The Willows At Ramapo Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Suffern, New York.
- Location
- 30 Cragmere Road, Suffern, New York 10901
- CMS Provider Number
- 335148
- Inspections on file
- 23
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at The Willows At Ramapo Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with intact cognition and diagnoses including amputations, CHF, and DM was restricted to withdrawing personal funds only on two days a week and in small amounts, despite facility policy stating residents must have 24/7 access to their money. Staff reported the resident was limited to $10 twice weekly, sometimes $15, and had been refused on other days, while the resident said they wanted more money available for vending machine purchases and had been turned away when requesting withdrawals.
Soiled Wheelchairs Observed for Two Residents: Two residents with significant cognitive and physical impairments were observed sitting in visibly soiled wheelchairs. One wheelchair had dry dirt caked on the frame and cushion, with soiled gauze around the leg rest attachments; the other had a white dried substance on the wheel spokes and side, a stained cushion corner, and dusty grime on the frame. Staff stated wheelchair cleaning was scheduled but inconsistent, not tracked, and often done only when soiling was noticed.
Failure to Provide Required Eating Assistance: Two residents with documented need for maximal or moderate assist with eating were observed receiving mostly set-up only or minimal help during meals. One resident had MS, dysphagia, dementia, and significant wt loss, while the other had dementia, severe protein-calorie malnutrition, dysphasia, and wt loss. Staff observations showed poor intake, untouched or inaccessible food items, and limited encouragement or hands-on feeding despite care plan and MDS requirements.
A resident with dementia and a high fall risk had a care plan calling for a well-lit, clutter-free environment, yet floor mats previously identified as a tripping hazard were still present in the room and observed folded against the wall. Staff confirmed the mats were for the resident, while the unit manager stated they had been discontinued because they were a tripping hazard.
Oxygen was not provided at the ordered rate for a resident with COPD, dysphagia, and Alzheimer’s disease. The resident’s order specified 2 L/min via NC continuously, but surveyors observed the concentrator running at 3 L/min while the resident was sleeping in bed on multiple occasions. An LPN acknowledged the oxygen was running above the ordered rate and stated the flow level was not checked during med pass, and the ADON confirmed staff needed to follow the physician’s order.
A resident with cognitive intactness, depression symptoms, and later socially inappropriate and aggressive behaviors made an inappropriate sexual comment to another resident. The MD ordered psychiatry and psychology consults, and the care plan included behavioral health interventions, but the RN UM and DON could not locate any consult notes in the EMR, and the psychology consultant confirmed the resident had not been requested for evaluation until later.
Food was not stored in accordance with professional standards during the survey. Multiple food items in the snack refrigerator, portable tray rack, and freezer were observed without proper identification, including fruit cups, cottage cheese cups, pudding cups, peanut butter cups, mixed vegetables, and lettuce. A dietary cook was also observed slicing chicken breasts without wearing a beard net, and the Dietary Supervisor stated that food needed to be labeled, dated, and that staff were to wear hair and beard nets if needed.
A resident with severe cognitive impairment and multiple medical conditions did not receive required ADL assistance, turning, and safety checks as documented in their care plan. The assigned CNA failed to provide care or transfer the resident to bed, and documentation was falsified. The resident was later found on the floor with injuries and was pronounced deceased. Staff interviews and video evidence confirmed lapses in care, communication, and supervision, resulting in actual harm.
A resident with severe cognitive impairment and multiple medical conditions was documented as having received ADL care by a CNA who reported not providing or recording such care. Additionally, an LPN documented hourly rounding for the resident after the resident had expired and was removed from the facility. These actions resulted in inaccurate medical records, contrary to professional standards.
Staff failed to consistently wear gowns while providing hands-on care to a resident on enhanced barrier precautions, despite clear signage and facility policy. Multiple staff, including a respiratory therapist and a nurse manager, provided direct care with only gloves, even when the resident was minimally clothed and diaphoretic. Interviews revealed lapses in awareness and adherence to infection control protocols among staff.
