Livingston Hills Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Livingston, New York.
- Location
- 2781 Route 9, Livingston, New York 12541
- CMS Provider Number
- 335389
- Inspections on file
- 29
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 49
Citation history
Health deficiencies cited at Livingston Hills Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was not allowed to manage his or her own financial affairs, in violation of regulatory requirements.
Residents did not receive mail on Saturdays because the activities department, responsible for sorting and distributing mail, was not available on that day. All residents present at a council meeting confirmed the lack of Saturday mail delivery, and staff interviews verified that mail was only distributed Monday through Friday, contrary to facility policy.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
Surveyors found that the facility lacked sufficient documentation of completed annual mandatory education for nurses and nurse aides, as required by the facility assessment. Staff reported no effective system to notify them of required training, and education records were incomplete. Education materials were left for staff to complete independently, but there was no consistent auditing or tracking. Leadership changes and missing prior records contributed to the deficiency, and there was no specific training provided for care of residents with dementia versus those with mental illness.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, as evidenced by observations and records.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
The facility failed to maintain a documented plan describing the process for conducting QAPI and QAA activities, as required for quality assurance and performance improvement.
Surveyors observed ongoing fly and insect activity in multiple resident rooms, staff areas, and the kitchen, with no evidence of a maintained pest control management book. The Director of Maintenance confirmed recent pest treatment by a vendor, but documentation of the service was not available at the time of the survey.
Menus were not consistently prepared in advance, followed, updated, or reviewed by a dietician, resulting in failure to meet the nutritional needs of residents according to their care plans.
Surveyors observed that food and drink served to residents was not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency.
The facility did not ensure residents were aware of the grievance process or provide consistent access to anonymous grievance submission. On one unit, no suggestion/grievance box was available, and most residents interviewed were unaware of how to file a grievance or who the grievance official was. Staff interviews revealed inconsistencies in knowledge about the grievance process and the location of grievance boxes.
Multiple residents did not have complete or accurate care plans addressing their clinical needs. For example, a resident with dementia and fall risk had floor mats in use without care plan documentation or provider order, and the call bell was not within reach as required. Another resident with edema lacked care plan goals or interventions, and a resident with a chronic wound had no care plan for wound care, despite ongoing treatment. Facility leadership confirmed these omissions.
Surveyors found that the facility's medication administration practices resulted in a medication error rate of 5 percent or greater, exceeding the regulatory limit.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident with significant cognitive and physical impairments was repeatedly observed wearing only a hospital gown in a common area because their personal clothing was not returned from the off-site laundry service. The resident reported this was a recurring issue, and staff confirmed that missing laundry was a known problem, sometimes requiring replacement if a grievance was filed. This failure prevented the resident from retaining and using their personal possessions, impacting their dignity.
The facility did not ensure that survey results and advocate agency information were readily accessible to residents and visitors, as required by policy. Residents reported not knowing where to find survey results, and observations showed the binder was either obstructed, missing, or not clearly marked, with staff unaware of proper signage or binder location.
A resident admitted with vascular dementia, depression, and metabolic encephalopathy did not have a baseline care plan developed and implemented within 48 hours of admission, as required by facility policy. Staff confirmed the absence of the care plan and were unable to explain why it was not completed.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with multiple medical and psychiatric conditions was found to have a bare room with no furniture or home-like touches, and a mattress placed on the floor, without any supporting care plan or physician order. Staff interviews revealed the changes were made due to safety concerns, but there was no documentation or care planning to justify the removal of furniture or the altered room setup.
A resident with cancer, diabetes, and heart failure developed a large, tender bruise on the left leg after a fall, but the bruise was not promptly assessed or reported. Required weekly skin checks were not documented as completed, and staff interviews confirmed that new skin issues should have been reported immediately to the charge nurse. The DON acknowledged that the necessary assessments and documentation were not performed as ordered.
A resident experienced a decline in range of motion or mobility because the facility did not provide appropriate care to maintain or improve ROM, and there was no documented medical reason for the decline.
Two disposable razors and an unlabeled electric razor were found accessible in a shared bathroom used by two residents—one with severe cognitive impairment and one with multiple chronic conditions. Staff interviews confirmed that razors should not have been left in the bathroom, as both residents required staff assistance or supervision for personal hygiene, and the presence of razors posed a risk for self-harm.
A resident with end stage renal disease did not have consistent documentation or communication of dialysis care as required by facility policy. Nursing staff failed to complete and log dialysis communication sheets for multiple treatment dates, and the communication book was missing during the survey. The electronic medical record also lacked documentation for several dialysis sessions, and staff were unable to provide the required records upon request.
Nurse staffing information was not posted in a location accessible to all residents and visitors on multiple days, as required by facility policy and regulations. Observations confirmed the absence of posted staffing data in key areas, and a staffing coordinator stated the information was not posted due to time constraints during the survey.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
The facility did not ensure access to resident medical records from before a system transition, failing to follow its compliance and ethics program for record retention. The Administrator, acting as Corporate Compliance Officer, was aware of the issue but did not report it to relevant committees or IT staff, resulting in incomplete medical record accessibility for residents admitted prior to the transition.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure that an effective training program was developed, implemented, or maintained for all new and existing staff members, as required by regulations.
The facility failed to appoint a licensed Nursing Home Administrator, relying instead on an unlicensed acting administrator. Despite extensions granted by the state, the licensed administrator was only present for limited hours weekly, leading to a deficiency in management and operational oversight.
The facility failed to implement effective Quality Assurance measures, resulting in recurring deficiencies in maintaining a safe environment, food safety, and infection control. Despite having a Quality Assurance Performance Improvement plan, there were no documented procedures for performance monitoring or corrective actions, leading to repeated issues identified in surveys.
