The Grand Rehabilitation And Nrsg At River Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Poughkeepsie, New York.
- Location
- 140 Main Street, Poughkeepsie, New York 12601
- CMS Provider Number
- 335827
- Inspections on file
- 20
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at The Grand Rehabilitation And Nrsg At River Valley during CMS and state inspections, most recent first.
Surveyors found that treatment and medication carts were left unlocked and unattended on two units, with one cart containing Nystatin cream and another parked at a resident’s doorway while an LPN administered medications inside the room. Both involved LPNs acknowledged they knew the carts should have been locked, and the Assistant DON confirmed that nursing staff are aware of the policy requiring carts to be secured when out of the nurse’s view.
Surveyors found that staff failed to follow PPE requirements for residents on transmission-based precautions. One CNA entered a resident’s room on contact precautions without donning any PPE, despite a precaution sign on the door and facility policies requiring appropriate PPE use. Another CNA correctly donned PPE to enter a resident’s room on droplet precautions but then walked in the hallway still wearing the same mask instead of removing it upon exit. Both CNAs acknowledged their errors, and one reported that infection control training is provided but could not recall when it was last received.
The facility did not follow its own policy or regulatory requirements to provide residents with confidential quarterly statements of their personal funds held by the facility. Several residents reported they did not know their account balances and had not received quarterly statements for many months. After the former finance coordinator resigned, the Administrator assumed responsibility for disbursing resident funds, while an offsite corporate finance office was supposed to generate statements; however, no onsite staff were assigned to deliver them, and the Administrator could not verify when statements were last issued or provide documentation that any quarterly statements had been given to residents.
Surveyors identified that cold, egg-containing foods and other cold items were not consistently maintained at safe temperatures. Following resident complaints about food being overcooked, undercooked, and not arriving hot, observations showed egg salad and yogurt held well above the required 41°F or below, including an egg salad sandwich at 70°F and yogurt at 51°F. Cold items were sometimes stored under the same cover as hot items, and changes in food presentation and tray service timing contributed to elevated holding temperatures. The acting Food Service Director reported that cold food racks were kept in the walk-in refrigerator until tray assembly but acknowledged that cold food temperatures were not routinely monitored or documented.
Surveyors found multiple failures in food storage, labeling, and staff hygiene, including unlabeled foods in kitchen refrigeration areas, expired items in the walk-in refrigerator and emergency food supplies, and expired milk products in a resident’s personal refrigerator. Staff were unclear about responsibility for discarding expired items and monitoring the resident’s refrigerator, and a CNA reported that the refrigerator thermometer was missing and temperature records were not clearly maintained. Additionally, a cook prepared food with a beard net that did not cover the moustache, and a recreation staff member worked in the kitchen without a beard net, despite prior education on hair and beard net use.
The facility did not follow its own policy requiring outside dumpsters to be kept closed and free of surrounding litter. Surveyors observed multiple dumpsters left open, overflowing with cardboard and garbage, and surrounded by scattered debris including gloves, straws, spilled food, a tube feeding formula bottle, and plastic bags of trash on the ground and partially under a dumpster. The acting Food Service Director and Housekeeping Director reported that garbage and recycling are collected several times a week, that dumpster lids are routinely left open during the day, and that staff attempt to fill and close one dumpster before using the next, with the last housekeeper expected to close the lids at night.
Two residents who remained in the facility after their Medicare Part A skilled coverage ended were not provided with required Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABNs) detailing the costs of continued skilled services. Facility records showed that each resident’s Medicare Part A services were discontinued, and Notices of Medicare Non-Coverage were issued, but there was no documentation that either the residents or a representative received an SNF ABN specifying financial liability for ongoing skilled care. One resident reported not receiving any notice about the cost of skilled services after coverage ended, and the Assistant Administrator stated that the MDS Coordinator, who was responsible for issuing ABNs, was not in place at the time, resulting in the forms not being provided.
