. On multiple occasions, residents did not receive their medications on time, including significant medications such as antianxiety, antidiabetic, anticoagulant, antihypertensive, antipsychotic, anti-Parkinson's, and antiseizure drugs. Despite receiving feedback from a Bureau of Narcotics representative and complaints from the Resident Council about late medication administration, the facility did not conduct a thorough investigation or audit the medication administration practices. The facility's QAPI meeting agendas for June and July 2024 did not include discussions specific to late medication administration, and the Resident Council meeting minutes indicated complaints about late medications affecting residents' ability to attend activities. The Director of Nursing was aware of the complaints but attributed the issue to staffing challenges, including multiple call-outs. During the survey, the Administrator acknowledged the lack of notification to attending physicians about late medication administration and the ongoing staffing issues, which were exacerbated by the use of agency staff.
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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