A resident with a history of accusatory behaviors required a two-person assist for care, but the care plan was not updated in the CNA documentation. This oversight led to a CNA providing care alone, resulting in an alleged abuse incident. The facility failed to ensure timely updates and communication of the care plan to all staff.
The facility failed to ensure food safety and proper storage, with issues including a soiled chest freezer, unlabeled ground beef, missing cooling logs, and nourishment refrigerators not maintained at safe temperatures. Additionally, food service staff did not follow safe food handling practices.
A resident with Multiple Sclerosis and optic neuritis was not provided with opportunities to participate in independent activities of their choice, despite their preferences being documented. The Activities staff did not visit the resident, and there was no evidence of participation in activities since February 2023.
A resident with severe cognitive impairment and multiple diagnoses was not provided soft booties as recommended by physical therapy to prevent contractures and pressure sores. The care plan and CNA task reports lacked directives for their use, and observations confirmed the resident was not wearing the booties on multiple occasions.
A resident with severe cognitive impairment and respiratory failure did not receive continuous oxygen therapy as ordered. The resident was observed multiple times without the nasal cannula, and staff did not ensure the oxygen saturation rate was maintained as required.
Restriction of Resident Access to Personal Funds
Penalty
Summary
The facility did not ensure it acted as a fiduciary for Resident #29’s personal funds by restricting access to the resident’s money to only two days a week and limiting withdrawals to amounts lower than the resident wanted. Resident #29 had diagnoses including a left below-the-knee amputation, partial right foot amputation, congestive heart failure, and diabetes, and the quarterly MDS documented intact cognition. The facility policy stated residents must have access to personal funds 24 hours a day, seven days a week, but staff told surveyors the resident was limited to $10 twice a week, sometimes $15, and had been refused when requesting money on other days. The resident’s family member had requested limits on how much money the resident could withdraw and how often, but the resident’s family member was listed only as an emergency contact and not as power of attorney. Staff interviews showed the Business Office Manager, receptionist, and social worker were involved in the restriction, while the Administrator stated no one was restricted and was not aware of any restriction on Resident #29’s account. The resident stated they had been turned away on days other than Tuesday and Friday, wanted more money available each week, and said not being able to get money when desired upset them. The resident’s personal fund records showed a balance over $1,000 and repeated withdrawals of $10 or $15 from the account.
Soiled Wheelchairs Observed for Two Residents
Penalty
Summary
The facility did not ensure two residents’ right to a safe, clean, comfortable, and homelike environment because their wheelchairs were visibly soiled. Resident #126, who had dementia, dysphagia, muscle weakness, severely impaired cognition, and was dependent on staff for transfers, was observed sitting in a wheelchair with dry dirt caked on the frame and cushion. On a later observation, the resident was again sitting in the wheelchair, and the protective white gauze wrapped where the leg rests attach bilaterally was visibly soiled and light brown in color. Resident #170, who had unspecified psychosis, dysphagia, cerebral ischemia, severely impaired cognition, and required moderate assistance for transfers, was observed sitting in a wheelchair with a white dried substance on the right wheel spokes and right side of the wheelchair up to the back rest. The right corner of the cushion was visibly stained, and there was dusty grime on the wheelchair frame. Staff interviews indicated wheelchairs were supposed to be cleaned on a schedule, but the process was inconsistent, not tracked, and soiled wheelchairs were cleaned as needed when noticed.
