The Hamptons Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in South Hampton, New York.
- Location
- 64 County Road 39, South Hampton, New York 11968
- CMS Provider Number
- 335850
- Inspections on file
- 14
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 4 (3 serious)
Citation history
Health deficiencies cited at The Hamptons Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was transferred to the hospital, and staff boxed the resident’s belongings for storage. Due to confusion with another resident who had the same last name and was later admitted to the same room, the boxed items were mistakenly given to the wrong resident and were not returned when the original resident came back from the hospital. The family later reported missing clothing with sentimental value, and staff interviews confirmed that the belongings had been misidentified and were no longer in the facility.
Two residents with intact cognition reported allegations of sexual abuse by a CNA, including inappropriate comments and unwanted touching during care. Despite these reports, the facility did not conduct thorough investigations, failed to assess the residents physically or psychosocially, and allowed the CNA to return to work with access to all residents. Leadership did not report the incidents or inform the medical director in a timely manner.
Two residents with intact cognition reported inappropriate and potentially abusive contact by a CNA, including unwanted touching and inappropriate comments. Facility leadership did not report these allegations to law enforcement or the state health department, nor did they conduct required investigations, as they did not believe the incidents constituted abuse. The facility's policy lacked guidance on reporting to law enforcement, and no physical or psychosocial assessments were completed for the affected residents.
Two residents with intact cognition reported inappropriate and distressing care by a CNA, including intimate care against their wishes and inappropriate comments. Despite facility policy requiring immediate reporting and investigation of abuse allegations, leadership dismissed the concerns without thorough inquiry or documentation, and no comprehensive investigation was conducted.
Three residents in a facility were found with fall prevention mats improperly placed on their sides against the beds, restricting their movement. The facility's policy requires these mats to be laid flat on the floor to prevent falls, not to act as restraints. Interviews with CNAs, LPNs, and the DON confirmed the incorrect placement of the mats, which was not in line with the facility's guidelines.
A survey found that call systems were not accessible to residents in their rooms, affecting three residents with conditions like Parkinson's, Dementia, and Aphasia. Observations showed call bells out of reach, despite facility policy and care plans requiring accessibility. Staff, including CNAs and LPNs, failed to ensure call bells were within reach, as confirmed by the DON.
A resident's dignity was compromised due to a failure to maintain cleanliness in their room. Despite the resident's preference for urinals on the floor for easy access, staff did not ensure the area was clean and odor-free. The resident, who required substantial assistance for toileting, expressed a desire for cleanliness, but staff failed to promptly address the issue, leaving a full urinal and soiled bed mat in place.
A resident with severe cognitive impairments fell from their bed, sustaining facial bruising. The facility failed to notify the resident's primary contact, the family member, as required by policy, and instead informed the group home. Staff interviews confirmed the oversight, acknowledging the family should have been the first contact.
A facility failed to maintain a safe and clean environment for residents, with issues including a broken bathroom door for a resident with dementia and stained privacy curtains and soiled bathroom floors for another resident. Despite maintenance and cleaning protocols, these issues persisted, indicating lapses in timely response and adherence to cleaning policies.
A resident with severe cognitive impairment and a history of falls was found on the floor with a laceration and bruising. The facility failed to obtain a statement from the Kitchen transporter, who first found the resident, as required by policy. This oversight was acknowledged by the RN Supervisor and DON, highlighting an incomplete investigation.
A facility failed to complete a Minimum Data Set (MDS) assessment within the required timeframe for a resident admitted with Congestive Heart Failure and Diabetes Mellitus. The assessment was completed six days late, and the MDS Coordinator acknowledged the delay but was unsure of the reason. The Administrator was unaware of the issue.
A resident with a tracheostomy did not receive proper respiratory care as a nurse failed to change the inner cannula as per physician orders, instead attempting to clean and reuse it. The facility's policy lacked specific directions for changing the cannulas, and there was no evidence of physician orders for outer cannula changes for several months. Interviews with staff confirmed the improper practice and highlighted the risk of infection due to these deficiencies.
A resident with severe cognitive impairment and cellulitis did not receive prescribed doses of Ampicillin at two scheduled times. The medication was not documented as administered, and the setup lacked proper labeling. Nursing staff interviews confirmed the oversight, highlighting a breach in the facility's medication administration policy.
The facility failed to adhere to food safety standards, as observed when a dietary aide handled food with contaminated gloves and cold food items were served above the required temperature. The aide did not change gloves after exiting the refrigerator, and cold food temperatures were not routinely checked, leading to potential contamination risks.
