Ocean Gardens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arverne, New York.
- Location
- 64 11 Beach Channel Drive, Arverne, New York 11692
- CMS Provider Number
- 335738
- Inspections on file
- 18
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ocean Gardens Care Center during CMS and state inspections, most recent first.
A resident with dementia, seizure disorder, moderately impaired cognition, and dependence on staff for bed mobility and transfers sustained a second-degree burn on the thigh consistent with contact from a radiator. Nursing assessment described a 15 cm by 8 cm erythematous, blistered area whose pattern matched the radiator surface, and the MD indicated the wound was consistent with a burn from a hot surface and would be avoidable if caused by the radiator. CNAs reported the resident required extensive assistance, had poor awareness of bed boundaries, and was turned and provided incontinence care during the night and morning without observed redness, while also stating the bed was not close to the radiator. The facility’s investigation concluded the resident likely shifted or rolled toward the radiator due to poor boundary awareness and the alternating pressure mattress, demonstrating a failure to control environmental hazards and provide adequate supervision to prevent this avoidable accident.
Surveyors found that the facility failed to comply with state requirements that resident beds be kept at least three feet from radiators, resulting in harm to a resident whose bed had been placed too close to a radiator. During an abbreviated survey triggered by this incident, interviews and room measurements showed that multiple beds in sampled rooms were positioned less than 36 inches from radiators, confirming that resident equipment was not consistently maintained at the required distance.
A resident with dementia, seizure disorder, and COPD had a care plan indicating dependence for bed mobility with a need for total assistance from two staff, but the MDS assessment was inaccurately coded as requiring only partial/moderate assistance. Observation showed two staff providing total assistance for bed mobility, and interviews with an RN, a CNA, and the rehab director all confirmed the resident required total care with two-person assistance for bed mobility and transfers. The rehab department completed the MDS bed mobility section, and the rehab director later acknowledged the coding error, while the MDS coordinator stated they were unaware of the discrepancy despite their usual process of using assessments, staff interviews, and record review for MDS completion.
The facility failed to ensure immediate notification of residents’ representatives following significant changes in condition. In one case, a resident with severe cognitive impairment sustained an unwitnessed fall resulting in a facial laceration and hospitalization, yet documentation incorrectly indicated no next of kin and showed no attempt to contact the listed representative. In another case, a resident with dementia and Parkinson’s disease developed a new skin opening on the foot; although the MD was notified and treatment ordered, the RN only documented an attempted call and planned re-attempt, with no follow-up or evidence that the sibling was ever informed, and no handoff to other staff for continued notification efforts.
Surveyors found that the facility did not follow its own policy and state mandates requiring immediate (within 2 hours) reporting of alleged abuse, neglect, mistreatment, and injuries of unknown origin to the State Survey Agency. One resident with dementia and impaired cognition was discovered with significant facial discoloration, redness, and swelling while in a wheelchair, with no witnesses and no explanation for the injury; staff and the Administrator were aware, but the incident was not reported to the state until several hours later. Another cognitively impaired resident with dementia, Parkinson’s disease, and cerebrovascular disease was found in another resident’s room with a bleeding eyebrow laceration of unknown cause, later treated with Steri-Strips, and the facility’s investigation did not determine what occurred; this event was documented as a fall and was never reported to the state as an injury of unknown origin, despite leadership acknowledging it met criteria for such reporting.
The facility did not report multiple incidents of alleged abuse, neglect, and misappropriation within required timeframes. Events included physical altercations between residents with cognitive impairments, exposure of private areas, and a theft allegation involving a staff member. Reports to authorities were delayed, and law enforcement was not notified in a case of alleged misappropriation, despite facility policy and state regulations.
A resident with intact cognition reported being punched by a staff member, resulting in a black eye. The incident was not immediately reported or assessed by the staff involved. The facility's investigation concluded that there was reasonable cause to believe abuse occurred, as the resident consistently identified the staff member responsible. The lack of immediate action and communication among staff contributed to the deficiency.
