Northern Riverview Health Care, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Haverstraw, New York.
- Location
- 87 South Route 9w, Haverstraw, New York 10927
- CMS Provider Number
- 335418
- Inspections on file
- 20
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Northern Riverview Health Care, Inc during CMS and state inspections, most recent first.
A resident with autism, severe ID, and limited mobility was sent from the facility to a hospital for an MRI without a clear discharge plan, physician clearance, or written notice to the guardian. The record lacked a discharge summary and social work documentation, the transfer paperwork listed behavioral symptoms rather than the test, and the group home had not arranged for the resident’s return. The resident arrived at the hospital outpatient area without an order, was redirected to the ER, and was left without a planned return to the facility or group home.
Unlabeled, undated, and expired foods were found in the kitchen and a unit refrigerator during survey observations. Surveyors saw multiple sandwiches, cooked peas, jello, peaches, quiche, chopped lettuce, tuna salad, egg salad, and an expired salad without proper dating, while the FSD stated staff were responsible for removing expired food and nursing staff were responsible for labeling and dating food stored in the refrigerator.
Failure to provide requested health records timely: The facility did not ensure that legal representatives received copies of residents’ health care records within the required timeframe. One resident with cerebral infarction, dementia, and DM had a proxy request records, but they were not sent for more than two months; another resident with spinal cord disease, autistic disorder, and severe intellectual disabilities had a guardian request records, but there was no documented evidence the records were provided. The DMR and Administrator stated they were unaware of the specific response timeline.
A resident with DM, bilateral above-knee amputation, dyspnea, and moderate cognitive impairment was observed eating lunch while lying flat in bed with the head in a low position and food spilling onto the chest. The resident said the bed would not tilt up to allow upright positioning and that nursing staff had been told about the issue, while the wife had also requested a bed that would let the resident sit upright for meals. Facility policy and staff interviews stated residents eating in bed should be positioned upright at 90 degrees.
Failure to Follow Ordered Pressure Ulcer Treatment: A resident with paraplegia, anemia, type 2 DM, and multiple stage 4 pressure ulcers had an order for Santyl to the left distal lateral foot wound, but an RN cleansed the wound and applied a Xeroform dressing instead. The RN stated the order was not checked before the dressing change, and the DON stated there was no excuse for not following the physician order.
Respiratory Treatment Orders and Oxygen Delivery Not Followed: Two residents did not receive respiratory care consistent with physician orders. One resident’s CPAP order lacked settings and administration details, and the TAR had no documented CPAP administration despite ongoing references to CPAP use. Another resident ordered for O2 at 2 L/min was repeatedly observed receiving 3.5 L/min, and the LPN unit manager confirmed the ordered rate was not followed.
Failure to Post Daily Nurse Staffing: The facility did not have the daily nurse staffing posted in a location accessible to residents and visitors. The lobby posting was outdated, and no staffing sheet was displayed for the missing day. The DON said the overnight nurse supervisor was responsible for the posting, while an RN supervisor stated the form was completed but left in the nursing supervisor's office.
Improper Garbage and Refuse Disposal: The recycle dumpster was observed open with cardboard boxes spilling over the top, and boxes, a plastic bag of cans, and other litter were on the ground around and under it. The compactor door was also observed held open with the door holding chain. The FSD stated the entire facility used both areas and that staff had been educated to close the compactor door after use and break down boxes to fit into the recycle dumpster.
Broken Bed Not Maintained in Working Condition: A resident’s bed would not incline beyond about 30 degrees, and the resident said it had been broken for about a month after staff were told. During observation, the resident was trying to eat lunch while lying back in bed and spilling food on their chest. The DON tried the bed controls and found they did not work, and the DOR later stated the bed had to be replaced because it would not incline to 90 degrees.
A resident with dementia and significant ADL assistance needs developed right knee pain and swelling during repositioning, leading to a STAT x-ray that identified an acute nondisplaced tibial plateau fracture, a serious bodily injury. The injury was identified and the resident was transferred to the hospital, but the facility did not notify the State agency within the required 2-hour timeframe and instead reported the incident the following day, documenting an incorrect incident date. The facility also failed to submit the required investigative report within 5 working days of identifying the injury, instead submitting it nearly two weeks later, after delays related to internal documentation practices and waiting for State confirmation.
Surveyors found that the facility failed to conduct complete investigations into injuries of unknown origin for two residents. One resident with dementia and severely impaired cognition developed a forehead hematoma, but the facility did not obtain statements from staff on prior shifts, did not interview the roommate who was present, and did not document whether abuse, neglect, or mistreatment was considered or ruled out, despite policy requirements for comprehensive staff and witness statements and a clear investigative conclusion. Another resident with dementia and significant transfer-assistance needs was found to have an acute right tibial plateau fracture after reporting knee pain, yet CNA statements lacked dates, identifying information, shift times, and descriptions of the care and transfers provided, and staff interviews revealed conflicting accounts about whether a Hoyer lift or stand-and-pivot transfer was used. The investigation did not include review of the resident’s transfer care plan, did not evaluate the reported Hoyer lift transfer, and did not identify all staff involved or the circumstances of the transfers across shifts, leaving the cause of the injury undetermined.