A non-verbal resident with severe communication impairments was sent to a Neurology appointment unaccompanied, resulting in the appointment's cancellation. The facility failed to document the cancellation or reschedule the appointment, and the resident's family was not informed. The LPN responsible did not follow the facility's policy requiring accompaniment for such residents, and the Director of Nursing acknowledged the lack of documentation and follow-up.
The facility failed to transmit MDS assessments to CMS within the required timeframe for six residents, with delays ranging from 46 to 65 days. The MDS Coordinator believed the assessments were submitted on time but did not receive validation reports, leading to a resubmission. The Administrator was unaware of the delays, highlighting a lapse in the facility's compliance with timely MDS submissions.
Failure to Safeguard and Return a Resident’s Personal Belongings After Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to be treated with respect and dignity and to retain personal possessions when transferred to the hospital. The facility’s policy on personal belongings stated that upon discharge to a hospital, valuables would be sent to the basement for storage and other belongings could remain in the room if security could be ensured, with property left more than 30 days after discharge subject to disposal. Resident #266, who had diagnoses including type 2 diabetes, cerebral infarction, and essential hypertension, and who had a Brief Interview of Mental Status score of 3 indicating severely impaired cognition and required assistance with all ADLs and was always incontinent, was transferred to the hospital for evaluation. During this transfer, the resident’s belongings were boxed and stored in the basement. After the resident’s return from the hospital, the belongings were not returned to the resident or family. A grievance filed by the resident’s family reported missing clothing that could not be located. The family stated that the belongings were never returned after the hospital transfer and that they were not informed what happened to the items until months later, when they were told by the Director of Housekeeping and the Administrator that the possessions had been accidentally given to another resident with the same last name. Interviews with staff revealed that CNAs typically pack belongings in a labeled box stored in the resident’s closet until removed, and that nurses and CNAs are responsible for packing belongings while housekeeping staff clean rooms and the Director of Housekeeping moves boxes to the basement. The Director of Housekeeping acknowledged that the boxed belongings of Resident #266 were mistakenly assumed to belong to a newly admitted resident with the same last name and were given to that resident, who later left the facility, and the items were no longer in the facility.
Failure to Protect Residents from Alleged Sexual Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from alleged sexual abuse, resulting in Immediate Jeopardy for two residents with intact cognition. Both residents reported inappropriate actions by a Certified Nursing Assistant (CNA), including sexually inappropriate comments and unwanted touching during personal care. Despite these allegations, there was no documented evidence that a thorough investigation was initiated, nor were the residents assessed by a registered nurse or provided with a psychosocial evaluation after expressing fear and discomfort. One resident, diagnosed with multiple sclerosis, protein calorie malnutrition, and pseudobulbar affect, reported that a male CNA made a sexually inappropriate comment and applied cream to intimate areas without proper consent. The resident had previously requested female caregivers, but this preference was not documented or honored. The incident was reported to facility leadership, but the CNA was only suspended for three days without a comprehensive investigation and was later allowed to return to work with access to all residents. There was no documentation of a physical or psychosocial assessment for the resident following the incident. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same CNA took an unusually long time wiping their genital area, making them feel unsafe. This concern was reported to another CNA and a registered nurse supervisor, but no formal investigation or assessment was conducted. The resident was transferred to another room, but there was no evidence of a registered nurse assessment or psychosocial evaluation. Facility leadership decided not to report or investigate the allegation, citing a lack of perceived sexual abuse, and the medical director was not informed until much later.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made. This deficiency was identified for two residents who reported allegations of inappropriate and potentially abusive behavior by a certified nursing assistant. The facility did not document evidence that these allegations were reported to local law enforcement or the New York State Department of Health as required by regulation. One resident, with a history of multiple sclerosis, protein-calorie malnutrition, and pseudobulbar affect, reported that a male certified nursing assistant made inappropriate comments about their shaved vaginal area and applied cream to their buttocks despite the resident's request to self-apply. The resident delayed reporting the incident due to embarrassment, and the family member subsequently informed facility leadership. Despite the resident and family expressing concerns about safety, the facility leadership determined within two hours that there was no evidence of abuse and did not report the incident to authorities. The facility's policy did not include guidance on reporting to law enforcement, and the staff involved did not consider the incident to be sexual abuse. A second resident, with diagnoses including type 2 diabetes, depression, and anxiety disorder, reported that the same certified nursing assistant rubbed their genital area in a manner that made them feel violated. The resident was visibly upset and reported the incident to another staff member, who escalated it to a supervisor. However, the facility did not document any report to authorities or conduct a formal investigation, as leadership did not believe the incident constituted abuse. Interviews with facility leadership and the medical director revealed a lack of awareness and appropriate response to the allegations, and no physical or psychosocial assessments were completed for the residents involved.