Burn Injury from Radiator Due to Inadequate Hazard Control and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment free of accident hazards and to provide adequate supervision and assistive devices to prevent avoidable accidents, resulting in a burn injury to one resident. The resident had diagnoses including dementia, anxiety disorder, and a seizure disorder, and the most recent Quarterly MDS documented moderately impaired cognition. The MDS and CNA documentation showed the resident required total assistance with transfers and toileting, used a Hoyer lift with two-person assistance for transfers, and needed substantial/maximal assistance with rolling in bed, indicating significant dependence for bed mobility and positioning. On the morning in question, the resident was observed with erythema on the left upper thigh extending to mid-thigh, approximately 15 cm by 8 cm, with irregular shape, uneven borders, bright pink to red coloration, and blistering in the mid-region. Nursing assessment documented that the resident appeared to have been lying with the thigh on a heating vent, although no staff witnessed this. The RN Supervisor later described the wound as a dark pink rectangular-shaped line on the left upper thigh with a small blister in the center, measuring 15 cm by 8 cm, and stated that the pattern of the lines on the resident’s thigh matched the line patterns on the top of the radiator. The physician who assessed the wound stated it could be a second-degree burn caused by a hot surface such as a radiator and that, if caused by the radiator, it would be avoidable. Staff interviews revealed that multiple CNAs and nursing staff had provided care and rounding for the resident before the burn was discovered, and that the resident was known to require extensive assistance with mobility and had poor awareness of bed boundaries. CNAs reported performing rounds and incontinence care during the night and early morning, stating that the resident’s bed was not close to the radiator and that they were able to walk around the bed. They also reported that the resident remained in the same position after being turned and that no redness was observed on the legs or thighs during earlier care. However, the facility’s incident investigation later concluded that, due to the resident’s poor awareness of bed boundaries and the alternating pressure of the air mattress, the resident likely shifted or rolled toward the radiator, resulting in the burn. This sequence of events demonstrates that the facility did not adequately control environmental hazards related to the radiator and did not ensure sufficient supervision and protective measures to prevent the resident from coming into prolonged contact with a hot surface.
Noncompliant Bed Placement Near Radiators Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to comply with N.Y. Comp. Codes R. & Regs. Tit. 10 § 713-1.3(h)(1), which requires that resident beds be placed so they can be approached from at least one side and one end and that no bed be closer than three feet to a window, radiator, or an adjacent bed. During an abbreviated survey conducted in response to an incident, surveyors determined that at least one resident’s bed had been positioned less than three feet from a radiator. This improper placement of the resident’s bed resulted in harm to that resident. The report identifies this as a failure to ensure compliance with applicable State and local laws governing the design and equipment of resident bedrooms for adequate nursing care, comfort, and privacy. Interviews and record review during the survey confirmed that the facility had not consistently maintained the required minimum three-foot distance between resident beds and radiators prior to the incident. The Maintenance Director reported that the bed in the involved room had been moved away from the radiator after the incident, preventing assessment of the original distance from the radiator. A sample of rooms measured by surveyors showed several beds with distances from the radiator to the mattress of less than 36 inches, including measurements of 32, 34, and 35 inches, indicating that the deficiency was not isolated to a single room. These findings support that the facility did not ensure resident equipment (beds) was kept at the minimum required distance from radiators, leading to the cited harm to a resident.
Inaccurate MDS Coding of Bed Mobility Assistance Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident. The facility’s policy on Resident Assessment, last reviewed on 10/25/2025, required comprehensive and accurate assessments using direct observation and communication with residents and direct care staff on all shifts. The resident, admitted with dementia, seizure disorder, and COPD, had a Comprehensive Care Plan effective 02/03/2026 documenting dependence for bed mobility (rolling left to right) with a need for total assistance of two staff. However, the MDS assessment dated [DATE] coded the resident’s bed mobility as requiring only Partial/Moderate assistance, indicating the helper did less than half the effort, which did not match the care plan or the resident’s actual needs. During observation on 03/11/2026 at 9:00 AM, the resident was seen receiving total assistance from two staff for bed mobility. In interviews, an RN stated on 03/10/2026 that the resident required total care with two people for bed mobility and turning/positioning, and a CNA reported that two staff had been providing total assistance for bed mobility since the resident’s readmission. The Director of Rehabilitation stated that the rehab department completed the MDS bed mobility section (GG0130), that the resident was on skilled therapy and required total care with assistance of two people for bed mobility and transfers, and acknowledged that the MDS coding was in error and should have been “dependent” rather than “partial/moderate.” The MDS Coordinator reported that they typically collect information from assessments, staff interviews, and medical record review and double-check records for accuracy before submitting MDS assessments, but stated they were not aware of the discrepancy in this resident’s MDS dated 02/12/2026.