A resident with dementia, severe cognitive impairment, and a history of wandering and falls required supervision with ambulation and had a care plan intervention for enhanced monitoring for safety after being found with a forehead hematoma of unknown origin. Staff and a roommate reported that the resident frequently walked the secure unit, entered other residents’ rooms, did not stay in bed, and was difficult to redirect. Despite this, staff interviews showed inconsistent awareness and use of enhanced monitoring, with one LPN stating the resident was only on a wandering checklist. Review of the enhanced monitoring tool revealed missing staff initials and absent supervisory signatures, and the DON acknowledged that the resident ambulated independently without staff accompaniment and that no one witnessed the incident leading to the injury.
A resident with severe cognitive impairment developed redness in the right eye, which was first identified by a family representative rather than staff. Facility staff did not document an assessment or notify the family of the change in condition prior to the family member's observation, and an RN supervisor ordered antibiotic eye drops without a documented assessment.
A resident with severe cognitive impairment was allegedly punched in the face by another resident, and the facility failed to report the incident to the State Department of Health or law enforcement within the required timeframe, despite being aware of the allegation and initiating an internal investigation.
A resident with severe cognitive impairment was allegedly punched in the face by another resident, and the facility failed to report the abuse allegation to the State Agency or law enforcement as required by policy and regulation. Although the incident was internally investigated, there was no documentation of timely external reporting, and facility leadership acknowledged the reporting failure.
A resident with severe cognitive impairment developed right-eye redness and was started on ciprofloxacin ophthalmic drops, but the care plan was not updated to include new, measurable interventions or goals related to this change in condition. The care plan still reflected previous concerns and did not address the current infection or treatment, and staff interviews revealed confusion about responsibility for care plan updates due to the absence of a charge nurse.
A resident with severe cognitive impairment developed right eye redness, which was first reported by a family member. Nursing staff did not document an assessment, provider notification, or clinical rationale for ordering antibiotic eye drops, and the resident was not evaluated by a medical provider until several days later, when a subconjunctival hemorrhage was diagnosed.
A resident with severe cognitive impairment and multiple diagnoses received antibiotic eye drops after a family member reported eye redness, but there was no documented nursing or physician assessment at the time the order was entered. The treatment was started without a provider evaluation, and the resident was not seen by a medical provider until several days later, contrary to facility policy requiring timely physician review and documentation.
The facility did not ensure immediate reporting of alleged abuse, neglect, or theft, nor did it submit required investigative conclusions to the Department of Health for three incidents involving residents with cognitive and physical impairments. These incidents included allegations of staff abuse, resident-to-resident sexual exposure, and concerns about a CNA's roughness and lack of empathy. Both the DON and Administrator were unaware that the required reports had not been submitted.
Care plans were not updated after incidents involving abuse allegations and inappropriate behavior between residents. Despite existing policies and the involvement of residents with complex medical and psychiatric conditions, the facility did not revise care plans to reflect new allegations or behaviors, as confirmed by staff interviews.
Two residents with significant physical and cognitive impairments did not consistently receive or have documented incontinence care as required by their care plans. CNA documentation showed multiple unsigned instances across several months, indicating lapses in care provision. Nursing leadership confirmed that documentation was expected to be reviewed daily, but issues such as short staffing and lack of consistent disciplinary action contributed to ongoing deficiencies.
The facility did not consistently provide the minimum number of certified nurse aides (CNAs) required by its own staffing assessment for the first floor, with multiple shifts in July and August showing CNA staffing below the established levels. Interviews and staffing records confirmed that actual staffing often fell short of the required ratios, despite the use of agency staff and scheduling tools.
A resident with dementia and moderate cognitive impairment was subjected to an incident where another resident entered their room, exposed themselves, and made an inappropriate comment, causing the affected resident significant distress. The facility failed to ensure the resident's right to dignity and protection from abuse, as required by policy.
A resident with cognitive impairment and a history of wandering was subjected to sexual exposure by a neighboring resident with a known history of sexually inappropriate behavior. Despite existing care plans and interventions, the incident led to significant emotional distress for the affected resident.