Failure to Investigate Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to thoroughly and promptly investigate allegations of sexual abuse involving two residents, resulting in a deficiency identified during an abbreviated survey. According to the facility's abuse prevention policy, all allegations of abuse must be immediately reported and investigated, including obtaining statements from staff, witnesses, and residents, as well as reviewing medical and employee records. However, in both cases, there was no documented evidence that a comprehensive investigation was initiated to rule out abuse, neglect, or mistreatment. One resident, with a history of multiple sclerosis and intact cognition, reported that a male CNA provided intimate care despite their request for a female caregiver and made inappropriate comments regarding the resident's body. The resident delayed reporting the incident due to embarrassment, but when the family member informed facility leadership, the Assistant Director of Nursing dismissed the allegation, believing the resident was fabricating the story, and did not pursue further investigation. The administrator also concluded within two hours that there was no evidence of abuse based on family input, without conducting a thorough inquiry. A second resident, also with intact cognition and a care plan identifying risk for psychosocial distress, reported discomfort and distress after a CNA allegedly took an unusually long time providing care to their genital area. The resident was visibly upset and requested a room change to avoid further contact with the CNA. Although the concern was reported to nursing and social work staff, no further questions were asked, and the Director of Nursing decided not to report or investigate the allegation, concluding it did not constitute sexual abuse. The administrator similarly determined no investigation was necessary. The medical director later stated that all allegations of abuse should be reported and investigated immediately.
Improper Use of Fall Prevention Mats as Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints that were not required for medical treatment. During an abbreviated survey, it was observed that three residents were subjected to improper use of fall prevention mats, which were placed on their sides against the beds, restricting the residents' freedom of movement. This setup was contrary to the facility's policy, which mandates that such mats should be laid flat on the floor next to the bed to prevent injuries from falls. Resident #1, diagnosed with Parkinson's Disease, Dementia, and Dysphagia, was observed in bed with fall prevention mats placed on their sides, restricting movement. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse Manager revealed that the mats were intended to be flat on the floor, not on their sides, as this would restrict the resident's ability to move freely. The Director of Nursing Services confirmed that the mats should not be placed on their sides as it could restrict movement. Similarly, Resident #2, with diagnoses including Cerebral Infarction and Dementia, and Resident #3, diagnosed with Dementia and Alzheimer's Disease, were also observed with fall prevention mats improperly placed on their sides. Interviews with CNAs and nursing staff confirmed that the mats were not positioned according to the facility's policy, which led to the restriction of the residents' freedom of movement. The Director of Nursing Services reiterated that the mats should be laid flat to be effective and not act as restraints.
Inaccessible Call Systems for Residents
Penalty
Summary
The facility failed to ensure that call systems were accessible to residents while they were in their rooms, as observed during an abbreviated survey. This deficiency was identified for three residents who were unable to reach their call bells, preventing them from calling for assistance. The facility's policy on call bell and alarm response, effective since October 2019, did not specify the placement of call bells, contributing to the oversight. Resident #1, diagnosed with Parkinson's Disease, Dementia, and Dysphagia, was observed multiple times with the call bell out of reach, hanging on the nightstand knob. Despite the care plan intervention to keep the call bell within reach, staff failed to ensure its accessibility. Certified Nursing Assistant #1, responsible for Resident #1, was unaware of the call bell's location and did not rectify the situation. Similarly, Resident #2, with Cerebral Infarction, Hemiplegia, and Dementia, had their call bell on the floor behind the headboard, out of reach. Staff, including Certified Nursing Assistant #2 and Licensed Practical Nurse #1, acknowledged the call bell should be within reach but did not ensure it was. Resident #3, with Dementia, Alzheimer's Disease, and Aphasia, also had their call bell out of reach, despite staff observations. The Director of Nursing Services confirmed that call bells should be clipped to the bed sheet and within reach, but this was not consistently practiced.
Failure to Maintain Resident Dignity and Cleanliness
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by the conditions observed in the resident's room. On the initial observation, a strong urine odor was present, and a disposable bed pad with a large urine stain was found on the floor next to the resident's bed, along with three urinals, one of which was full. The resident, who was cognitively intact and required substantial assistance for toileting due to functional limitations, expressed a desire for the area to be clean. Despite the resident's preference for having urinals on the floor for easy access, the staff did not maintain a clean and odor-free environment. Certified Nursing Assistant #1 was informed of the situation but did not take immediate action to address the issue, leaving the full urinal and soiled bed mat in place. An hour later, the Licensed Practical Nurse (unit manager) acknowledged that the urinal should have been emptied and the bed mat removed. The Director of Nursing Services confirmed the resident's preference for urinals on the floor but emphasized the need for cleanliness. The resident reiterated their difficulty in getting out of bed and the aides' busyness, underscoring their wish for a clean area.