The facility failed to uphold residents' rights and dignity by not providing appropriate clothing and privacy. A resident was left in a hospital gown for days due to a lack of fitting clothes, another was exposed in a gown visible from the hallway, and a third resident wandered with soiled clothing. Staff admitted difficulties in providing suitable clothing, relying on donated items and hospital gowns.
The facility failed to protect residents' personal property, as belongings sent for laundering were not returned timely. Despite policies for labeling and inventorying items, these were not consistently followed, leading to missing items for four residents. Staff interviews revealed inconsistencies in the process, contributing to the deficiency.
The facility failed to resolve grievances in a timely manner for three residents, as grievances were not documented or addressed through the facility's process. Residents were unaware of who handled grievances, and staff interviews revealed inconsistencies in the grievance process, including inaccessible grievance forms and unclear procedures for inventorying belongings. This led to unresolved issues such as missing personal items.
The facility failed to develop and implement comprehensive care plans for three residents. Two residents on anticoagulants lacked documented interventions, and another resident with significant weight loss did not have physician supervision documented. This was contrary to the facility's policy requiring timely and individualized care plans.
The facility was found to have insufficient nursing staff competencies, failing to conduct proper evaluations for licensed staff. A resident with multiple inhalers expressed concerns about timely access to a rescue inhaler, while another resident's PICC line dressing was improperly maintained. Staff interviews revealed gaps in training and competency assessments, with no documented policies or procedures in place.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist for several residents, as required by policy. Despite observations of normal resident interactions, documentation revealed missing reviews for multiple months. Interviews indicated a misunderstanding of review frequency requirements among staff.
The facility failed to properly label and store medications and biologicals, as observed during a survey. Urine specimens were stored with insulin, and several medications lacked expiration dates. The controlled substance cabinet lock was broken, and staff reported inconsistent directives due to frequent changes in leadership.
During a survey, deficiencies in food safety and sanitation were observed in the facility's main kitchen and a kitchenette. Issues included dented cans, an uncalibrated thermometer, and unclean equipment. Additionally, the South Unit kitchenette had a split refrigerator gasket and soiled cabinets, indicating a failure to meet professional food service standards.
A resident with cerebral palsy and other health conditions was unable to get out of bed due to the facility's failure to provide an appropriate wheelchair. Despite the resident's repeated requests and their ability to self-propel, they were only offered unsuitable options, leading to a violation of their right to self-determination and choice.
A resident with severe cognitive impairment had inconsistent documentation of their advance directive, specifically their code status, in a LTC facility. The Medical Orders for Life-Sustaining Treatment indicated a Do Not Resuscitate/Do Not Intubate status, while social work notes documented a Cardio-Pulmonary Resuscitation status. Observations and staff interviews revealed that the code status was not consistently documented across the resident's chart, ID bracelet, and electronic records, leading to a deficiency.
A resident with chronic respiratory conditions experienced a significant change in health status, requiring hospitalization and new respiratory treatments. Upon return, the facility failed to update the care plan to include these changes, as confirmed by staff interviews. This oversight led to a deficiency in care planning.
A facility failed to complete a baseline care plan for a resident with a fractured back, diabetes, and chronic bladder inflammation within 48 hours of admission, as required by policy. The resident, who had moderate cognitive impairment, did not have their care plan completed and signed until several days later. Interviews with staff revealed inconsistencies in understanding and executing the policy, indicating a systemic issue in policy adherence.
A facility failed to update a resident's Comprehensive Care Plan following changes in their psychotropic medication regimen. Despite adjustments in the resident's sertraline dosage, the care plan was not revised to reflect these changes, as required by facility policy. The oversight was identified during a recertification survey, with the DON acknowledging the need for person-centered care plans that include non-pharmacological interventions and monitoring.
A resident with Alzheimer's and heart disease was not provided with prescribed compression stockings due to non-compliance and oversight in care planning. Despite having a standing order for the stockings to manage edema, staff did not apply them, citing the resident's tendency to remove them. The facility's policy for comprehensive care planning was not followed, and leadership changes contributed to the oversight.
A resident with a history of chronic obstructive pulmonary disease and other conditions was found using tobacco in their room, violating the facility's smoking policy. The care plan did not address the resident's non-compliance, and staff were aware but did not consistently enforce the policy. Tobacco products were confiscated from the resident's room, indicating a failure to prevent unsupervised access.
A resident with significant cognitive impairment and multiple diagnoses experienced a 17.45% weight loss over several months without adequate medical supervision. Despite dietary notes indicating weight loss and dehydration, the physician was not notified, and the resident's meals were observed to be unappetizing and insufficient. Facility policies requiring notification of significant condition changes were not followed.
A resident was prescribed Aripiprazole without a documented indication for use, violating facility policy. Despite monthly medication regimen reviews, the necessary documentation was missing, as confirmed by staff interviews and record reviews.
The facility was found to have improper disposal of garbage and refuse, with one dumpster leaking a black oily liquid and a build-up of leaves around another dumpster, indicating inadequate maintenance and cleanliness.
A resident with a PICC line experienced improper infection control practices, as the dressing was found peeling and soiled, and the line was not properly managed. Despite the facility's policy, the dressing was not dated, and a port was left uncapped. The resident had a history of osteomyelitis and other conditions, and the issue was addressed by the nurse upon notification.