Unsafe discharge without notice or return plan
Penalty
Summary
The facility failed to plan a safe and appropriate discharge for a resident admitted from a group home for individuals with intellectual disabilities and receiving short-term rehabilitation after hospitalization. The resident had diagnoses including a spinal cord disease, autistic disorder, and severe intellectual disabilities, and the admission MDS documented that the resident was rarely or never understood, had unclear speech, required extensive assistance with daily care, used a wheelchair, did not walk, and was frequently incontinent. The care plan addressed impaired cognition with interventions such as simple questions, consistent routines, simple choices, and simple directions. An interdisciplinary meeting was held at the request of the group home to assess the resident’s progress and discuss a magnetic resonance imaging test of the back and head. The meeting form was incomplete, not signed or dated, and did not identify who completed it. The record did not contain a discharge summary by a medical provider, social work notes regarding the discharge, or documented evidence of a discharge plan. The SNF-to-hospital transfer form listed behavioral symptoms as the reason for transfer, not diagnostic testing, and the resident was transferred to the hospital with belongings. The resident was sent from the facility to the hospital outpatient department without notice of a non-urgent discharge, without written discharge notice or appeal rights, and without a documented plan or date for return to the group home. The resident was not cleared by a physician for safe discharge, and the group home had not evaluated the resident’s ability to safely return. Survey interviews showed the group home was not expecting the resident to be discharged from the facility, the outpatient department had no order for the MRI, and the resident was directed to the emergency room. The resident’s guardian stated the resident was left at the hospital and was later taken home because the nursing home was not taking the resident back.
Unlabeled and Expired Foods Found in Kitchen and Unit Refrigerator
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards for food service safety because unlabeled, undated, and expired foods were found in the kitchen and unit pantry refrigerators during the recertification survey. The facility policy required foods to be covered, labeled, dated, and date-marked, and another policy required food brought by family or visitors and left for later consumption to be labeled with the resident name, room number, item, date received, and discard date, with refrigerated foods discarded within 48 hours. During the initial kitchen tour, surveyors observed 16 sandwiches and a full pan of cooked peas that were unlabeled and undated, along with multiple expired items including cups of jello dated 02/03/2026, 02/26/2026, and 03/05/2026, a pan of peaches dated 02/28/2026, and pans of quiche, chopped lettuce, prepared tuna salad, and prepared egg salad all dated 03/05/2026. The Food Service Director stated they were not sure why the expired food had not been discarded and said all staff were responsible for removing expired food and had been educated on labeling and dating food. In the unit 3 resident refrigerator, surveyors found a pizza box, soup, a cinnamon roll in a baggie, a peanut butter and jelly sandwich, pasta, a Styrofoam container of vegetables from the facility kitchen, a grocery bag of Chinese food, and an expired salad dated 03/05/2026, as well as a medical ice pack in a plastic bag in the freezer. The Food Service Director stated nursing staff were responsible for labeling and dating food stored in the refrigerator and for discarding expired food, while housekeeping staff were responsible for cleaning the refrigerator.
Failure to Provide Requested Health Records Timely
Penalty
Summary
The facility did not ensure that a resident’s legal representative received a copy of the resident’s health care record within two working days after a written request. For one resident, who had diagnoses including cerebral infarction, dementia, and diabetes and had moderate cognitive impairment on the Minimum Data Set, the resident’s health care proxy requested records covering a specified date range, but the records were not provided until more than two months later. The facility’s medical records policy stated that authorized requests would be handled in accordance with applicable laws and that the Administrator would be notified of all requests. For another resident, who had diagnoses including disease of the spinal cord, autistic disorder, and severe intellectual disabilities and was rarely or never understood with unclear speech, the legal guardian requested health care records for a specified period. The Director of Medical Records stated the facility informed the guardian that the records were ready and quoted a cost for electronic and photocopying services, but there was no documented evidence that the requested records were provided. During interview, the Director of Medical Records stated they were not aware there was a specific time period to respond to requests for medical records, and the Administrator was unable to provide a specific timeline for when records had to be provided.
Resident ate meals lying flat in bed instead of upright
Penalty
Summary
The facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary care and services for eating and positioning. Resident #138 had diagnoses including diabetes mellitus, bilateral above-knee amputation, and dyspnea, and a quarterly MDS documented moderate cognitive impairment, moderate assistance needed from lying to sitting, independent feeding, and dependence on a mechanical lift for transfers. The resident care plan included assistance with self-care and mobility related to fatigue, limited mobility, and limited range of motion, with interventions for set up and clean-up for eating. During survey observations, Resident #138 was seen eating lunch while lying in bed with the head in a low position, and later was observed lying flat in bed eating lunch with food spilling over the chest while moving the utensil horizontally across the body to the mouth. The resident stated the bed did not tilt up so the resident could sit up straight and reported telling nursing staff about this about a month earlier while waiting for maintenance to repair the bed. The resident’s wife had emailed that the resident needed a bed that could allow sitting upright when eating. Facility policy stated residents should be positioned in an upright position for meals, and staff interviews confirmed residents eating in bed should be set up at 90 degrees for safe eating.