The facility did not ensure accurate completion of a PASARR Level I screen for a resident with schizophrenia, depression, and anxiety disorder. The preadmission form indicated the presence of a serious mental illness, but the required categorical determination items used to decide if a Level II evaluation was needed were left blank. Both Admissions and Social Work staff reported that they are responsible for reviewing PASARR forms for accuracy before and after admission, yet the missing categorical determinations were not identified or corrected, resulting in noncompliance with the facility’s PASARR policy and NYCRR 415.11(e).
The facility did not ensure that comprehensive care plans were reviewed and revised by the IDT in conjunction with required quarterly MDS assessments for two residents. One resident with atrial fibrillation, type 2 DM, and anemia had quarterly MDS assessments completed, including one showing intact cognition, but there was no documentation that the care plan was reviewed or updated after those assessments. Another resident with a head/scalp abscess, chronic skull osteomyelitis, and hemiplegia, and with moderately impaired cognition on a quarterly MDS, had no documented quarterly team care plan meeting during a several‑month period. The DON and Director of Social Work confirmed that quarterly care plan reviews and meetings should occur, but they did not for these residents.
A cognitively intact resident with paraplegia and multiple sclerosis, who had documented upper extremity limitations, was identified in a care plan as a smoker in a non‑smoking facility with instructions that staff secure lighters and assess smoking safety, yet later MDS assessments recorded that the resident did not use tobacco. Despite a signed agreement not to keep smoking materials in the room, the resident reported routinely storing cigarettes and a lighter in a bedside drawer and was observed smoking outside the facility gate and carrying a lighter in a fanny pack. Staff interviews showed conflicting practices and knowledge: the DON, Social Work Director, and Administrator stated that smoking materials should be locked at the front desk, while a CNA and the resident confirmed the resident kept smoking items in the room, and the receptionist reported not storing any resident cigarettes or lighters or maintaining a list of smokers. A NP stated the resident was safe to go out to smoke and could do as they wished beyond the gate, and acknowledged the resident may have smoked in their room previously, demonstrating the facility’s failure to evaluate and analyze hazards, and to monitor and adjust care plan interventions related to smoking materials.
A resident with COPD, respiratory failure, and heart failure received continuous oxygen at 4 L/min via nasal cannula without a physician’s order, despite facility policies requiring verification of orders before administering medications, including oxygen. The resident’s care plans directed staff to provide oxygen per MD orders, and observations showed the resident on oxygen from both a room concentrator and portable tanks. Record review revealed no oxygen order or MAR documentation from admission through the survey period, and interviews with an LPN, an RN, the MD, and the DON confirmed that oxygen therapy present on admission was continued without being entered into the electronic health record.
Surveyors found that MDS assessments did not accurately reflect the status of two residents. One resident with multiple comorbidities had repeated refusals of medications, IV therapy, and care, along with documented aggressive/combative behavior and behavior symptoms in nursing notes, MARs, and CNA ADL records, yet the MDS indicated no refusals or behaviors. Another resident with a chronic scalp infection and osteomyelitis had physician orders and documented treatments for a right temporal wound, but both the 5-day and quarterly MDS assessments recorded no ulcers, wounds, or skin problems. The Regional MDS Coordinator reported that errors occurred due to new staff completing MDS sections and a vacancy in the MDS Coordinator role, with corporate staff attempting to keep up with assessments.
The facility did not conduct required annual performance reviews or ensure that nurse aides completed at least twelve hours of in-service education per year. Interviews with leadership confirmed that performance evaluations were not performed, and documentation showed that two aides did not meet the annual training requirement.
A resident with severe cognitive impairment and dementia was the victim of sexual abuse by another resident. Although facility policy required prompt notification, the resident's representative was not informed of the incident until several days later, and there was no documentation of timely notification or attempts to notify. Staff interviews confirmed the delay and lack of documentation.