Failure to Honor Resident's Right to Manage Financial Affairs
Penalty
Summary
The facility failed to honor a resident's right to manage his or her own financial affairs. This deficiency was identified based on the surveyor's findings that the resident was not permitted to exercise control over personal financial matters as required by regulation. No additional details regarding the specific actions or inactions by staff, the resident's medical history, or the resident's condition at the time of the deficiency are provided in the report.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. According to facility policy, residents have the right to send and receive mail, including letters, packages, and other materials delivered by means other than the postal service. However, during a surveyor-led Resident Council meeting, all residents present reported that mail was not delivered to them on Saturdays. Interviews with staff confirmed that mail was only delivered Monday through Friday, as the activities department, responsible for sorting and distributing mail, was not available on Saturdays. The administrator was unaware of the specific mail delivery schedule and deferred to the activities director for details. This practice affected all residents in the facility.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Incomplete Staff Education and Competency Documentation
Penalty
Summary
The facility did not have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services necessary to assure resident safety and to help residents attain or maintain their highest practicable well-being, as determined by resident assessments and individual care plans. Observations, record reviews, and interviews revealed that documentation of completed annual mandatory education for nursing staff was incomplete and varied among staff members. The facility assessment identified required staff training and competencies, including resident rights, abuse prevention, infection control, dementia care, and other specialized care needs, but education records for several nurses and nurse aides were found to be incomplete. Interviews with staff indicated there was no effective system in place to notify staff of required education, and staff reported a lack of time to complete mandatory training. Education materials were left near the time clock for staff to complete on their own, but there was no consistent auditing or tracking of completion. The Director of Nursing, who also served as the Nurse Educator, acknowledged that education organization and tracking were lacking, and that annual evaluations had not been completed. The facility had recently undergone changes in leadership, and previous education records were missing, requiring the creation of a new tracking system. Staff also reported that there was no specific education provided for care of residents with dementia versus those with mental illness.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Accommodate Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified based on observations and records indicating that residents were not always served meals that met their documented dietary needs and preferences.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Lack of QAPI and QAA Process Plan
Penalty
Summary
The facility did not have a plan that describes the process for conducting Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities. This deficiency was identified based on the absence of documentation or evidence outlining the procedures or steps the facility uses to carry out QAPI and QAA functions as required.
Failure to Maintain Pest-Free Environment and Effective Pest Control Program
Penalty
Summary
Surveyors identified that the facility failed to maintain a pest-free environment and did not have an effective pest control program in place across both resident units. Persistent fly activity was observed in multiple locations, including resident rooms, the main kitchen, staff areas, and the North Unit activity room, throughout the survey period. Specific instances included flies in the rooms of several residents, in a staff office, and small flying insects in a resident bathroom. Additionally, there was no evidence of a maintained Pest Control Management book, and the Director of Maintenance reported that although a vendor had recently treated for flies, documentation of the service had not yet been received.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals and drinks served to residents.
Failure to Ensure Resident Awareness and Access to Grievance Process
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process and did not provide all residents with the option to file grievances anonymously, as required by facility policy and regulation. Specifically, on the South Unit, there was no suggestion/grievance box available for residents to submit anonymous grievances, and the box that was previously there had been removed after a resident attempted to tamper with it. Additionally, there was no suggestion/grievance box located by the social work office as stated in the facility's policy, nor were there boxes in other common areas such as the lobby, dining room, or therapy gym. Only the North and East Units had visible suggestion/grievance boxes across from the nurse's station. During a surveyor-led Resident Council meeting, seven out of eight residents reported they did not know how to file a grievance within the facility, and all eight were unaware of who the grievance official was. Interviews with facility staff, including the Director of Social Services, Administrator, and DON, revealed inconsistencies in their knowledge of the location of grievance boxes and the process for anonymous grievance submission. The Director of Social Services stated that residents were verbally informed of the grievance official upon admission, but this information was not included in admission paperwork. The Administrator and DON both assumed that grievance boxes were available on all units, but this was not the case, leading to a lack of access and awareness for residents regarding the grievance process.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for multiple residents, as required by policy and regulation. For one resident with dementia, major depressive disorder, and atrial fibrillation, the care plan for fall risk did not include the use of floor mats, despite their presence in the resident's room, and there was no documented provider order for their use. Additionally, the resident was observed in bed late in the morning, not yet cleaned up or gotten up for the day, with the call bell on the floor and floor mats in place, contrary to the care plan's directive to keep the call bell within reach and the environment safe and clutter-free. Another resident with malignant neoplasm of the kidney, type 2 diabetes, and heart failure had a care plan for edema that lacked documented goals or interventions. A third resident with inflammatory spondylopathies, chronic pain syndrome, cellulitis, and a venous or arterial ulcer had ongoing wound care orders and was being followed on wound rounds, but there was no comprehensive care plan addressing wounds, open areas, or impaired skin integrity. Interviews with facility leadership confirmed that care plans should include goals and person-centered interventions for each area of care, and that a care plan should have been in place for the resident's wound.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors among residents. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Resident Denied Access to Personal Clothing Due to Laundry Service Failure
Penalty
Summary
A deficiency was identified when a resident with diagnoses of Parkinson's Disease, major depressive disorder, and schizophrenia was observed on multiple occasions sitting in a common area wearing a hospital gown, which was untied in the back. The resident reported that their personal clothing had not been returned from the off-site laundry service, resulting in them having no clothing to wear. The resident stated that this issue with missing laundry occurred frequently. Facility staff interviews confirmed that laundry was sent to an outside service, with each resident's items placed in a labeled mesh bag. Staff acknowledged that articles of clothing were sometimes missed and later relocated, and that the facility would replace items if a grievance was filed. The facility's policy allows residents to keep and use their personal belongings as long as it does not interfere with others' rights or safety. However, the failure to ensure the timely return of the resident's clothing resulted in the resident being unable to use their personal possessions, which did not honor their right to dignity and respect.