Failure to Follow Ordered Pressure Ulcer Treatment
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with pressure ulcers. Resident #14 had diagnoses of paraplegia, anemia, and type 2 diabetes, and the quarterly MDS dated 11/24/2025 documented that the resident was at risk for pressure injuries and had three stage 4 pressure ulcers. The facility policy on Pressure Ulcer Treatment, revised 11/2024, stated that dressings and treatments were to be applied according to the manufacturer’s direction, the care plan, and the physician order. The physician’s order dated 01/26/2026 directed staff to apply Santyl External Ointment (Collagenase) to the resident’s left distal lateral foot every day shift for the pressure wound. During a dressing change observation on 03/11/2026, RN #2 cleansed the left foot wound with normal saline, then applied a Xeroform dressing and wrapped it with gauze and kling. RN #2 stated they did not check the physician order before entering the resident’s room and said the floor nurses usually changed the dressing. The DON stated there was no excuse for RN #2 not to follow the physician order and did not know why it happened.
Respiratory Treatment Orders and Oxygen Delivery Not Followed
Penalty
Summary
The facility did not ensure proper respiratory care for two residents reviewed for respiratory treatment. One resident with COPD, respiratory failure, and obstructive sleep apnea was reportedly using a CPAP machine, but the physician order entered on 9/24/2025 did not include specific scheduling details, CPAP settings, or administration parameters. The treatment and medication administration records from October 2025 through January 2026 contained no documented evidence of an order for or administration of CPAP, even though physician progress notes continued to reference CPAP use at night for obstructive sleep apnea. During interviews, the NP stated that CPAP initiation required a physician order and that the order should include machine settings and delivery route, with nursing staff responsible for documenting the procedure in the clinical record. An LPN stated that CPAP machines were provided with specific settings and that the order, including settings, should be placed in the TAR so nurses could verify the settings and document treatment. The DON stated the order had been entered as a general order, did not include scheduling details, and was not triggered in the system to populate in the TAR for nursing documentation. A second resident with COPD, vascular dementia, and chronic kidney disease had a physician order for supplemental oxygen via nasal cannula at 2 liters per minute every shift for hypoxia, and the care plan directed oxygen to be provided per physician orders. However, during multiple observations, the resident was seen receiving oxygen at 3.5 liters via nasal cannula and concentrator. The LPN unit manager confirmed the physician order and TAR documented 2 liters per minute every shift, but stated the resident did not receive the correct oxygen rate and the physician’s order was not followed. The DON stated the unit manager or charge nurse was responsible for ensuring residents received the correct oxygen per physician order.
Failure to Post Daily Nurse Staffing
Penalty
Summary
The facility did not ensure daily nurse staffing was posted in an area accessible to all residents and visitors, as the posting for all nursing staff working each shift was not displayed for 03/08/2026. During an observation on 03/09/2026 at 6:10 AM, the nurse staffing posted in the lobby was dated 03/07/2026, and there was no observed staffing posting for 03/08/2026. During an interview on 03/13/2026 at 10:20 AM, the DON stated the overnight nurse supervisor was responsible for posting the nurse staffing for the day and did not know why the posting was not on the lobby bulletin board for 03/08/2026. During an interview on 03/13/2026 at 11:28 AM, RN Supervisor #8 stated it was their responsibility to post the nurse staffing in the lobby, that they completed the form on the morning of 03/08/2026, but left it in the nursing supervisor's office.
Improper Garbage and Refuse Disposal
Penalty
Summary
Improper disposal of garbage and refuse was identified during the recertification survey when the facility did not keep the recycle dumpster and compactor area in the condition required by policy. The facility policy titled Garbage - Food and Refuse Disposal, revised 12/2020, stated that outside dumpsters provided by garbage pickup services would be kept closed and free of surrounding litter. During an observation of the garbage area with the Food Service Director, the recycle dumpster was open with cardboard boxes spilling over the top, and there were boxes, a plastic bag of cans, and other litter on the ground around and under the dumpster. At the same time, the compactor door was observed held open with the door holding chain. During interview, the Food Service Director stated the entire facility used both the compactor and recycle dumpster, kitchen staff had been educated to close the compactor door after use and to break down boxes to fit into the recycle dumpster, and all departments were responsible for keeping the area clean and garbage picked up.
Broken Bed Not Maintained in Working Condition
Penalty
Summary
The facility did not ensure that essential equipment was maintained in a safe and operating condition for one resident reviewed for the environment. Resident #138’s bed was broken and could not be inclined beyond 30 degrees, despite the resident needing to sit more upright for meals and other care. The facility policy stated that maintenance services were responsible for keeping equipment in a safe and operable manner. During observation, Resident #138 was attempting to eat lunch while lying back in bed at about a 30-degree incline and was spilling food over their chest while moving the utensil horizontally across their body to reach their mouth. The resident stated the bed had been broken in that position for about a month and that they had told nursing staff, but it had not yet been repaired. The DON was notified, attempted to raise the bed with the control, and found that it did not work. The Director of Maintenance later stated the bed had to be replaced because it was not inclining to 90 degrees, and the DON provided an email from the resident’s wife stating a need for a bed that could allow the resident to sit upright.