Two residents with cognitive impairment were not protected from abuse, as one was forcefully handled by a CNA during transport and another was subjected to inappropriate touching by a peer, with both incidents witnessed by staff and reported for investigation.
Staff failed to immediately report an observed incident of suspected abuse between two residents, both with cognitive impairment, to the State Survey Agency within the required timeframe and did not notify law enforcement, despite facility policy and state law requiring prompt reporting of such allegations.
A resident with severe cognitive impairment and a history of dementia and anxiety was the victim of a witnessed sexual abuse incident. The care plan, which previously addressed risk for abuse, was not updated to reflect the incident or to include new interventions, despite facility policy requiring care plan revisions after significant changes. Staff interviews confirmed the care plan should have been revised but was not.
A resident with arthritis, lymphedema, and peripheral neuropathy experienced multiple falls, but the facility failed to update the fall care plan. Despite documented falls, the care plan created years earlier was not revised. The DON acknowledged the oversight, noting that the ADON, DON, and RN responsible for A/I reports did not update the care plan.
Unsecured Medication and Treatment Carts Left Unattended
Penalty
Summary
The deficiency involves the facility’s failure to keep medications secure and inaccessible to unauthorized individuals, as required by its own policy and 10 NYCRR 415.18(e)(1-4). During an abbreviated survey, a treatment cart on Unit 3 East was observed at 10:20 a.m. left unlocked and unattended near a resident room, with Nystatin cream placed on top of the cart. The cart was under the responsibility of one LPN, who acknowledged in an interview that the cart had been left unlocked with the medication on top and stated that the cart should have been locked, offering no excuse for not doing so. A second incident was observed on Unit 5 East at 11:00 a.m., where a medication cart was parked at the entrance of a resident room, left unlocked and unattended while another LPN was inside the room administering medications to a resident. In an interview, this LPN admitted awareness that the cart was left unlocked and stated that it needed to be locked, noting that they normally do lock the cart. The Assistant DON later stated that nurses know they should always lock the carts and that they were likely taking a shortcut, confirming that staff were aware of the requirement that carts be locked when not in the nurse’s presence.
Failure to Adhere to PPE Requirements for Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper use of personal protective equipment (PPE) during an abbreviated survey. The facility’s infection control policy, last reviewed in January 2025, required the use of transmission-based precautions when more stringent measures than standard precautions were needed, and its PPE policy required appropriate barrier use based on the nature of resident interaction and likely mode of transmission, with supplies readily accessible. Despite these policies, on 3/2/2026 at 12:04 p.m., a Certified Nurse Aide (CNA #1) was observed entering the room of Resident #2, who had a contact precaution sign posted on the door, without donning any PPE prior to entry. During an interview immediately following this observation, CNA #1 stated they believed Resident #2 was on contact precautions due to “something with their head,” acknowledged they had entered the room without PPE, and admitted they should have applied PPE because the resident was on contact precautions, explaining they forgot and were rushing to answer the call bell. On 3/3/2026 at 10:37 a.m., another aide (CNA #2) was observed correctly donning PPE to enter the room of Resident #3, who was on droplet precautions. However, at 10:50 a.m., CNA #2 was observed in the hallway still wearing the mask used in the droplet precaution room. In a subsequent interview, CNA #2 acknowledged wearing the mask in the hallway and stated it should have been removed, and also reported that the facility does provide infection control training but could not recall when they were last trained, while stating they understood that PPE must be applied when residents are on precautions and removed after care is completed.
