King Street Home Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Chester, New York.
- Location
- 787 King Street, Port Chester, New York 10573
- CMS Provider Number
- 335447
- Inspections on file
- 16
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at King Street Home Inc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Surveyors determined that the facility did not send the required transfer notice to the State LTC Ombudsman when a resident with vascular dementia, post-stroke sequelae, constipation, and atrial fibrillation—who had documented memory impairment, behavioral symptoms, and dependence for toileting and transfers—was sent to the hospital via ambulance. A nursing note recorded the transfer, but there was no documentation that the Ombudsman was notified. During interviews, the Director of Social Services and the Assistant Administrator stated that Ombudsman notifications for hospitalizations and discharges were usually emailed in batches and acknowledged that no email notification for this transfer could be located, characterizing the omission as an oversight.
Two residents received incorrect psychotropic medications or experienced delays in recommended medication changes due to failures in order transcription, documentation, and verification. Errors included administration of medications intended for another resident with a similar last name and delayed implementation of psychiatry consult recommendations, with incomplete documentation in the medical record.
A resident's legal representative requested medical records, but the facility did not provide the records within the required two working days, instead taking twelve days to fulfill the request. Facility policy and staff practice allowed for a seven to ten business day turnaround, which did not meet federal regulations.
The facility did not post required contact information for State agencies and advocacy groups in areas accessible to residents or their representatives. Only limited information, such as the Ombudsman contact, was posted, while other required documents were kept in a logbook and not made visible or accessible. The deficiency was confirmed through observation and staff interview.
The facility did not post the most recent Department of Health survey results in a location that was easily accessible to residents, families, or visitors. Instead, the results were kept in the back of the visitor sign-in logbook, and staff were either unaware of their location or acknowledged that visitors would not know the results were available unless specifically requested.
A resident's care plans were mistakenly sent to another resident's representative, resulting in a breach of confidentiality. The error occurred when an administrative staff member, while rushing to meet a deadline, compiled and sent the wrong medical records. The mistake was discovered when the receiving physician's office identified the error.
A resident's representative filed multiple grievances over several months regarding care, safety, and rights violations, but the facility failed to post information about the grievance process, did not provide written decisions or document specific resolutions, and staff interviews confirmed inconsistent tracking and communication regarding grievances.
A resident with multiple diagnoses and cognitive impairment had inconsistent documentation in their MDS assessments, with discrepancies in extremity impairments, assistive device use, and functional abilities. Errors were made by different staff members responsible for various MDS sections, and the MDS Coordinator acknowledged that the assessments did not accurately reflect the resident's status.
A resident with severe cognitive impairment and multiple health issues was diagnosed with pneumonia and prescribed antibiotics and oxygen therapy, but no care plans were initiated for these treatments. Staff interviews revealed confusion over responsibility for updating care plans, and the required care plans for pneumonia, antibiotic use, and oxygen therapy were not created, resulting in a deficiency.
A resident with multiple diagnoses, including vascular dementia and mood disorder, did not have their care plans for medication refusals, physical aggression, social needs, and nutritional problems reviewed or updated by the interdisciplinary team following a quarterly MDS assessment. Staff interviews confirmed that required quarterly care plan reviews and documentation were not consistently completed.
The facility did not ensure safety during a fire alarm system outage exceeding four hours, as required by NFPA 101. The alarm was offline due to renovations, but the facility failed to notify the Department of Health or conduct a fire watch. The Director of Maintenance confirmed the alarm was offline to prevent false alarms, and the Assistant Administrator acknowledged the need for future fire watch implementation.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
Surveyors found that the facility failed to ensure that a copy of the notice of transfer was sent to the State Long Term Care Ombudsman for one of three residents reviewed for hospitalization, as required by 10 NYCRR 483.15(c)(3). The resident involved had diagnoses including vascular dementia with behavioral disturbance, sequelae of cerebral infarction, constipation, and atrial fibrillation, and the quarterly MDS documented short- and long-term memory problems, verbal and physical behavioral symptoms toward others, and dependence for toileting and transfers. A nursing progress note recorded that the resident was transferred to the hospital via ambulance in the early morning hours, but there was no documented evidence that a transfer notice was sent to the New York State Ombudsman for this hospitalization. During interviews, the Director of Social Services reported that Ombudsman notifications for hospitalizations and discharges were typically sent via email on a monthly basis and acknowledged they were unable to locate the notification for this transfer, and the Assistant Administrator confirmed that both Social Services and Medical Records could not find an email notification for the transfer, describing the lack of notification as an oversight.