Failure to Notify Primary Contact of Resident's Fall
Penalty
Summary
The facility failed to ensure that a resident's primary representative was immediately informed of an accident resulting in injury, which had the potential for requiring physician intervention. This deficiency was identified during a recertification survey for a resident who fell from their bed and sustained bruising to their face. Despite the facility's policy requiring immediate notification of the resident's family or next of kin in such incidents, the family member, who was listed as the primary contact, was not informed of the fall. Instead, the group home, listed as a secondary contact, was notified. The resident involved had severe cognitive impairments and was non-verbal, with diagnoses including cerebral palsy, quadriplegia, and seizure disorder. The incident report documented that the resident was found on the floor by a housekeeper, and the physician and group home manager were notified. However, the family member only learned of the fall the following day through another organization. Interviews with facility staff, including the Assistant Director of Nursing Services and the Director of Nursing Services, confirmed that the family should have been notified first, as per the resident's medical record contact list.
Deficiencies in Environmental Maintenance and Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in Unit E, as observed during a recertification survey. Specifically, Resident #144's bathroom door had broken hinges, preventing it from closing, a condition that had persisted for months despite being reported in the maintenance log. The maintenance worker acknowledged the issue, noting that the door had supposedly been fixed earlier in the month, but the problem recurred. The unit manager confirmed the long-standing nature of the issue, indicating a lapse in timely maintenance response. Additionally, Resident #56's room was found to have stained privacy curtains and a soiled bathroom floor. Despite daily cleaning protocols, the curtains remained stained, and the bathroom floor was not adequately cleaned. Interviews with staff revealed that the housekeeping team was responsible for these tasks, yet the issues persisted. The housekeeper claimed the curtain was recently changed but acknowledged the need for further cleaning. The Director of Housekeeping and the Director of Nursing Services both recognized the unacceptability of the conditions, highlighting a failure to adhere to the facility's cleaning policies.
Incomplete Investigation of Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate an accident involving a resident, which resulted in a deficiency. The incident occurred when a resident with severe cognitive impairment and a history of falls was found on the floor with a six-centimeter laceration and bruising on the left side of their face. The facility's policy required statements from all staff involved, but the investigation did not include a statement from the Kitchen transporter, who was the first to find the resident on the floor. This omission was due to the Certified Nursing Assistant not reporting the Kitchen transporter's involvement to the Nursing Supervisor, and the Registered Nurse Supervisor not obtaining the necessary statement. The resident had a history of falls and required moderate assistance for transfers and ambulation. Despite the facility's policy mandating comprehensive collection of statements from all relevant personnel, including those who interacted with the resident within the last 24 hours, the investigation was incomplete. Interviews with staff revealed that the Registered Nurse Supervisor and the Director of Nursing Services acknowledged the oversight in not obtaining the Kitchen transporter's statement, which was crucial for a thorough investigation of the incident.
Delayed Completion of MDS Assessment
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment within the required timeframe for a resident, leading to a deficiency during a recertification survey. Resident #486, who was admitted with diagnoses of Congestive Heart Failure and Diabetes Mellitus, had their admission MDS assessment initiated on July 7, 2024, but it was not completed until July 25, 2024, which was six days beyond the required 14-day period. The MDS Coordinator acknowledged the delay and admitted responsibility for ensuring timely completion of assessments but was unsure why this particular assessment was late. The Administrator was unaware of the delay in completing MDS assessments on time.
Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as observed during a survey. Specifically, a registered nurse did not change the inner tracheostomy tube (cannula) as ordered by the physician. Instead, the nurse attempted to clean and reuse the disposable inner cannula, which is against the manufacturer's guidelines and the physician's orders. This action was observed during a tracheostomy care session for the resident, who has severe cognitive impairment and is dependent on staff for all care. The facility's policy on tracheostomy care, revised in May 2023, requires aseptic cleaning of the tracheostomy cannula, stomas, and surrounding areas, with nurses authorized to change the inner cannula. However, the policy did not specify a timeframe for changing the outer cannula. The resident's comprehensive care plan also lacked specific directions for changing the inner or outer cannula. The manufacturer's brochure for the tracheostomy tube used by the resident specifies that the inner cannula is for single use and the outer cannula should be changed every 28 days, but there was no documented evidence of physician orders to change the outer cannula from March 2023 to October 2023. Interviews with facility staff, including a nurse practitioner, the medical director, the director of nursing services, and a respiratory therapist, confirmed that the inner cannula should not have been reused and that the outer cannula should have been changed every three months. The respiratory therapist, who took over the resident's care in January 2024, stated that they have been changing the tracheostomy tube every 90 days since then. The failure to follow proper procedures for tracheostomy care placed the resident at risk for infections, as noted by the staff during interviews.