Failure to Timely Report Serious Injury of Unknown Origin and Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged violation and injury of unknown origin involving Resident #4 to the New York State Department of Health (NYSDOH) within required timeframes. Resident #4 had diagnoses including anemia, dementia, and hypothyroidism, with an Annual MDS dated 10/24/2025 documenting severely impaired cognition, a need for supervision with bed mobility, and substantial to maximal assistance with transfers, toileting, and showers. On 01/21/2026 at 11:00 AM, while being turned and positioned, Resident #4 was observed guarding the right knee, complaining of pain, and exhibiting swelling of the right knee. The charge nurse was called, and a STAT right knee x-ray was ordered and completed. On 01/21/2026 at 07:55 PM, the radiology report documented an acute nondisplaced fracture of the right tibial plateau, constituting a serious bodily injury. At 08:37 PM, an SBAR note documented the x-ray result and a provider recommendation to transfer the resident to the hospital for further evaluation. At 10:00 PM, the physician was notified of the x-ray findings, and the nursing progress note at 10:03 PM recorded that the Director of Nursing was made aware and that the resident was transferred via EMS to the hospital. The facility’s hospital transfer form documented that the transfer occurred at 10:11 PM on 01/21/2026. The hospital after-visit summary received by the facility at 02:18 AM on 01/22/2026 documented four views of the right knee and a questionable fracture of the lateral tibial plateau. Despite the fracture being identified on 01/21/2026, the facility did not report the injury of unknown origin to NYSDOH until 01/22/2026 at 1:20 PM, exceeding the regulatory requirement to report serious bodily injury not later than 2 hours after identification. The Nursing Home Investigation Form submitted to NYSDOH documented the date of incident as 01/22/2026 and indicated that the resident was identified with an injury, although the injury had been identified the previous day. The facility was required to submit the investigative report within 5 working days of identifying the injury, which would have been 01/28/2026, but the investigative report (Submission #22298) was not submitted until 02/09/2026, 13 days after the injury was identified. During an interview on 02/12/2026, the Director of Nursing stated that the facility documented the date of incident as 01/22/2026, initiated the incident report and investigation upon the resident’s return, and waited for confirmation of receipt from NYSDOH before sending the investigative report, contributing to the delay beyond the required 5-working-day timeframe.
Failure to Thoroughly Investigate Injuries of Unknown Origin for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate injuries of unknown origin for two residents, contrary to its own Accident–Incidents policy. The policy, last reviewed on 06/01/2024, requires that the Incident/Accident Statement Form list nursing staff caring for the resident at the time of the incident and one shift prior, identify any witnesses by name with completed statements, and that the Incident/Accident Report Form include all required information, staff identification, statements, and a complete investigation with a conclusion. For one resident with anemia, dementia, and hypothyroidism who had severely impaired cognition and required supervision with transfers and ambulation, a forehead hematoma was discovered on 12/10/2025 and reported to the Department of Health as an injury of unknown origin. The facility’s documentation did not include staff statements from those who provided care on prior shifts, nor did it contain a detailed description of the care provided before the injury was identified. The roommate of this resident stated that no staff member interviewed them about the incident, and they were not asked to provide a written or verbal statement, despite being present in the room during the timeframe when the resident was last observed prior to being found with the hematoma. The facility’s investigation file did not contain a statement from the roommate and did not document whether abuse, neglect, or mistreatment was considered or ruled out. The Administrator reported that he did not initiate or complete the investigation, that the prior DON was responsible, and that he did not review the investigation or know whether it was complete. The current DON stated that the hematoma was determined to be an injury of unknown origin and that the investigation consisted only of statements from staff working the shift when the hematoma was identified, with no statements obtained from staff on prior shifts and no additional documentation beyond what was submitted to the Department of Health. For another resident with anemia, dementia, and peripheral vascular disease, who had moderately impaired cognition, required supervision with bed mobility, was dependent for toileting and showering, and required substantial to maximal assistance with transfers, an acute non-displaced right tibial plateau fracture was identified by STAT X-ray after the resident complained of pain and guarded the body during turning and positioning. The facility’s investigation report documented that no incident was witnessed, but the Accident/Incident Statement Forms completed by one CNA lacked required identifying information, dates, shift or time of assignment, and did not describe the type of care provided, including how the resident was transferred or assisted with ADLs at the time of the occurrence. Another CNA’s statement form inconsistently indicated that they were not assigned and did not provide care, while elsewhere noting they were the assigned aide for an appointment, and the form did not describe the care provided, the role during the outside appointment, or how the resident was prepared or transferred. Interviews with CNAs revealed conflicting accounts of whether a Hoyer lift or a stand-and-pivot transfer was used to move the resident into the wheelchair for an outside medical appointment and back into bed afterward. One CNA initially reported that a Hoyer lift was used to transfer the resident into the wheelchair, then later stated this was a mistake and clarified that the Hoyer lift was used only upon return from the appointment to transfer the resident back to bed because the resident was tired, while also stating that the resident was not a Hoyer lift resident and was not identified as requiring a Hoyer lift at that time. Another CNA described assisting with dressing and transferring the resident into the wheelchair using a stand-and-pivot method and stated that a Hoyer lift was not used. The facility’s Accident/Incident investigation did not include a review of the resident’s care plan for transfer requirements, did not evaluate the Hoyer lift transfer, did not include interviews with staff from all shifts involved in the resident’s care and transfers, and did not identify the transfer requirements, staff involved across shifts, or the circumstances surrounding the transfer to determine how the fracture occurred.