Significant Medication Errors Due to Order Transcription and Administration Failures
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication order transcription and administration. One resident, who was cognitively intact and required assistance with mobility and daily activities, was mistakenly prescribed and administered Lexapro (an antidepressant) and Seroquel (an antipsychotic) for a period of 12 days. These medications were not part of the resident's original regimen and were intended for another resident with a similar last name. The error was discovered during a discharge medication review with the resident's family representative, who alerted the nurse that the resident had never been on those medications. The nurse confirmed the error after reviewing the medication list and contacting the prescriber, who acknowledged that the orders were made in error. There was no documentation in the progress notes regarding the verbal orders received, nor was there a physician's order noted for the verbal order given. Another resident, who had moderate cognitive impairment and required significant assistance with daily activities, did not receive recommended changes to their psychotropic medication regimen in a timely manner. Following a psychiatry consult, recommendations were made to adjust the resident's Seroquel and Lexapro dosages due to improved condition and lack of behavioral issues. However, the recommended changes were not initiated for several days, and the medication administration record did not reflect the adjustments as ordered. The resident continued to receive the previous dosages beyond the recommended change date, and the consult notes did not accurately reflect the resident's current medication regimen. The facility's policy required that all medication orders, including changes and discontinuations, be documented in the resident's medical record and that verbal orders be documented immediately and signed by the physician within 24 hours. In both cases, there was a lack of proper documentation and verification of medication orders, leading to administration errors. The errors were attributed to confusion between residents with similar last names and a lack of regular familiarity with the residents by the nurse transcribing the orders. The events were confirmed through interviews with nursing staff and the prescriber, as well as review of medical records and facility documentation.
Delayed Provision of Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with a copy of the resident's medical records within the required timeframe after a request was made. The legal representative requested the records via email, but did not receive them until twelve days after the initial request, exceeding the regulatory requirement of providing access within two working days. The delay was confirmed through review of email correspondence and interviews with facility staff. Additionally, the facility's policy on access to medical records did not align with federal regulations. The policy stated that copies of medical records would be provided within seven to ten business days, which does not meet the federal requirement for access within two working days. Interviews with the Administrative Coordinator and Assistant Administrator revealed that staff were only aware of the seven to ten business day timeframe and were not familiar with the correct regulatory timeframe.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to ensure that postings containing the names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups were accessible and understandable to residents and their representatives. During the survey, it was observed that there were no visible postings of this required information throughout the facility. The only postings observed were the staffing schedule, information about the wound care company, and contact information for the Office of Long-Term Care Ombudsman program, which were located in a glass encasement near the Assistant Administrator's office and in the elevators. No additional postings with the required information were found in other areas accessible to residents or their representatives. A review of the visitor sign-in logbook revealed that some documents, such as the New York State Department of Health complaint hotline number, Ombudsman hotline number, Residents' Rights, and survey results, were present but not posted; instead, they were kept in sheet protectors within the logbook and not accessible to residents. During an interview, the Assistant Administrator stated that the Department of Health complaint number was posted in the survey book at the front desk and included in the admission packet, but the surveyor confirmed that resident rights were not posted in the facility. The required postings were not observed in the glass encasement or elsewhere during the onsite survey.