Failure to Provide Required Eating Assistance
Penalty
Summary
The facility did not ensure that residents who were unable to perform activities of daily living independently received the level of assistance with eating that was documented in their care plans and assessments. The facility policy stated that residents unable to carry out ADLs independently were to receive appropriate support and assistance with dining, including meals and snacks. During the survey, two residents were identified as not receiving the assistance they required during meals despite documented needs for maximal or moderate assistance. Resident #128 had diagnoses including multiple sclerosis, dysphagia, and dementia, and the Significant Change MDS documented severely impaired cognition, maximal assistance with eating, and significant weight loss. The care plan and current CNA Kardex both documented maximal assistance with eating. The resident’s weight decreased from 161 pounds in October 2025 to 135 pounds in March 2026, a 16% loss. During multiple lunch observations, the resident was seen picking at food, struggling to drink from a cup, and eating only small portions of the meal, while staff provided no observed assistance beyond asking if the resident wanted to eat more when the tray was being removed. Resident #140 had diagnoses including dementia, severe protein calorie malnutrition, and dysphasia, and the Quarterly MDS documented severely impaired cognition and moderate assistance with eating. The care plan and CNA Kardex also documented moderate assistance with eating. The resident’s weight decreased from 124 pounds in October 2025 to 120 pounds in March 2026. During observations, the resident was seen playing with utensils and wrappers, leaving food untouched, and having sealed items remain inaccessible, while staff provided little or no assistance or encouragement until late in the meal or when the tray was being removed. Staff interviews reflected differing understandings of the resident’s needs, with one CNA stating the resident only required set-up assistance, while the Director of Rehabilitation and the Dietician stated that the resident required moderate assistance and encouragement with eating.
Unsafe Use of Floor Mats for a High-Fall-Risk Resident
Penalty
Summary
The facility did not ensure that Resident #72’s environment remained as free of accident hazards as possible. Resident #72 had diagnoses including dementia, obstructive uropathy, and cerebral ischemia, and was assessed as high risk for falls with risk factors including prior falls, antihypertensive use, impaired memory recall, total incontinence, and inability to independently stand. The resident’s care plan included interventions such as keeping the environment well lit and free of clutter, and the resident also had a history of actual falls documented in the record. Although floor mats had previously been identified as a tripping hazard and were documented as removed from both sides of the bed, floor mats were still observed in the resident’s room during the survey. One mat was seen folded up and leaning against the wall by the bed, and later two mats were observed folded up against the wall on the resident’s side of the room. Staff stated the mats were for Resident #72 and were in the room, while the unit manager stated the mats should not have been in the room or in use because they had been discontinued as a tripping hazard.
Oxygen Administered Above Ordered Flow Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #69. The resident had diagnoses including dysphagia following other cerebrovascular disease, Alzheimer's disease, and chronic obstructive pulmonary disease. The quarterly MDS documented severe cognitive impairment, shortness of breath when lying flat, and oxygen therapy. A physician order dated 03/03/2026 directed oxygen at 2 liters via nasal cannula continuously every shift for COPD, and the care plan addressed oxygen therapy related to ineffective gas exchange with interventions including administering medications as ordered. During observations on 03/08/2026, 03/09/2026, and 03/12/2026, Resident #69 was found sleeping in bed with oxygen being administered via nasal cannula while the oxygen concentrator was running at 3 liters/minute. On 03/12/2026, an LPN stated the concentrator was administering between 3 and 4 liters/minute and acknowledged the ordered rate was 2 liters per minute, adding that oxygen concentration levels were not checked during medication pass earlier in the shift and should have been. The ADON later stated physician orders needed to be followed for oxygen administration and confirmed the order was for 2 liters/minute.
Failure to Complete Ordered Behavioral Health Consults
Penalty
Summary
The facility did not ensure a resident received necessary behavioral health services in accordance with the comprehensive assessment and plan of care. Resident #9 had diagnoses including displaced intertrochanteric fracture of the left femur, bilateral osteoarthritis of the hip, and hypertension, and the admission MDS documented the resident was cognitively intact, reported feeling down, depressed, and hopeless several days, and had no behaviors, hallucinations, or rejection of care. A physician order documented psychology consult and follow up as needed, and the care plan identified a potential psychosocial well-being problem with interventions including pastoral care, social services, and psychological services. After Resident #9 made an inappropriate sexual comment to another resident, nursing documented that the resident was redirected, social services were notified, and the physician was notified with a plan for psychiatry follow-up. The care plan was updated to note socially inappropriate behavior, including making sexual comments to another resident, with interventions for enhanced monitoring and psychiatric and psychology evaluation as needed. Additional nursing notes documented episodes of upset, refusal to attend a pulmonary appointment, and aggressive behavior when staff intervened while the resident was speaking with another resident. During interviews, the RN Unit Manager stated the physician requested psychiatry and psychology consults after the sexual comment, but no psychiatry or psychology consult note could be located in the EMR from that time to the survey date. The DON also stated they were unaware whether Resident #9 had been seen by psychiatry or psychology and could not locate a consult note. The psychology consultant stated routine consults are usually completed within 24 to 48 hours or immediately for crisis residents, but Resident #9 had not been requested for consultation until the day of the interview, and the consultant confirmed no request had been made previously.