Failure to Consistently Implement Enhanced Monitoring for a Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and consistent implementation of an identified safety intervention for a resident with severe cognitive impairment and a history of wandering and falls. The resident, admitted with diagnoses including anemia, dementia, and hypothyroidism, had an Annual Minimum Data Set documenting severely impaired cognition and a need for supervision with transfers and ambulation. The resident’s fall risk care plan identified risk factors such as confusion, gait and balance problems, incontinence, and vertigo, and included an intervention for enhanced monitoring for safety initiated after an incident in which the resident was found with a forehead hematoma of unknown origin. On the date of the incident, documentation showed that a CNA last provided care to the resident in the late afternoon and last observed the resident in bed about an hour before the resident was later found with a forehead hematoma, with no staff able to identify when or how the injury occurred. The resident was evaluated in a hospital emergency department, where multiple imaging studies, including CT scans of the head and cervical spine and X‑rays of both knees and the pelvis, revealed no abnormalities, and the resident returned to the facility with continued neurological checks. Interviews with CNAs, an LPN, and the resident’s roommate consistently described the resident as frequently walking around the secure unit, entering other residents’ rooms, not remaining in bed, and being difficult to redirect without becoming upset. Despite the care plan intervention for enhanced monitoring for safety, staff interviews revealed inconsistent understanding and implementation of this intervention. One LPN stated that the resident was not on enhanced monitoring checks for safety and was only on a wandering checklist signed once per shift. The DON confirmed that the resident ambulated independently on the unit, was not accompanied by staff, and that no staff witnessed the incident resulting in the forehead hematoma. Review of the Enhanced Monitoring Rounding Tool for the period following initiation of enhanced monitoring showed multiple missing staff initials and blank Unit Manager/Supervisor signature lines, demonstrating that the facility did not consistently document or verify completion of the enhanced monitoring intervention as required by facility policy and the resident’s care plan.
Failure to Notify Family of Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely notification of a change in condition to a resident's family representative, as required by policy. A resident with severe cognitive impairment and multiple diagnoses, including dementia, anemia, and systemic lupus erythematosus, was observed by their family representative to have redness in the right eye. The family representative reported this observation to facility staff and was informed that the redness was due to an allergic reaction and had already been addressed by the physician. However, there was no documented evidence that nursing staff had identified, assessed, or reported the redness prior to the family representative's observation. Further review revealed that ciprofloxacin ophthalmic drops were ordered for the resident's right eye without a documented assessment or clear reason for the order. Interviews with facility staff confirmed that the family representative was the first to identify and report the change in the resident's condition, and that staff had not notified the family representative of the issue prior to their visit. The nurse supervisor admitted to initiating the antibiotic order in response to the family representative's concerns, without completing or documenting a nursing assessment beforehand.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an alleged incident of resident-to-resident physical abuse as required by both facility policy and state regulations. On 09/12/2025, a family representative informed the facility that a resident had been punched in the face by another resident. Although the facility's policy required immediate notification to the State Agency and local law enforcement, no documentation was found to show that the allegation was reported to the New York State Department of Health or law enforcement within the required timeframe. The internal investigation was initiated the following day, but the results were not reported to the appropriate authorities within five working days as mandated. The resident involved had severe cognitive impairment and multiple medical diagnoses, including dementia, anemia, and systemic lupus erythematosus. Interviews with facility staff confirmed awareness of the allegation and acknowledged the failure to report the incident as required. The facility's investigative documentation indicated the incident was categorized as resident-to-resident physical abuse, but there was no evidence of timely or proper notification to state authorities or law enforcement, as stipulated by both policy and regulation.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident physical abuse to the New York State Department of Health within the required timeframe. On 09/12/2025, a family representative informed the facility that a resident had been punched in the face by another resident. Documentation showed that the facility received this information on the same day, and an internal investigation was initiated several days later. However, there was no evidence that the allegation was reported to the State Agency or local law enforcement as required by both facility policy and state regulations. The facility's abuse policy mandates immediate notification to the appropriate authorities, but no documentation was provided to show that this occurred. The resident involved had diagnoses including dementia, anemia, and systemic lupus erythematosus, with a recent assessment indicating severely impaired cognition. Interviews with facility leadership confirmed awareness of the allegation and acknowledged that the incident should have been reported to the Department of Health. The investigation form categorized the event as resident-to-resident physical abuse, but there was no record of a report being submitted to the State Agency. The complainant also stated that they contacted law enforcement due to concerns for the resident's safety and confirmed that the facility did not report the allegation to the Department of Health.