Failure to Notify Representatives of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify residents’ representatives of significant changes in condition, including an accident with injury and a new skin opening, as required by facility policy and 10 NYCRR 415.3(f)(2)(ii)(c). For one resident with schizophrenia, anxiety, dementia, and severe cognitive impairment, an unwitnessed fall occurred in the evening, during which the resident was found sitting on the floor with a laceration to the left eyebrow that required hospitalization. The accident/incident report documented that family was not notified and indicated “No Next of Kin,” and a nursing progress note also stated there was no next of kin to notify. However, the resident’s face sheet contained next of kin contact information, and there was no documented evidence that staff attempted to call the designated representative. For another resident with non-Alzheimer’s dementia, Parkinson’s disease, cerebrovascular disease, and severely impaired cognitive skills, nursing documentation showed a new skin opening on the left dorsal foot, with the MD notified and treatment ordered. A subsequent nursing note recorded that the nurse called the resident’s next of kin to provide an update and would re-attempt contact later, but there was no documentation that the representative was ever successfully notified of this change in condition. The RN Supervisor who wrote the note later stated they did not recall if they actually reached the sibling, and they were out sick for at least a month afterward. The DON reported that next of kin notification is done by nursing or social work, that the RN Supervisor did not leave a voicemail per facility policy, and that the need for follow-up notification was not communicated in the end-of-shift report, leaving no evidence that the representative was informed.
Failure to Timely Report Injuries of Unknown Origin to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse, neglect, mistreatment, and injuries of unknown origin were reported to the State Survey Agency immediately, and no later than two hours after discovery, as required by facility policy and state reporting mandates. The facility’s written policy, revised 05/06/2025, required that all alleged violations involving serious injuries of unknown source be reported and investigated immediately, with findings reported to the New York State Department of Health (NYSDOH) within two hours, as well as to law enforcement and other required agencies. Surveyors found that this policy was not followed for two residents whose injuries met criteria for injuries of unknown origin. For one resident with cellulitis, sepsis, and dementia, an Annual MDS documented moderately impaired cognitive skills and a need for supervision or assistance with activities of daily living. On 04/12/2024 at approximately 7:00 AM, this resident was observed in a wheelchair in the hallway with facial discoloration, redness to the right forehead and cheek, and ecchymosis and redness around both eyes, with mild swelling to the forehead and eyelids. The resident was unable to explain what happened due to cognitive impairment and a language barrier, and employee statements did not identify any witness to the injury. The Accident/Incident Report identified the event as an injury of unknown source, staff became aware at 7:00 AM, and the Administrator was notified at 9:00 AM. However, the incident was not submitted to NYSDOH until 1:57 PM, exceeding the two-hour reporting requirement. During interview, the Assistant DON confirmed the incident was reported but did not provide an explanation for the late submission. For another resident with non-Alzheimer’s dementia, Parkinson’s disease, and cerebrovascular disease, an Annual MDS documented short- and long-term memory problems and severely impaired cognitive skills for decision-making. On 11/21/2025 at 6:00 AM, this resident was found sitting in a wheelchair in another resident’s room with blood dripping from the left side of the face and a 2 cm laceration to the left eyebrow; the location of occurrence was unknown, and the resident could not state what occurred due to severely impaired cognition. The resident was sent to the hospital for evaluation and later returned with Steri-Strips and swelling to the left eyebrow. The facility’s incident report documented no conclusion as to what occurred, and there was no documented evidence that this injury of unknown origin was reported to NYSDOH. In interviews, the DON stated the incident was initially documented as a fall and acknowledged that, upon review, it could be considered an injury of unknown origin, and the Assistant DON stated the incident should have been reported as an injury of unknown origin because there was no clear evidence of a fall and did not recall any discussion about reporting it.