Failure to Provide Quarterly Personal Funds Statements to Residents
Penalty
Summary
The facility failed to provide required quarterly personal funds statements to multiple residents whose personal money was managed by the facility. The facility’s written policy, dated 01/2025, stated that residents were to be provided with a confidential quarterly statement of funds on deposit and activity since the previous statement. However, record review and interviews showed there was no documented evidence that six residents with personal needs accounts managed by the facility received these quarterly statements. The Administrator confirmed they were unable to provide documentation that quarterly personal funds statements had been provided. Several residents reported not receiving information about their account balances or quarterly statements. One resident stated they did not know how much money was in their account and had not received an account statement in the past year. Another resident reported not receiving quarterly statements for their personal funds account, and a third resident stated they did not know their personal fund account balance and had not received quarterly statements since approximately 06/2025. The Administrator reported they had assumed responsibility for resident banking after the former Finance Coordinator resigned in 11/2025, and that the corporate finance office, which operates offsite, was responsible for generating quarterly statements. The Administrator also stated there were no onsite staff designated to deliver the statements and that they did not know when the last quarterly statements were sent out. The facility could not produce any documentation to show that quarterly statements had been provided, in violation of 10 NYCRR 415.26(h)(5)(ii)(a-c).
Failure to Maintain Safe Cold Holding Temperatures for Egg-Containing Foods
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were palatable and maintained at safe, appetizing temperatures, particularly for cold, egg-containing items. During a resident council meeting, multiple residents reported that foods were sometimes overcooked, undercooked, and did not arrive hot. In response to these complaints, surveyors observed a test tray and meal services where egg salad and yogurt were not held at appropriate cold temperatures. On one occasion, an egg salad sandwich on a test tray registered a holding temperature of 70°F, and during a lunch meal service, egg salad and yogurt were held at 58°F, both above the FDA Food Code standard of 41°F or below for cold holding of cooked eggs and egg-containing foods. Further observations showed that the last lunch tray served on one unit included an egg salad sandwich, a cold item, at 70°F and stewed tomatoes, a hot item, at 126.7°F, with both items stored under the same plate cover. The cook stated that this unit was the last to receive lunch service, that cold foods should be kept well below 70°F, and that the kitchen had recently changed the food presentation, which might have affected holding temperatures. In another observation, yogurts and pre-portioned egg salad cups held on a rack for tray assembly measured 51°F and 43°F, respectively, after being out of the walk-in refrigerator for less than ten minutes. The acting Food Service Director confirmed that the procedure was to keep the rack in the walk-in until just before tray assembly, noted that refrigerator temperature logs were within normal limits, and acknowledged that cold food temperatures were typically not obtained and tracked on the temperature log.
Failure to Maintain Safe Food Storage, Labeling, and Staff Hygiene Practices
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards and its own policies. Surveyors observed multiple unlabeled food items in the main kitchen, including a plate of unlabeled food in the walk-in refrigerator, a bag of unlabeled tortellini in the freezer, and an unlabeled pan of white smooth food on the cook’s counter that staff inconsistently identified as either pancake batter or alfredo sauce. In the walk-in refrigerator, surveyors found grape jelly, chopped lettuce, chopped tomato, hard-boiled eggs, and several gallons of whole milk that were past their labeled discard or expiration dates. In the emergency food supply, a case of honey-thick apple juice and a case of rice cereal were also found to be expired. The acting Food Service Director stated that unlabeled food should not have been stored there, that it was the evening cook’s responsibility to discard expired items, and that expired milk had been delivered and left unchecked at the door, with no one available to verify it upon delivery. The facility also did not ensure staff complied with dress code requirements for beard coverage and did not properly monitor a resident’s personal refrigerator. During kitchen observations, a cook was preparing chicken with a beard net that did not cover their moustache, and a recreation staff member was filling beverage containers without a beard net, despite prior staff education on hair and beard nets. In a resident’s room, surveyors found a personal refrigerator containing multiple individual servings and cartons of milk with dates indicating they were expired. A CNA reported that the refrigerator previously had a thermometer but did not know its current location or who was responsible for temperature records, and believed the CNA assigned each shift cleaned the refrigerator. An LPN Unit Manager stated the resident’s personal refrigerator had been “grandfathered in” and was unsure who monitored or cleaned it.