Failure to Update Care Plan After Change in Condition
Penalty
Summary
The facility failed to revise a resident's Comprehensive Care Plan to include measurable, resident-specific interventions following a change in condition involving right-eye redness, which led to the initiation of ciprofloxacin ophthalmic drops. Although the physician ordered antibiotic eye drops for the resident's right-eye redness, the care plan was not updated to reflect this new condition or the associated treatment. The last update to the care plan addressed a previous influenza-related infection and did not include any documentation or interventions related to the resident's current eye condition. There were also no nursing progress notes, assessments, or physician assessments documenting the necessity for the eye drops until several days after the order was initiated. Interviews with facility staff revealed that the responsibility for updating care plans was unclear during the period when the deficiency occurred, as there was no charge nurse assigned to the unit at the time. The Assistant Director of Nursing and the Director of Nursing both stated that care plans should be updated with any change in condition, but acknowledged that the absence of a charge nurse contributed to the failure to revise the care plan. The Regional Director of Nursing and a Registered Nurse Supervisor confirmed that the resident's change in condition and new treatment should have resulted in updated care plan interventions, but this was not completed.
Failure to Assess and Document Change in Condition Following Eye Redness
Penalty
Summary
The facility failed to provide necessary care and services to maintain a resident's highest practicable physical well-being after a change in condition was reported. On 08/29/2025, a family representative notified nursing staff of redness in the resident's right eye. There was no documented nursing assessment, change-in-condition evaluation, or physician notification at that time. The medical record did not show that staff identified the redness prior to the family report, nor was there any documentation of a registered nurse assessment or a physician evaluation when ciprofloxacin ophthalmic drops were ordered and initiated. The first medical provider assessment occurred six days after the initial report, at which time the resident was diagnosed with a subconjunctival hemorrhage. The resident involved had severe cognitive impairment and multiple medical diagnoses, including dementia, anemia, and systemic lupus erythematosus. Interviews with facility staff confirmed that no assessment or documentation was completed at the time of the reported change in condition. The order for antibiotic eye drops was placed without a documented clinical rationale or provider assessment, and staff could not recall the appearance of the resident's eye at the time. The family representative was told the condition had already been addressed, but there was no evidence of prior notification or assessment. Facility leadership and medical staff were unable to provide documentation supporting appropriate assessment, provider notification, or justification for the treatment initiated.
Failure to Ensure Timely Physician Oversight and Assessment After Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper physician supervision and oversight of medical care for a resident who experienced a change in condition. Specifically, an order for ciprofloxacin ophthalmic drops was entered by a Registered Nurse Supervisor after a family representative reported redness in the resident's right eye. There was no documented nursing or physician assessment at the time the order was entered, and the physician was contacted by text message without documentation of notification in the medical record. The antibiotic treatment was initiated the following day without a provider evaluation, and the resident was not seen by a medical provider until six days after the change in condition was identified and treatment had already begun. The resident involved had diagnoses including dementia, anemia, and cardiac arrhythmias, with severe cognitive impairment and extensive assistance needs. The facility's policy required physician review and documentation of orders, as well as evaluation of residents as clinically indicated, but these steps were not followed. Interviews confirmed that there was no documented assessment or timely provider evaluation, and no documentation of an ophthalmology referral or visit was found. The lack of timely physician oversight and documentation led to the deficiency cited under 10 NYCRR 415.15(b)(1)(i)-(ii).
Failure to Timely Report and Submit Abuse Investigation Conclusions
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately, and that the results of investigations were submitted to the New York State Department of Health within the required timeframe. Specifically, the facility did not report the investigative conclusions for three separate incidents involving three different residents, as required by state law and facility policy. The incidents included allegations of staff abuse, resident-to-resident sexual exposure, and concerns about a certified nurse aide's roughness and lack of empathy. In one case, a resident with chronic obstructive pulmonary disease, schizophrenia, and major depressive disorder reported to their representative that staff had physically abused them in the dining room. The administrator was not informed of the allegation until several days after the incident, and there was no documented evidence that the investigative conclusion was submitted to the Department of Health. In another case, a resident with dementia and schizoaffective disorder exposed themselves to another resident, causing distress, but again, the investigative conclusion was not reported to the Department of Health. A third incident involved a resident with muscle weakness, major depressive disorder, and anxiety, who complained that a certified nurse aide was rough and showed no empathy. The facility investigated and found no evidence of abuse, but did not submit the investigative conclusion to the Department of Health. Interviews with the Director of Nursing and the Administrator revealed a lack of awareness regarding the failure to submit the required reports, despite both being responsible for reporting and documentation.