Failure to Timely Report Alleged Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported within the required timeframes to the appropriate authorities. Multiple incidents involving residents with varying degrees of cognitive impairment and mental health diagnoses were not reported immediately, or within the mandated two-hour or 24-hour windows, as required by state regulations and the facility's own policies. These incidents included physical altercations between residents, exposure of private areas, and allegations of theft by staff. For example, one incident involved a resident with intact cognition kicking and pulling the arm of another resident with severely impaired cognition after the latter wandered into their room. This event was not reported to the New York State Department of Health until more than a day later. In another case, a resident was found standing at the bedside of another resident, both with private areas exposed, but the incident was not reported until several hours after discovery. Additional incidents included a resident with impaired cognition being pushed by another resident, and a resident hitting another after being confronted for going through personal belongings, with delayed reporting in both cases. An allegation of theft was also not reported to local law enforcement as required. A resident with memory problems and poor decision-making reported that a housekeeper took their money, and although the facility's investigation found reasonable cause to believe misappropriation may have occurred, there was no documented evidence that law enforcement was notified. Interviews with facility leadership confirmed awareness of the reporting requirements, but the documented actions did not meet the mandated timelines.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a nursing home staff member. This incident involved a resident who was observed with a black eye, which they reported was caused by being punched by a staff member, specifically a Registered Charge Nurse. The resident, who had intact cognition, was able to identify the staff member involved in the incident. The facility's policy on the prohibition of resident abuse was not adhered to, as the staff member did not assess the resident or report the incident to the appropriate authorities. The incident occurred when the resident was redirected from entering a dining room with a wet floor, leading to an altercation where the resident reportedly slapped the staff member. The staff member did not report this altercation or the subsequent discoloration observed on the resident's face. Multiple staff members, including a Licensed Practical Nurse and a Certified Nursing Assistant, observed the discoloration but did not take immediate action to report or assess the situation. The Director of Nursing was eventually informed by an Occupational Therapist, who noticed the resident's condition and reported it. The facility conducted an investigation and concluded that there was reasonable cause to believe that abuse had occurred. The resident consistently reported being punched by the staff member, and the staff member failed to follow protocol by not reporting the incident or assessing the resident's condition. The lack of immediate action and communication among staff members contributed to the deficiency in protecting the resident from abuse.
Plan Of Correction
Plan of Correction: Approved April 29, 2025 Element #1: What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice Residents #1 who was affected by this deficient practice was assessed by RN Supervisor (RNS), PMD and Psychiatrist. Right periorbital x-ray was ordered and result showed no fracture. Accused RN was immediately removed from duty. Completed 4/17/2025. Element #2: How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents under the care of accused RN had the potential to be affected by the deficient practice. Consequently, upon report of occurrence on 9/7/2023, the accused RN was immediately removed from duty and employment subsequently terminated. Cognitively intact residents who were under the care of accused RN will be interviewed and assessed for abuse or inappropriate interactions. Residents who are cognitively impaired, their NOK will be interviewed instead. Completed 6/3/2025. Element #3: What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Facility Abuse prevention policy and procedure was reviewed and revised to include that staff accused of abuse must be removed from duty immediately. All employees will be monitored by their respective department head to ensure they are not abusing residents. Specifically, unit CNA, LPN, and RN will be monitored by RN Supervisor. ADNS will supervise RNS for any inappropriate or abusive interactions with residents. Employees identified with behaviors or negative interactions that equate to abuse will be removed from duty immediately. All residents will be monitored by unit RN Supervisor and Social Worker to ensure they are not abused by staff. All staff who directly interact with residents—such as nursing, medical, housekeeping, social work, activities, rehabilitation, and administration—will be re-inserviced on abuse prevention by ADNS and/or their direct supervisor. Social Work Director and/or designee will attend monthly resident council meetings to educate residents on the procedure for promptly reporting abuse. DNS will monitor for sustained compliance of staff abuse prevention education and observation to ensure all residents are free from staff abuse. Completed by 5/31/25. Element #4: How the corrective actions(s) will be monitored to ensure the deficient practice will not recur—what quality assurance program will be put into practice Social Worker will audit/interview 5 residents weekly to assess comfort with caregivers and/or report of abuse and report to DNS and/or Administrator of their findings. Negative findings will be addressed promptly. ADNS will conduct weekly audits of direct staff interaction with residents on unit and report to DNS and/or Administrator of their findings; negative findings will be addressed promptly. Audit findings will be reported and reviewed at QAPI weekly x 2 weeks; monthly x 2 months, then quarterly thereafter. Completed by 5/31/2025. Element #5: The date for correction and the title of the person responsible for correction of each deficiency Director of Nursing and/or designee Date: 6/3/2025
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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