Failure to Provide Accessible Survey Results and Advocate Agency Information
Penalty
Summary
The facility failed to ensure that residents could easily view the results of the most recent survey and access information about advocate agencies, as required by facility policy and regulatory standards. Although the policy stated that survey results would be posted in a place readily accessible to residents, family members, and legal representatives, observations and interviews revealed that this was not consistently implemented. During a Resident Council Meeting, all residents present reported not knowing where to find the survey results. A walkthrough showed that the binder containing survey results was placed on a second shelf in the lobby, partially obstructed by a sign listing visiting hours, and there were no signs indicating the availability of survey results in the lobby or on any of the facility's units or hallways. Further interviews with facility staff, including the administrator, receptionist, and DON, confirmed that the survey results were sometimes kept in the administrator's office and not always available in the lobby as intended. Staff were unaware of any signage indicating the location of the survey results, and at one point, the binder was missing from its usual location in the lobby. These actions and inactions resulted in residents and visitors not having clear or consistent access to the survey results or information about advocate agencies, contrary to facility policy and regulatory requirements.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The facility's policy, last revised in May 2024, requires that every resident have an interdisciplinary baseline care plan initiated within 48 hours of admission. However, record review and staff interviews revealed that for a resident admitted with vascular dementia, depression, and metabolic encephalopathy, there was no documented evidence of a baseline care plan in the medical record. The resident's Minimum Data Set assessment indicated severe cognitive impairment, but the resident was usually able to understand and be understood by others. Despite these needs, the baseline care plan was not located, as confirmed by the Regional Nursing Coordinator and the DON, who acknowledged the requirement but could not explain the omission. This failure was cited under 10 NYCRR 415.11.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Lack of Care Planning and Documentation for Room Modifications
Penalty
Summary
A deficiency was identified when a resident's room was found to be devoid of home-like touches and furniture, with the mattress placed directly on the floor and no decorations or personal items present. The resident, who had diagnoses of type 2 diabetes mellitus, dementia, and schizoaffective disorder, was assessed as severely cognitively impaired but able to communicate. Observations confirmed the lack of furniture and home-like environment, and documentation review revealed no physician order or care plan supporting the removal of the bed frame, furniture, or the placement of the mattress on the floor. Interviews with facility staff indicated that the furniture and bed frame had been removed due to the resident's behaviors and safety concerns, such as attempts to take apart the bed frame. However, staff were unaware of any care plan or physician order authorizing these changes, and the care plan did not reflect the current room setup. The lack of documentation and care planning for these significant environmental modifications resulted in the resident not receiving care and services in accordance with their preferences, choices, values, and beliefs.
Failure to Timely Assess and Report Large Bruise Following Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of malignant neoplasm of the kidney, type 2 diabetes mellitus, and heart failure did not receive timely assessment and reporting of a large bruise on the left outer leg, extending from the knee to midcalf. The resident was cognitively intact and required one-person assistance for bathing, dressing, and toilet use. The bruise was first documented by physical therapy on 7/15/2025 as being tender to the touch, and the resident reported pain in the left knee. The resident also reported to staff that they had fallen, and this was communicated to the medical provider. However, the Accident and Incident Report indicated the fall occurred on 7/08/2025 or 7/09/2025, suggesting a delay in recognition and reporting. Further review revealed that weekly skin checks, as ordered, were not documented as completed on 7/01/2025 or 7/08/2025 in the Treatment Administration Record. Interviews with staff confirmed that all ordered care should be provided and documented, and that new bruises or skin issues identified by CNAs should be reported immediately to the charge nurse. The Director of Nursing acknowledged that weekly skin checks should have been completed and signed for, and that the bruise should have been reported promptly. The lack of timely assessment and documentation led to the deficiency.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care was provided unless a decline was for a documented medical reason. This resulted in a resident experiencing a decline in ROM or mobility without evidence that the decline was medically unavoidable.
Failure to Remove Razors from Shared Bathroom Creates Accident Hazard
Penalty
Summary
Surveyors identified that the facility failed to ensure the resident environment was free from accident hazards for one of nine residents reviewed. Specifically, two disposable razors and an unlabeled electric razor were found in the shared bathroom of a semi-private room. One resident in this room had multiple sclerosis, COPD, and tachycardia, was cognitively intact, and required set-up assistance for personal hygiene. The roommate had Alzheimer's disease, major depressive disorder, and COPD, with severe cognitive impairment and required supervision for personal hygiene. Despite these conditions, razors were accessible in the shared bathroom on multiple observations. Interviews with staff confirmed that razors should not have been left in the bathroom, as staff are responsible for shaving both residents. The LPN acknowledged the risk of residents using the razors to harm themselves and indicated the razors would be removed. The DON stated that personal belongings, including razors, should not be left in shared bathrooms for infection control reasons and due to the risk posed to residents, especially those with mental health issues or who are ambulatory.