Survey Results Not Readily Accessible to Residents and Families
Penalty
Summary
The facility failed to ensure that the results of its most recent New York State Department of Health survey were posted in a location that was readily accessible to residents, their families, and other interested parties. During the survey, it was observed that the survey results were kept in the back of the visitor sign-in logbook, which was not visible or easily accessible to visitors unless specifically requested. There was no notice posted in prominent or public areas of the facility to inform residents or visitors of the availability of these reports. Interviews with facility staff revealed a lack of awareness regarding the location of the survey results. The Assistant Administrator stated that the Department of Health complaint number was included in the survey book at the front desk and in the admission packet, but acknowledged that the survey results were not posted in prominent locations. The Receptionist confirmed that the survey results were in the back of the logbook and would not be noticed unless someone asked for them. The Director of Nursing was unaware of where the most recent survey results were located. These findings indicate that the facility did not comply with its own policy or state regulations regarding the posting of survey results.
Confidentiality Breach in Medical Record Handling
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical records for one out of three residents reviewed for confidentiality. Specifically, the Administrative Coordinator sent the care plans of one resident to the representative of another resident in error. This occurred when the representative of a resident requested medical records to be forwarded to the resident's physician, but the records sent included the care plans of a different resident. The error was identified when the physician's office notified the representative about the incorrect records. The incident involved residents with significant cognitive impairments and complex medical histories, including diagnoses such as vascular dementia, cardiomyopathy, mood disorder, major depression, and pulmonary embolism. The Administrative Coordinator acknowledged that the mistake happened because they were rushed to send the documentation before a deadline, resulting in the wrong resident's information being compiled and sent. The facility's policy requires confidential treatment of all personal and medical records, but this was not followed in this instance.
Failure to Inform Residents of Grievance Process and Document Resolutions
Penalty
Summary
Surveyors found that the facility failed to ensure residents and their representatives were properly informed about the grievance process, including how to file grievances, who the grievance official was, and the contact information for independent entities such as the State agency and Ombudsman. There were no postings in prominent locations throughout the facility to notify residents of their rights to file grievances orally or in writing, nor was there information about the expected time frame for grievance review or the right to receive a written decision. The facility's policy required such notifications and prompt investigations, but these were not observed in practice. A review of grievance reports revealed that a resident's representative filed daily grievances over several months, covering issues such as care, safety, hygiene, financial matters, and rights violations. The documentation of these grievances consistently lacked specific resolutions, with reports often stating that issues remained ongoing and that the representative's expectations were considered unrealistic. The facility's records did not include written decisions confirming or denying the grievances, details of corrective actions taken, or the dates decisions were issued, as required by regulation. Interviews with facility staff, including the Director of Social Services and the Assistant Administrator, confirmed that the grievance process was not consistently followed. The Director of Social Services, who served as the grievance officer, did not keep track of grievances or their resolutions and was unsure if the grievance process was posted in the facility. The Assistant Administrator acknowledged ongoing difficulties with the resident's representative and confirmed that no satisfactory resolutions had been documented for the grievances. The lack of proper documentation and notification contributed directly to the deficiency cited.
Inaccurate MDS Assessments Due to Documentation Discrepancies
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident's status, resulting in discrepancies across multiple assessment dates. Specifically, the MDS assessments for one resident showed inconsistent documentation regarding extremity impairments, use of assistive devices, and functional abilities. For example, some assessments indicated impairment in upper and/or lower extremities and the use of a wheelchair or walker, while others documented no impairments and no assistive device use, despite the resident consistently using a wheelchair. The resident involved had diagnoses including vascular dementia, cardiomyopathy, and a mood disorder, and was noted to have varying levels of cognitive impairment and functional dependency in the MDS records. The inconsistencies were found in assessments completed by different staff members, including the Regional Director and the Director of Rehabilitation, who admitted to errors in coding the resident's use of assistive devices and functional status. The MDS Coordinator acknowledged that the information in several assessments was incorrect and that the resident's use of a wheelchair had not changed. Interviews revealed that the MDS Coordinator oversees the completion of the MDS but relies on each department to complete and sign off on their respective sections. The Coordinator stated that it was unrealistic to review all areas of the assessment and that the discrepancies should have been identified, especially when the same person completed multiple sections. The Director of Rehabilitation also confirmed an error in coding the resident's device use, further contributing to the inaccurate assessments.