Improper Management and Disposal of Garbage and Refuse at Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in accordance with its policy and regulatory requirements. The written policy titled "Food-Related Garbage and Refuse Disposal," reviewed in January 2024, required that outside dumpsters provided by garbage pickup services be kept closed and free of surrounding litter. During an observation of the garbage area with the acting Food Service Director, only one of three dumpsters had its lid closed, while the other two were open. Litter was observed on the ground, including an unused plastic garbage bag, plastic straws, used blue and white plastic gloves, cardboard, spilled food, and a plastic bag full of garbage on the ground between the two open dumpsters. A subsequent observation of the garbage area showed all three dumpster lids open. The right dumpster was spilling over with cardboard boxes, with one box on the ground, and the middle dumpster was full of garbage and boxes, including a bag hanging over the side. Additional litter was scattered in front of the dumpsters, including an empty bottle of tube feeding formula, straws, gloves, plastic, napkins, and a plastic bag of garbage partially under the dumpster. The third dumpster was partially full, with cardboard boxes trapped under it and surrounding debris such as a milk carton and used gloves. In interviews, the acting Food Service Director and the Housekeeping Director stated that garbage and recycling were picked up multiple times per week and that dumpster lids were routinely left open during the day, with the expectation that staff would fill one dumpster and close it before using the next, and that the last housekeeper would close the lids late at night.
Failure to Provide Required SNF Advanced Beneficiary Notices After Medicare Part A Ends
Penalty
Summary
The facility failed to ensure residents were informed of items and services they could be charged for and the amounts of those charges when Medicare Part A coverage ended, as required for beneficiary notification. Record review showed that two residents, both of whom remained in the facility after their Medicare Part A skilled coverage ended, did not receive a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) outlining the cost to continue skilled services. Facility records documented that one resident was discharged from Medicare Part A services on 09/30/2025 and another on 12/04/2025, yet there was no documented evidence that either resident or the second resident’s representative received an SNF ABN specifying the financial liability for continued skilled services. The Notice of Medicare Non-Coverage for one resident, dated 09/25/2025, contained the resident’s signature acknowledging that Medicare Part A services would end on 09/30/2025, but did not include information on the cost of continued skilled services. For the other resident, the Notice of Medicare Non-Coverage dated 12/04/2025 indicated cognitive impairment and that a phone call to the resident’s representative on 12/01/2025 went unanswered, with no further documentation of SNF ABN issuance. During an interview, a resident stated they did not receive any notice from the facility about the cost of skilled services after Medicare Part A coverage ended. The Assistant Administrator reported that the MDS Coordinator was responsible for providing ABN forms, but that position was vacant when these residents’ Medicare coverage ended, and as a result, the ABN forms were not issued to them or their representative.
Failure to Complete PASARR Categorical Determinations for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the PASARR Level I preadmission screening for one resident. The facility’s policy required that all individuals applying for new admission be screened to identify serious mental illness or intellectual/developmental disability, and that the Admissions Department review the Level I screen to determine if a Level II referral was needed. For Resident #81, who was admitted with diagnoses including schizophrenia, depression, and anxiety disorder, the preadmission screen dated 03/21/2025 indicated "yes" to the presence of a serious mental illness in item 23. However, the categorical determination section (items 27 to 30), which is used to determine whether a Level II screen is indicated, was not completed as instructed. Interviews with facility staff confirmed that both the Admissions Department and Social Work were responsible for reviewing the PASARR screens for accuracy before and after admission. The Assistant Director of Social Work stated that once a resident is admitted, social work checks the screens for accuracy and that items 27 to 30 should have been completed once a serious mental illness was identified. The Director of Admissions similarly stated that admissions staff review the screens for accuracy prior to admission and that, after admission, the social worker should re-check the screen and have any errors corrected. Despite these stated processes, the categorical determinations for Resident #81 were left incomplete, resulting in a failure to follow the facility’s PASARR policy and regulatory requirements under NYCRR 415.11(e).