Failure to Consistently Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards and the facility's own policy. Specifically, nursing staff did not consistently complete, review, or log dialysis communication sheets for a resident between early April and late July. The facility's policy required staff to document pre- and post-dialysis information, including vital signs and continuity of care notes, in a communication book that should accompany the resident to and from dialysis. However, during the survey, the communication book could not be located, and only a few dates were documented in the log, despite evidence in the electronic medical record that the resident had attended additional dialysis sessions for which no communication documentation was available. The resident involved had diagnoses of end stage renal disease, essential hypertension, and adjustment disorder, and was cognitively intact. The care plan specified regular dialysis sessions and required monitoring and communication with the dialysis center. Interviews with nursing staff and the DON revealed uncertainty about the location of the communication book and inconsistent documentation practices. Requests for additional documentation covering a broader date range were not fulfilled, and the missing records were not located in the electronic medical record as expected. This lack of consistent documentation and communication failed to meet the facility's policy and professional standards for dialysis care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in an area accessible to all residents and visitors, as required by both facility policy and regulatory requirements. Specifically, nurse staffing levels for each shift were not posted in the facility on several dates, including July 21 through July 25, 2025, and July 28 through July 29, 2025. Observations confirmed that the required information was not displayed at the reception desk, in the lobby, or on any units or hallways. During an interview, the staffing coordinator acknowledged that the information was supposed to be posted at the receptionist's desk but admitted it was not done due to lack of time while the survey team was onsite. The facility's policy, last revised in September 2024, mandates that nurse staffing information be posted daily at the beginning of each shift in a clear and readable format in a prominent location accessible to residents and visitors.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Implement Compliance Program for Medical Record Retention
Penalty
Summary
The facility failed to effectively communicate and implement the standards of its compliance and ethics program, specifically regarding the retention and accessibility of resident medical records. During the survey, it was found that medical records dated prior to November 2024 were not accessible due to issues with transitioning between electronic medical record systems. The facility's policy requires retention of all medical records for the period required by law, but this was not followed, as records from the previous system were not available for residents admitted before November 2024. Interviews revealed that the Administrator, who also served as the Corporate Compliance Officer, was aware of the lack of access to these records but did not identify it as a concern or communicate the issue to the Corporate Compliance Committee, the Quality Assurance Performance Improvement Committee, or the Corporate Information Technology Nurse. The Corporate Information Technology Nurse and the Operator both stated they would have expected the Administrator to report the issue for continuity of care. The failure to ensure access to all required medical records was not addressed or escalated as required by the facility's compliance and ethics program.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and/or maintain an effective training program for all new and existing staff members. This deficiency was identified based on the lack of evidence that staff received adequate training as required by regulations. The report notes that the training program was either not in place, not properly implemented, or not maintained for both new hires and current employees. No specific residents or patient conditions are mentioned in the report, and there are no details provided about individual staff members or the direct impact on resident care.
Deficiency in Administrator Licensing and Oversight
Penalty
Summary
The governing body of the facility failed to implement policies ensuring that professional staff were licensed, certified, or registered according to Federal and State laws. Specifically, the facility did not appoint a licensed and currently registered Nursing Home Administrator to provide full-time, onsite oversight. The facility had been operating with an unlicensed acting administrator, Assistant Administrator #1, whose role was extended multiple times due to unsuccessful recruitment efforts for a permanent licensed administrator. Despite the New York State Department of Health's approval for Assistant Administrator #1 to act as an unlicensed administrator, the facility did not have a licensed Nursing Home Administrator present onsite as required. During the recertification survey, it was observed that the Nursing Home Administrator was not present in the building, and all administrative queries were directed to Assistant Administrator #1, who was not licensed. Interviews with staff, including a Licensed Practical Nurse, revealed confusion and lack of clarity regarding the oversight of Assistant Administrator #1. The facility's documentation confirmed that Assistant Administrator #1 was acting in the capacity of an administrator without the necessary licensure, and the licensed administrator was only present for limited hours weekly. This situation led to a deficiency in the facility's management and operational oversight.
Failure in Quality Assurance and Recurring Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies. This was evidenced by repeat deficiencies in maintaining a safe, clean, comfortable, and homelike environment, food procurement and safety, and infection control. The facility did not have documented evidence of written procedures for developing, monitoring, and evaluating performance indicators, nor did it have procedures for developing corrective actions to prevent quality of care, quality of life, or safety problems. Additionally, there was no evidence of procedures for obtaining feedback, data collection, or monitoring adverse events. The deficiencies were identified during recertification and abbreviated surveys, where it was noted that previously approved Plans of Correction for the cited deficiencies were not implemented, as the same issues were found in the current survey. The facility's Quality Assurance Performance Improvement plan was intended to evaluate and improve the residents' experience and care quality, but lacked documented procedures for performance monitoring and corrective action development. Interviews with facility staff revealed that while there were daily meetings and tracking sheets for department heads, there was no structured system for addressing and preventing recurring deficiencies.
Failure to Uphold Resident Dignity and Rights
Penalty
Summary
The facility failed to protect and promote the rights of residents, as evidenced by several deficiencies observed during a recertification survey. Three residents were affected by the facility's failure to provide appropriate clothing and maintain their dignity. One resident was unable to access their clothing, and staff reported difficulty in finding clothes that fit. This resident expressed dissatisfaction with wearing a hospital gown for several days due to the lack of available clothing. Another resident was observed in a hospital gown with their back and buttocks exposed, visible from the hallway for over an hour. This lack of privacy and dignity was noted during multiple observations. Additionally, a third resident was found wandering the unit with a noticeable odor of feces and wearing soiled clothing, indicating a lack of proper hygiene and care. Interviews with staff revealed that the facility relied on donated clothing and hospital gowns for residents without personal clothing. Staff acknowledged the difficulty in finding appropriate clothing for residents, particularly those with larger sizes, and admitted that the situation should not have occurred. The facility's failure to provide adequate clothing and maintain residents' dignity and privacy was a clear violation of residents' rights.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to ensure the protection of residents' personal property from loss or theft, as evidenced by the experiences of four residents whose belongings sent out for laundering were not returned in a timely manner. The facility's policy on Personal Property Theft and Loss Risk, dated October 2023, mandates the safekeeping of personal property and requires labeling and inventorying of residents' belongings. However, observations and interviews revealed that these procedures were not consistently followed, leading to missing items for Residents #1, 34, 73, and 108. Resident #1, who was cognitively intact, reported that clothing sent to laundry was missing for approximately three weeks. Resident #73, also cognitively intact, mentioned missing personal laundry but did not file a grievance, believing the facility would not take action. Resident #34, with significant cognitive impairment, and Resident #108, who was cognitively impaired, also experienced issues with missing belongings. The facility's grievance records for April 2024 showed only one grievance related to missing items, which was resolved, indicating a lack of formal complaints despite the ongoing issue. Interviews with staff revealed inconsistencies in the process of labeling and inventorying residents' belongings. Certified Nurse Aide #1 and Licensed Practical Nurses #3 and #4 described a process where belongings were supposed to be labeled and inventoried by the receptionist or Laundry Person #1, but this was not consistently done. The inventory sheets were not regularly checked or updated, especially when residents were transferred between units. The facility's failure to adhere to its own policies and procedures contributed to the deficiency in safeguarding residents' personal property.