Failure to Initiate Care Plans for Pneumonia, Antibiotic, and Oxygen Therapy
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident diagnosed with pneumonia who was prescribed antibiotics and oxygen therapy. Record review showed that, despite physician orders for oxygen therapy and antibiotics, there were no corresponding care plans initiated for pneumonia, antibiotic use, or oxygen use. The resident in question had multiple diagnoses, including severe cognitive impairment, required assistance with activities of daily living, and used oxygen for shortness of breath. The facility's policy required that care plans be updated as residents' conditions changed, but this was not followed in this case. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The DON acknowledged weaknesses in the current care plan update process and noted ongoing efforts to improve it. The MDS Coordinator and nursing staff provided conflicting accounts of who was responsible for initiating and updating care plans following new orders. Ultimately, the care plans for pneumonia, antibiotic use, and oxygen therapy were not created or updated as required, resulting in noncompliance with regulatory requirements.
Failure to Review and Update Care Plans After Quarterly Assessment
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly Minimum Data Set (MDS) assessments. Specifically, the care plans addressing medication refusals, physical aggression, social needs, and nutritional problems for a resident with diagnoses such as vascular dementia, cardiomyopathy, and mood disorder were not reviewed or updated in conjunction with the quarterly MDS completed on 12/17/2024. The care plans had last been revised on various dates prior to the quarterly assessment, and there was no documentation indicating that the interdisciplinary team had reviewed or updated them at the required interval. Interviews with facility staff, including the MDS Coordinator RN and the Assistant Administrator, confirmed that the process for care plan review and updates was not consistently followed. The MDS Coordinator RN acknowledged that while care plans are supposed to be reviewed quarterly and updated as changes occur, there was no notation or documentation in the care plans to indicate that a review had taken place if no changes were needed. The Assistant Administrator stated that responsibility for updating care plans is shared among the nursing supervisor, MDS coordinator, and other team members, but the required quarterly review and documentation were not evident in the resident's records.
Failure to Implement Fire Watch During Alarm System Outage
Penalty
Summary
The facility failed to ensure occupant safety during a period when the fire alarm system was out of service for more than four hours, as required by the 2012 NFPA 101 standards. During a complaint investigation survey, it was discovered that the fire alarm system in the West Unit was offline due to ongoing renovations, which had been occurring for approximately two weeks. Signage at the nursing stations indicated that the fire alarm was out of service and instructed to call 911 in case of fire. However, the facility did not notify the Department of Health about the impairment, nor did they implement a fire watch to protect the occupants during this period. The Director of Maintenance acknowledged that the fire alarm system was intentionally placed offline to prevent false alarms due to dust from the renovation work. Despite this, the facility did not take the necessary steps to ensure safety by notifying the appropriate authorities or conducting a fire watch. The Assistant Administrator later stated that the facility would implement a fire watch on an hourly basis in the future, but at the time of the survey, these measures were not in place, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 4, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Facility will notify the department of health and will conduct a fire watch when/if the fire alarm is impaired for more than 4 hours at any given time. 03/01/2025 2. The facility’s Fire Safety and Alarm Impairment Policy has been revised to ensure full compliance with NFPA 101: 9.6.1.6 and NYCRR regulations. Updates include: - Mandatory notification to the Department of Health for any fire alarm impairment over 4 hours. - Immediate implementation of a fire watch whenever the fire alarm system is offline, regardless of the duration. - Documentation of fire watch rounds, including times and assigned staff, to be maintained for regulatory review. - All involved staff members have been in-serviced. 03/01/25 3. The Maintenance Director will conduct weekly audits for the next 90 days to verify compliance with fire alarm impairment protocols and fire watch implementation. Any non-compliance will be immediately addressed. 03/01/25 4. Maintenance Director will be responsible for making Environmental rounds quarterly and reporting findings to Assistant Administrator to review at QA to ensure compliance for one year. 03/01/25 5. Responsible party: Director of Maintenance and Assistant Administrator. 03/01/25
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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