Failure to Complete Quarterly IDT Care Plan Reviews and Meetings
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) in conjunction with required comprehensive and quarterly Minimum Data Set (MDS) assessments, as required by facility policy and regulation. For one resident with paroxysmal atrial fibrillation, type 2 diabetes mellitus, and anemia, the quarterly MDS dated 11/18/2025 documented that the resident was cognitively intact, yet there was no documented evidence that the resident’s comprehensive care plan was reviewed or revised following the quarterly MDS assessments completed on 08/25/2025 and 11/18/2025. The facility’s policy titled “Care Plans, Comprehensive Person-Centered,” last reviewed January 2025, required that the IDT review and update the care plan at least quarterly in conjunction with the quarterly MDS, and the DON confirmed in interview that care plans should be reviewed every quarter to determine if changes and updated interventions were needed. For another resident with diagnoses including abscess of the head/scalp, chronic osteomyelitis of the skull, and hemiplegia, there was no documented evidence that a quarterly team care plan meeting was held during the period between 09/2025 and 01/2026, despite a quarterly MDS dated 01/02/2026 that documented moderately impaired cognition. The Director of Social Work stated that care plan meetings were to be held every quarter and that the MDS Coordinator typically sent a list of residents due for care plan meetings, but acknowledged that a quarterly team care plan meeting for this resident did not occur during the specified period because the facility did not have an MDS Coordinator. These findings demonstrate that the facility did not follow its own policy or regulatory requirements for timely IDT review and revision of care plans in conjunction with quarterly MDS assessments for the residents reviewed.
Failure to Control Resident Smoking Materials and Enforce Smoking Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to adequately supervise a resident who smoked and possessed smoking materials, contrary to facility policy and regulatory requirements. One resident with paraplegia and multiple sclerosis, who was cognitively intact but had functional limitations in both upper extremities, was care planned in 2022 as a smoker in a non‑smoking facility, with instructions that staff assess physical and mental ability, remove the lighter to a secure location, and instruct the resident, noting the resident chose to be non‑adherent. A 2023 contract signed by the resident documented agreement not to keep smoking materials such as lighters or matches in the room. However, the 2025 Annual MDS documented that the resident did not use tobacco, and subsequent MDS assessments continued to show cognitive intactness and upper extremity limitations without reflecting ongoing tobacco use. Surveyor observations and interviews showed that the resident continued to smoke and keep smoking materials in their possession and room, without documented evaluation of hazards, analysis of risks, or monitoring and modification of care plan interventions. The resident was observed smoking outside the facility gate and later reported routinely retrieving cigarettes and a lighter from a bedside drawer, informing staff they were going downstairs, and then smoking outside the gate. On another observation, the resident had a lighter in a fanny pack. Staff interviews revealed inconsistent understanding and implementation of the smoking policy: the DON and Social Work Director stated that resident cigarettes and lighters were to be kept in a locked drawer at the front desk, while the receptionist stated the front desk did not keep resident cigarettes or lighters and had no list of smokers, and a CNA reported that the resident kept cigarettes and a lighter in the room because they were considered responsible. The Nurse Practitioner stated the resident was physically and cognitively safe to go out on leave of absence for smoking and that once beyond the gate the resident could do whatever, acknowledging the resident had possibly smoked in their room in the past. The Administrator stated smoking materials should be kept at the front desk and not held by residents, underscoring the discrepancy between policy and practice.