Failure to Resolve Resident Grievances Timely
Penalty
Summary
The facility failed to ensure that grievances were resolved in a timely manner for three residents, as observed during a recertification survey. The facility's grievance policy, dated 10/01/2022, required grievances to be documented and resolved by the appropriate party. However, grievances from residents were not documented or resolved through the facility's grievance process. For instance, one resident reported missing personal laundry but did not file a grievance due to a belief that it would not lead to any resolution. Another resident experienced a delay of approximately three weeks before some of their missing clothing was returned, and they had not filed a grievance either. During a Resident Council Meeting, residents expressed that they were unaware of who was responsible for handling grievances and noted that staff often promised to look into issues without providing resolutions. Interviews with staff revealed inconsistencies in the grievance process, such as the location and accessibility of grievance forms. A Certified Nurse Aide mentioned that they would report missing laundry to maintenance or housekeeping, but did not fill out grievance forms. A Licensed Practical Nurse indicated that grievance forms were kept in their office, and the box for forms was obstructed by a linen cart, making it difficult for residents to access. The facility's grievance process was further complicated by unclear procedures for inventorying residents' belongings. Staff interviews revealed that belongings were supposed to be inventoried upon admission, but this process was not consistently followed. Additionally, there was confusion about who should be notified if items went missing, with some staff believing it was the responsibility of the Social Worker or Maintenance. This lack of clarity and follow-through in the grievance process contributed to the facility's failure to address and resolve residents' grievances effectively.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, as identified during a recertification survey. Specifically, two residents who were on anticoagulant medications did not have care plans that included interventions for the use of these blood thinners. Additionally, another resident experienced significant weight loss, but the care plan did not document physician supervision or interventions to address this issue. These deficiencies were identified through observations, record reviews, and interviews. The facility's policy on Comprehensive Care Plans, dated September 2023, mandates that each resident should have an interdisciplinary care plan initiated within 48 hours of admission. This care plan should address priority problems and needs, be current, realistic, and time-specific, and involve the resident and/or family in the planning process. However, the facility did not adhere to this policy for the residents in question, as evidenced by the lack of documented interventions for anticoagulant use and the absence of physician supervision for significant weight loss.
Deficiency in Nursing Staff Competency and Care Quality
Penalty
Summary
The facility was found to have insufficient nursing staff with the appropriate competencies and skills to ensure resident safety and well-being. Specifically, the facility failed to conduct proper competency evaluations for licensed nursing staff, which are necessary to assess the knowledge, skills, and abilities required for their roles. This deficiency was evidenced by several observations and interviews during the recertification survey. One resident, admitted with atherosclerotic heart disease, cachexia, and severe protein-calorie malnutrition, was observed to have multiple inhalers in their room. The resident expressed a lack of confidence in the staff's ability to provide timely access to a rescue inhaler, leading them to keep it within reach. Additionally, the facility's medication room was found to have a 24-hour urine specimen stored alongside medications, including insulin, which is a breach of proper storage protocols. Further observations revealed issues with the care of another resident who had a peripherally inserted central catheter (PICC) line. The dressing was found to be peeling, soiled, and undated, indicating a lack of proper maintenance. Interviews with staff highlighted gaps in training and competency evaluations, with some staff unable to recall when they last received training or competency assessments. The facility lacked documented policies and procedures, and there was no process in place to assess the competencies of new hires, contributing to the overall deficiency in staff competency and care quality.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, as required by their policy. This deficiency was identified during a recertification survey, which included observations, record reviews, and interviews. The survey found that the drug regimens for four residents were not reviewed monthly, as evidenced by gaps in the documented reviews. The facility's policy required a comprehensive medication regimen review to be performed monthly by a consultant pharmacist, with findings and recommendations reported to the director of nursing and other relevant parties. Resident #23, who was admitted with diagnoses including fatty liver and fibromyalgia, had missing monthly reviews for several months. Similarly, Resident #78, with chronic systolic congestive heart failure and major depressive disorder, also had months without documented reviews. Resident #30, with significant medical conditions such as the absence of a right leg and atherosclerosis, and Resident #67, diagnosed with unspecified dementia and major depressive disorder, both had missing reviews for multiple months. Despite these lapses, the residents were observed interacting normally with staff and other residents, without signs of overmedication or medication-related issues. Interviews with facility staff, including the Director of Nursing and a registered nurse, revealed a misunderstanding of the review frequency requirements. The Director of Nursing believed reviews should occur on admission, quarterly, or with changes in condition, while the registered nurse mentioned reviews were done on admission and with medication changes. The pharmacist confirmed that reviews were conducted monthly and emailed to the Director of Nursing, but the documentation did not reflect consistent monthly reviews for the residents in question.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to maintain drugs and biologicals in accordance with professional standards, as observed during a recertification survey. Specifically, urine specimens were improperly stored in the same refrigerator as insulin pens and vials, and a purified protein derivative solution was found without an open date and was expired. Additionally, several medications, including eye drops, ear drops, Vitamin D, and insulin pens, were found in the medication cart without expiration dates. The controlled substance cabinet's inside lock was also broken, compromising the security of controlled drugs. Licensed Practical Nurses reported a lack of clear directives due to frequent changes in the Director of Nursing, leading to inconsistent practices. The facility's policies required separate storage for lab specimens and medications, but these were not followed, as evidenced by the co-mingling of urine specimens with medications. The Nurse Educator acknowledged the ongoing process of creating and implementing nurse competencies, indicating that current staff training and oversight were insufficient to ensure compliance with medication labeling and storage standards.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during a recertification survey. Observations in the main kitchen and one of the unit kitchenettes revealed several deficiencies. In the main kitchen, a #10-sized can of mashed potatoes had a V-shaped dent in the top seam, and two #10-sized cans of red pepper strips had metal touching metal at the top seam. Additionally, the slicer, stainless steel utility cart, handwashing sink, and the floor under the cooking equipment line were soiled with food particles and dirt. The food temperature thermometer was found to be out of calibration, reading 25 degrees Fahrenheit when tested using the standard ice-bath method. In the South Unit kitchenette, the refrigerator door gasket was split and uncleanable, and the drawers and cabinets were soiled with food particles. These observations were confirmed through staff interviews, where it was acknowledged that the dented cans should have been segregated, and the kitchen equipment required cleaning. The deficiencies indicate a lack of proper food storage, preparation, and cleanliness, which are essential for maintaining food safety standards.