Significant Medication Error: Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that all residents were free from significant medication errors, as observed during a recertification survey. Specifically, a resident with severe cognitive impairment and diagnosed with acute osteomyelitis and cellulitis did not receive their prescribed doses of Ampicillin, an antibiotic, at 12:00 AM and 6:00 AM on a specific date. The Medication Administration Record lacked documentation of these doses being administered, which is a violation of the facility's medication administration policy. During the survey, it was observed that the intravenous medication setup by the resident's bedside was not labeled with the time of reconstitution or administration. Interviews with nursing staff revealed that the 6:00 AM dose was prepared but not administered, and the 12:00 AM dose was administered but not documented. The Director of Nursing Services and a medical doctor emphasized the importance of adhering to physician orders for antibiotic administration to maintain medication effectiveness.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that food was prepared and served in accordance with professional standards for food service safety. During a kitchen observation, Dietary Aide #1 was seen handling peeled, hard-cooked eggs with the same gloves used to enter and exit the walk-in refrigerator, which is against the facility's handwashing and glove use policies. Dietary Aide #1 acknowledged the mistake, recognizing the increased risk of food contamination due to not changing gloves. Additionally, the facility's policy requires hands to be washed frequently and gloves to be changed when switching tasks, which was not adhered to in this instance. Furthermore, during a lunch meal tray line observation, cold food temperatures were found to be above the safety zone. The egg salad sandwich was measured at 60 degrees Fahrenheit, and the health shake at 45 degrees Fahrenheit, both exceeding the facility's policy requirement of maintaining cold food at or below 40 degrees Fahrenheit. The Food Service Supervisor admitted that they did not routinely check the temperatures of cold food items before meal services, relying instead on the refrigerator's temperature. This oversight could potentially lead to bacterial growth and illness among residents, as acknowledged by the Food Service Director.
Failure to Ensure Accompaniment for Non-Verbal Resident's Medical Appointment
Penalty
Summary
The facility failed to ensure that timely arrangements were made for outside services that met professional standards, as evidenced by the case of a resident with severely impaired communication who was transferred to a Neurologist's office for a medical appointment. The resident, who had diagnoses including Cerebral Palsy, Quadriplegia, and Seizure Disorder, was not accompanied by facility staff or a representative who could communicate on their behalf, leading to the cancellation of the appointment. There was no documentation in the resident's medical record regarding the cancellation of the appointment, coordination of future appointments, or communication with the resident's primary care provider about the missed appointment. The facility's Transport Policy for Medical Appointments required that a qualified staff member or family member accompany residents during transport to ensure their comfort and safety, and that all transport-related activities be documented in the resident's medical record. However, the Licensed Practical Nurse (LPN) responsible for the resident's care did not document discussions with the resident's family or group home staff, nor did they document the appointment cancellation or reschedule the appointment. The LPN was unaware of the facility's policy for sending a non-verbal resident to an appointment unaccompanied. Interviews revealed that the resident's family was not informed of the appointment and would not have agreed to it due to concerns about the resident's comfort during transport. The Director of Nursing Services acknowledged that all communications should have been documented and that there should have been follow-up regarding rescheduling the appointment. The Nurse Practitioner was aware of the appointment cancellation but did not recall documenting their communication with the resident's family in the medical record.
Delayed Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Centers for Medicare and Medicaid Services (CMS) within the required timeframe. This deficiency was identified during a Recertification Survey conducted from September 23 to September 30, 2024. Specifically, six residents' MDS assessments were not transmitted within 14 days of completion, as required. The assessments for these residents were transmitted between 46 to 65 days late. The facility's policy, last reviewed in March 2024, mandates timely transmission of MDS assessments, but this was not adhered to in these cases. The Minimum Data Set Coordinator, responsible for submitting these assessments, stated during an interview that they believed the assessments had been submitted on time but did not receive the validation report, indicating otherwise. Consequently, the assessments were resubmitted on September 26, 2024. The Administrator, during a separate interview, acknowledged that the MDS Coordinator is responsible for timely submissions and was unaware of the delays. This oversight resulted in the facility's non-compliance with the regulatory requirement to transmit MDS assessments within the specified timeframe.
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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