Oxygen Therapy Provided Without Physician Order
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred when a resident with chronic obstructive pulmonary disease, respiratory failure, and heart failure was administered continuous oxygen therapy without a physician’s order. Facility policies required that medications, including oxygen, be administered only in accordance with physician orders and that staff verify orders prior to administration. The resident’s admission MDS documented intact cognition, assistance needs with ADLs, and shortness of breath when lying flat or on exertion. Care plans addressing cardiovascular and respiratory function directed staff to provide oxygen per medical doctor orders and to assess oxygen needs and provide oxygen as ordered. During multiple observations over several days, the resident was noted to be receiving oxygen at 4 liters per minute via nasal cannula from both an oxygen concentrator in the room and portable tanks on the wheelchair. The resident reported having been on 4–5 liters per minute of oxygen prior to admission. Record review on 1/22/2026 showed no oxygen orders in the medication administration record or physician orders from admission through that date. Nursing staff, including an LPN and an RN, stated the resident arrived on 4 liters per minute of continuous oxygen and that this therapy was simply continued without an order being entered into the electronic health record, resulting in no documentation of oxygen administration on the MAR. The physician confirmed that orders are typically entered by providers or nurses at admission and acknowledged that the resident’s oxygen administration was correct but not entered. The DON stated there should have been an order for oxygen and that its absence was an oversight.
Inaccurate MDS Coding for Refusals and Chronic Scalp Wound
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status for two residents reviewed for skin issues. For one resident with diagnoses including diabetes mellitus, heart failure, and morbid obesity, the quarterly MDS dated 09/29/2024 documented intact cognition and no behaviors, including no refusals of care, medications, or activities of daily living. However, nursing notes showed that this resident refused an IV catheter for IV infuvite on 09/23/2024 and refused milk of magnesia on 09/27/2024, stating they had not eaten in days. Additional documentation on 09/27/2024 described the resident as aggressive/combative and resisting/refusing care. The September Medication Administration Record showed refusals of Eliquis on 09/22/2024, 09/24/2024, and 09/25/2024, and CNA ADL documentation for September 2024 recorded behavior symptoms on multiple dates. Despite these documented refusals and behaviors, they were not captured on the MDS, and the Regional MDS Coordinator later acknowledged that these behaviors should have been included and that information may have been entered incorrectly by new staff. For a second resident with diagnoses including urinary abscess of the head/scalp, unspecified open wound of the head, and chronic osteomyelitis of the skull, the MDS assessments also failed to accurately reflect the resident’s condition. A physician’s note dated 11/26/2025 documented a chronic right scalp infection with greenish-brown exudate, and physician orders on 11/26/2025 and 11/27/2025 directed cleansing of the right temporal area with normal saline, application of a clean dry dressing, and topical Gentamicin Sulfate for osteomyelitis of the scalp. The Treatment Administration Record showed that the ordered scalp treatment was administered on 12/30/2025 and 12/31/2025. Despite this, both the Five-Day and Quarterly MDS assessments documented that the resident did not have other ulcers, wounds, or skin problems. The Regional MDS Coordinator stated that staff entering the MDS information made mistakes, that the MDS Coordinator position had been vacant, and that corporate staff were attempting to complete assessments while the Regional Coordinator was overseeing them but having difficulty keeping up.
Failure to Complete Annual Performance Reviews and In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that performance reviews for certified nurse aides were completed at least once every 12 months and that each aide received no less than twelve hours of in-service education per year, as required by facility policy and state regulation. During interviews, the Director of Human Resources, Director of Nursing, Administrator, and former Staff Educator all confirmed that performance evaluations for clinical staff, including nurse aides, were not conducted. Documentation reviewed for three certified nurse aides showed that performance reviews were not available for any of them. Additionally, the review of mandatory annual education packets revealed that two of the three certified nurse aides did not complete the required twelve hours of in-service education within the year. Specifically, one aide completed 7.5 hours and another completed 9 hours, with the former Staff Educator noting that the tally of education minutes was not up to date. The facility's own policy states that in-service training should be based on the outcome of annual performance reviews and must total at least twelve hours per year, but this was not followed.