Failure to Provide Appropriate Wheelchair for Resident
Penalty
Summary
The facility failed to ensure that Resident #80's right to self-determination and choice was upheld, as evidenced by the resident's inability to get out of bed due to the lack of an appropriate wheelchair. Resident #80, who has cerebral palsy, morbid obesity, and congestive heart failure, was observed in bed on multiple occasions and expressed that they had repeatedly requested a suitable wheelchair for months. The resident was provided with a geriatric chair, which they refused because they could not self-propel it, and a standard wheelchair that was too narrow for comfort. Despite having moderate cognitive impairment, the resident was alert and oriented, with full upper body strength, and expressed a desire to attend the gym, which was not possible without the appropriate wheelchair. Interviews with facility staff revealed a misunderstanding of the resident's needs and preferences, as both a Certified Nurse Aide and a Licensed Practical Nurse stated that the resident refused to get out of bed. The Director of Rehabilitation acknowledged that the resident had plateaued in therapy and was no longer receiving it, but also noted that a custom-sized bariatric wheelchair could be ordered for residents with special needs. The lack of an appropriate wheelchair and the discontinuation of therapy contributed to the resident's inability to exercise their right to self-determination and choice, as outlined in the facility's policy and New York State regulations.
Inconsistent Documentation of Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically their code status, was consistently documented and easily identifiable by all staff. The resident in question, who had severe cognitive impairment and was diagnosed with unspecified dementia, early onset Alzheimer's disease, and type 2 diabetes, had conflicting documentation regarding their code status. While the Medical Orders for Life-Sustaining Treatment indicated a Do Not Resuscitate/Do Not Intubate status, social work progress notes documented a Cardio-Pulmonary Resuscitation code status. Observations and interviews revealed that the resident's code status was not consistently documented across various records, including the resident's electronic chart and identification bracelet. Staff interviews indicated that the code status should be available in the resident's chart, on their ID bracelet, and in the electronic records. However, the resident was observed without an ID bracelet, and the Medical Order for Life-Sustaining Treatment was not initially scanned into the electronic system. The facility's policy required that advance directives be maintained in the care plan, as a physician order, and on the resident's ID band. Despite this, there was a delay in updating the electronic records with the Medical Order for Life-Sustaining Treatment, which was only scanned into the system after the deficiency was identified. Staff interviews highlighted inconsistencies in the process of updating and maintaining accurate records of the resident's code status, contributing to the deficiency.
Failure to Update Care Plan for Significant Change in Resident's Condition
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set assessment for a resident who experienced a significant change in health status. The resident, who was admitted with chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes, was sent to the hospital due to a change in respiratory status. Upon returning to the facility, the resident was diagnosed with respiratory bronchiolitis interstitial lung disease and required oxygen and inhaler use. Despite these changes, the facility did not update the resident's care plan to reflect the new respiratory needs, including the use of inhalers and nebulizer treatments. Interviews with facility staff revealed that the care plan should have been updated within 48 hours of the resident's readmission from the hospital. The LPN acknowledged that documentation for the resident's respiratory issues was missing from the care plan, and the MDS Coordinator confirmed that the care plans and Minimum Data Set should have been updated due to the significant change in the resident's condition. This oversight resulted in a deficiency as the facility did not adhere to its policy of updating care plans for significant changes in a resident's condition.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who was admitted with a fractured back, diabetes, and chronic bladder inflammation, had moderate cognitive impairment but was able to understand and be understood by others. The baseline care plan for this resident was not completed and signed until several days after admission, which is a violation of the facility's policy that mandates the completion of such plans within 48 hours. Interviews with facility staff revealed a lack of clarity and consistency in the understanding and execution of the baseline care plan policy. The Minimum Data Set Coordinator acknowledged that baseline care plans were not always completed within the required timeframe. Additionally, the Director of Nursing displayed uncertainty about the exact timeframe for completing these plans, indicating a possible systemic issue in policy adherence and staff training. This deficiency was identified during a recertification and abbreviated survey, highlighting a failure in the facility's processes to ensure timely and effective care planning for new admissions.