Failure to Update Care Plans Following Abuse and Behavioral Incidents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised in response to significant events for three residents reviewed. Specifically, one resident reported being beaten by staff, but their abuse care plan was not updated to reflect this allegation. Another resident was exposed to inappropriate behavior by a peer, yet neither the abuse care plan for the affected resident nor the behavior care plan for the resident exhibiting the behavior was updated to document the incident. These omissions occurred despite facility policy requiring care plans to be revised as residents' conditions or circumstances change. Record reviews showed that the residents involved had complex medical and psychiatric histories, including diagnoses such as COPD, schizophrenia, dementia, and major depressive disorder. The care plans in place prior to the incidents included interventions for abuse risk and behavioral concerns, but these were not revised to address the new allegations or behaviors. Interviews with nursing staff and administration confirmed that care plans should have been updated following these events, but this did not occur.
Failure to Provide and Document Required Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) independently received the necessary care and assistance, specifically in the area of incontinence care. Two residents with significant physical and cognitive impairments, including diagnoses such as Parkinson's disease, dementia, hemiplegia, and hemiparesis, were identified as being dependent on staff for toileting and incontinence care. Both residents had care plans in place that required staff to check and provide toileting care every two to four hours as tolerated. Record reviews revealed multiple instances where Certified Nurse Assistant (CNA) documentation for incontinence care was not signed, indicating that care may not have been provided as required. For one resident, there were five unsigned instances in June and seven in July. For the second resident, there were four unsigned instances in July and fourteen in August. These lapses occurred across various shifts, including day, evening, and night shifts, and were documented in the facility's electronic medical record system. Interviews with nursing leadership confirmed that CNA documentation is expected to be reviewed daily by supervisors and that missing documentation is followed up with staff. However, it was acknowledged that issues such as short staffing and assignment splitting sometimes contributed to incomplete documentation. Despite reminders and monitoring at multiple levels, including from the DON and corporate oversight, the problem of incomplete documentation persisted, and at the time of the survey, there was no consistent disciplinary action for failure to complete documentation.
Failure to Maintain Minimum CNA Staffing Levels on Multiple Shifts
Penalty
Summary
The facility failed to consistently provide sufficient certified nurse aide (CNA) staffing to meet the needs of residents on the first floor, as determined by its own facility assessment and staffing grid. Review of daily staffing schedules for July and August 2024 revealed multiple shifts where CNA staffing fell below the minimum levels established by the facility, including instances where only two or three CNAs were present during day and evening shifts, and occasions with only one or no CNAs on night shifts. These staffing levels did not align with the provider average ratio levels required for the unit, which called for five CNAs on day shift, four on evening shift, and two on night shift. The facility's policy states that adequate staffing must be maintained to meet resident care needs as outlined in their comprehensive care plans. Interviews with the Administrator and Human Resources Director confirmed that staffing had been an issue in the past, with reliance on agency staff to cover callouts and a history of insufficient CNA numbers. The Human Resources Director acknowledged the use of a staffing application and a weekly scheduling process, but records showed that actual staffing often did not meet the established minimums. The Administrator provided documentation confirming the required staffing ratios, which were not consistently met during the reviewed period.
Failure to Protect Resident Dignity Following Exposure Incident
Penalty
Summary
A deficiency was identified when a resident's right to a dignified existence was not ensured. On the specified date, one resident entered the room of another resident, unzipped their pants, exposed themselves, and made an inappropriate comment while holding their penis. The affected resident, who had a history of dementia, major depressive disorder, and moderate cognitive impairment, was found to be upset and crying as a result of this incident. The resident's care plan noted a risk for abuse and mood symptoms, including crying outbursts and verbalizations of fear following the exposure event. The facility's policy on resident rights, last revised in May 2024, states that all residents are to be treated with dignity and be free from abuse and exploitation. Documentation showed that the incident was reported to the Director of Nursing, and the affected resident expressed distress and fear related to the behavior of the other resident. The care plan for the resident included monitoring for signs of abuse and encouraging family involvement, but the incident still occurred, resulting in a violation of the resident's right to dignity.
Failure to Protect Resident from Sexual Exposure by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of dementia, major depressive disorder, and wandering behavior was subjected to sexual exposure by a neighboring resident. The incident involved the neighbor entering the resident's room, unzipping their pants, and exposing themselves, which caused the resident to become upset, cry, and express fear of being raped. The affected resident's care plan had identified a risk for abuse and included monitoring for signs and symptoms of abuse, but the incident still occurred. The resident who exposed themselves had a documented history of sexually inappropriate behavior toward roommates, female staff, and other residents, with interventions in place such as behavioral contracts, documentation of behaviors, and psychiatric evaluation as needed. Despite these interventions, the inappropriate behavior recurred, resulting in emotional distress for the affected resident. The facility's abuse policy prohibits mistreatment, neglect, and abuse by anyone, including other residents, but the policy and care plans did not prevent this incident from occurring.
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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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