Failure to Timely Notify Resident Representative After Significant Incident
Penalty
Summary
The facility failed to ensure timely notification of a resident's representative following a significant incident involving sexual abuse. On 12/13/24, a certified nurse aide observed another resident touching the resident's left breast, and the incident was documented as having reasonable cause to believe abuse, neglect, or mistreatment may have occurred. Despite facility policy requiring that the resident and their representative be kept informed of the progress of the investigation, there was no documented evidence that the resident's family member was notified of the incident when it occurred. The accident/incident report noted a notification time but did not include a date, and review of the nurse's notes confirmed that the resident's son was not notified until 12/16/24. The resident involved had severe cognitive impairment, dementia, anxiety, and required assistance with activities of daily living. Interviews with staff, including the assistant director of nursing and the director of nursing, confirmed that the family was not notified at the time of the incident and that documentation of any attempted or successful notification prior to 12/16/24 was lacking. The director of nursing acknowledged that the family should have been notified when the incident occurred, but there was no evidence to support that this was done in a timely manner.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, as evidenced by two separate incidents involving three residents with cognitive impairments. In the first incident, a Certified Nurse Aide was observed by a Registered Nurse Supervisor forcefully pushing a resident's arm off a door jam while attempting to wheel the resident out of the dining room. The resident, who had severe cognitive impairment and was care planned as being at risk for abuse, was assessed immediately after the incident and found to have no injuries. The event was reported to the Director of Nursing, and the facility's policy required prompt investigation and reporting of abuse allegations. In the second incident, another Certified Nurse Aide witnessed a resident with moderately impaired cognition touching the breast of another resident who also had severe cognitive impairment and required assistance with activities of daily living. The facility's accident and incident report concluded there was reasonable cause to believe that abuse, neglect, or mistreatment may have occurred. The Director of Nursing, after investigation, stated they could not rule out that abuse may have occurred in this case as well.
Failure to Timely Report Suspected Abuse and Notify Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by policy and state law. Specifically, a Certified Nurse Aide observed one resident touching another resident's breast, and the incident was documented as having reasonable cause to believe that abuse, neglect, or mistreatment may have occurred. Despite this, the facility did not report the incident to the State Survey Agency until the following day, well beyond the required two-hour timeframe, and did not notify local law enforcement at any point, even though the facility could not rule out abuse. The residents involved had significant cognitive impairments and required assistance or supervision with activities of daily living. The facility's own policies required immediate reporting of suspected abuse and notification of both the State Survey Agency and law enforcement in cases of reasonable suspicion of a crime, including sexual abuse. Interviews with facility staff confirmed the delay in reporting and the failure to notify law enforcement, with the DON stating that law enforcement is only contacted if at least one resident involved is alert and oriented, which is not consistent with policy requirements.
Failure to Update Care Plan After Abuse Incident
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised in a timely manner following a significant event involving a resident. Specifically, a resident with severe cognitive impairment, dementia, anxiety, and muscle weakness was the victim of a witnessed sexual abuse incident. Although the resident's care plan, dated prior to the incident, included interventions to assess for and report abuse, there was no documented evidence that the care plan was updated to reflect the abuse incident or to include new interventions after the event occurred. Facility policy requires the interdisciplinary team to review and update the care plan when there is a significant change in a resident's condition. Despite documentation in the physician's note that the resident's son was informed and staff would increase monitoring and prevent further contact with the perpetrator, these interventions were not incorporated into the resident's care plan. Interviews with facility staff confirmed that the care plan should have been updated to document the incident and the new interventions, but this was not done.
Failure to Update Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team for a resident who experienced multiple falls. Resident #59, who had diagnoses including arthritis, lymphedema, and peripheral neuropathy, experienced falls on 2/4/23 and 2/28/23. Despite these incidents, the resident's fall care plan, initially created on 10/7/19, was not updated to reflect the new falls. The resident's Annual Minimum Data Set (MDS) dated 8/26/23 indicated intact cognition and required limited assistance for mobility and toileting. The Accident/Incident reports documented the falls, but there was no evidence of care plan revision. The Director of Nursing (DON) acknowledged that the care plans were not updated and stated that the responsibility lay with the Assistant Director of Nursing (ADON) and the DON, as well as the registered nurse (RN) who completed the A/I reports.
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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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