Failure to Update Comprehensive Care Plan After Medication Changes
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised after each assessment and in response to changes in medication for a resident. Specifically, the care plan for a resident with diagnoses of unspecified dementia with agitation, major depressive disorder, and hypertension was not updated following changes in their psychotropic medication regimen. The resident's Minimum Data Set indicated moderate cognitive impairment, and the facility's policy required care plans to be modified to reflect new diagnoses, medications, or abnormal labs. However, despite changes in the resident's sertraline dosage, the care plan was not updated to reflect these changes. The Medication Administration Records showed a series of dosage adjustments for sertraline, but the comprehensive care plan was last updated in December 2023, documenting a daily dose of 175 milligrams, which was no longer accurate. The Director of Nursing acknowledged that the care plan should have been person-centered and revised to include non-pharmacological interventions and monitoring, reflecting the resident's current needs and interventions. This oversight was identified during a recertification survey, highlighting a deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Apply Compression Stockings for Resident with Edema
Penalty
Summary
The facility failed to ensure that a comprehensive assessment and appropriate care were provided to a resident, specifically regarding the application of compression stockings. Resident #89, who was admitted with Alzheimer's Disease, Atherosclerotic Heart Disease, and depression, had a standing order for compression stockings to manage bilateral lower extremity edema. However, during the recertification survey, it was observed that the resident was not wearing the prescribed compression stockings, and staff confirmed that they were never applied because the resident would remove them due to their severe cognitive impairment. The facility's policy required comprehensive care plans to be developed and interventions to be specific and timely, yet this was not adhered to in the case of Resident #89. Interviews with the Director of Nursing and a Licensed Practical Nurse revealed that the order for compression stockings had not been reviewed or discontinued despite the resident's non-compliance. The facility had experienced several leadership changes, which contributed to the oversight. A new Nurse Practitioner had recently started and was expected to assess residents' needs, but the deficiency had already occurred.
Resident's Non-Compliance with Smoking Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for a resident who was observed using tobacco in their room without supervision. The resident, who was cognitively intact and had a history of chronic obstructive pulmonary disease, respiratory bronchiolitis interstitial lung disease, and type 2 diabetes, was found to be non-compliant with the facility's smoking policy. The policy prohibited smoking within the facility and possession of tobacco products by residents. Despite this, the resident was observed using chewing tobacco in their room, which was against the policy. The facility's comprehensive care plan for the resident did not include interventions to address the resident's potential or actual non-compliance with the smoking policy. Although the care plan acknowledged the resident as a smoker who was only allowed to smoke under supervision at designated times, it failed to address the resident's possession and use of tobacco products in their room. Interviews with staff revealed that the resident sometimes had cigarettes and chewing tobacco in their possession, and staff had to remind the resident of the policy. However, the resident often became irate when reminded and continued to keep tobacco products in their room. Staff interviews and observations indicated that the resident's possession of tobacco products posed a potential hazard, as other residents could mistake the tobacco spittoon for a drink. The facility's staff, including CNAs and LPNs, were aware of the resident's non-compliance but did not consistently enforce the policy or develop a plan to address the issue. The Director of Nursing confirmed that tobacco products were confiscated from the resident's room, highlighting the facility's failure to prevent the resident from accessing and using tobacco products unsupervised.
Failure to Provide Adequate Medical Supervision for Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #63, received adequate medical supervision for significant weight loss. Resident #63, who was admitted with traumatic subdural hemorrhage, urinary calculus, and scoliosis, experienced a 17.45% weight loss between December 2023 and April 2024. Despite the resident's significant cognitive impairment and the need for total assistance with meals, there was no documented evidence that the physician was notified of the weight loss. The dietary notes from January and April 2024 indicated significant weight loss and dehydration, yet the physician's note from March 2024 did not address these concerns. Observations during a lunch period revealed that Resident #63's meal portions were small and unappetizing, with the meat appearing undercooked and other items tasting unpleasant. The facility's policies required notification of changes in a resident's condition, such as significant weight loss, but this protocol was not followed. The registered dietician stated that care plans were based on resident preferences and interdisciplinary team input, yet the care plan interventions to monitor and report signs of malnutrition were not effectively implemented for Resident #63.
Failure to Document Indication for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the use of the antipsychotic medication Abilify. The resident, who had diagnoses including chronic systolic congestive heart failure and major depressive disorder with psychotic symptoms, was prescribed Aripiprazole in two different dosages without an indication for use documented in the physician's orders. This lack of documentation did not comply with the facility's policy, which required a written diagnosis or indication for each medication order. The deficiency was identified during a recertification survey, where it was noted that the medication regimen reviews did not contain a reason for the medication order. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, revealed that medication regimen reviews were conducted on admission, quarterly, or when there were changes in condition. However, the reviews provided did not include the necessary documentation for the prescribed medication. The pharmacist confirmed that reviews were completed monthly and sent to the Director of Nursing, but the required indication for the medication was still missing.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as evidenced by observations during a recertification survey. One of the three dumpsters was found to be leaking a black oily liquid from the bottom, and there was a build-up of brown leaves on the ground around another dumpster. These observations were made during a site visit, indicating improper maintenance and cleanliness of the dumpster area.
Infection Control Deficiency in PICC Line Management
Penalty
Summary
The facility failed to adhere to infection control practices for a resident with a peripherally inserted central catheter (PICC) line. The facility's policy required that dressings remain clean, dry, and intact, and be changed every 5-7 days or as needed. However, during the survey, it was observed that the dressing on the resident's PICC line was peeling, with curled and soiled edges, and was not dated. Additionally, the double lumen lines were improperly managed, as they were dangling and tucked behind the resident. The resident involved had a history of osteomyelitis, obstructive and reflux uropathy, and systemic lupus erythematosus, with moderate cognitive impairment. Despite the facility's policy and the physician's orders, the dressing change was not performed correctly, and the dressing was not dated. Furthermore, the white port of the PICC line was found uncapped, which was immediately rectified by the nurse upon notification. The Director of Nursing acknowledged the oversight and mentioned that the nurse responsible was experienced in changing central line dressings.
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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