Improper Food Labeling and Beard Net Use
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety during the recertification survey. During the kitchen inspection with the Dietary Supervisor, six food items were observed without proper identification in the snack refrigerator, portable tray rack, and freezer, including trays of apple and pineapple cups, cottage cheese cups, apples in cups, oranges in cups, pudding cups, peanut butter cups, a bag of mixed vegetables not in its original container, and five plates of lettuce. The facility policy titled Food Receiving and Storage, last approved 09/12/2025, documented that refrigerated foods are to be labeled, dated, and monitored. In addition, a dietary cook was observed leaning over and slicing chicken breasts without wearing a beard net, and the cook stated they knew they were supposed to wear one but had forgotten that morning. The Dietary Supervisor stated that food needed to be labeled, dated, and that all staff were to wear hair and beard nets if needed.
Failure to Provide Required ADL Assistance and Supervision Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependence for activities of daily living (ADLs), and multiple medical conditions including pneumonia, coronary artery disease, heart failure, and a stage two pressure ulcer, did not receive required care and assistance as outlined in their care plan. The care plan specified frequent turning and repositioning, assistance with toileting and dressing, and regular safety checks, particularly due to the resident's incontinence, oxygen therapy, and pressure ulcer. On the evening in question, video surveillance and documentation review revealed that the assigned Certified Nurse Aide (CNA) did not provide the necessary care, including transferring the resident to bed, changing clothing, or performing safety checks, despite documentation indicating otherwise. The resident was last seen in their wheelchair, fully clothed, and not in bed as was their usual routine. Staff interviews and video evidence confirmed that no staff entered the resident's room for an extended period during the evening shift. The resident was later found on the floor, face down between the bed and wheelchair, with their oxygen cannula dislodged and sustaining lacerations to the forehead and neck. The resident was non-verbal, short of breath, and subsequently pronounced deceased at the facility. The incident investigation determined that the resident experienced a medical event leading to a fall, and due to their condition, was unable to get up or call for help, resulting in further injury. Interviews with staff revealed lapses in communication and assignment handoff, with the CNA stating they did not receive a report or assignment sheet and did not provide care to the resident. The LPN on duty acknowledged noticing the resident was not changed or in bed but did not follow up to ensure care was provided after instructing the CNA. Other staff and the resident's family confirmed that the resident was typically in bed early in the evening and always required assistance. The failure to provide care and supervision as required by the care plan resulted in actual harm to the resident.
Inaccurate Documentation of Resident Care and Rounding After Resident Death
Penalty
Summary
The facility failed to maintain accurate and professional documentation of medical records for one resident reviewed for activities of daily living (ADL) care. Specifically, a Certified Nurse Aide (CNA) was documented in the electronic medical record as having provided ADL care to a resident on a certain date, but the CNA stated during interview that they did not provide care to the resident on that date, nor did they enter the documentation. The CNA also indicated that the resident's name was not on their assignment sheet. The facility's Director of Nursing confirmed that CNAs are instructed not to share their passwords and that documentation should only be completed by the assigned CNA using their unique credentials. Additionally, a Licensed Practical Nurse (LPN) documented hourly rounding for the same resident from late evening through early morning, including times after the resident had expired and their remains had been removed from the facility. The LPN stated that documentation was started later in the shift due to an incident and police presence, and acknowledged that the resident's name should have been removed from the rounding sheet after death. The Director of Nursing confirmed that the resident was removed from the unit by the Medical Examiner and was unable to explain why documentation continued after the resident's removal. These actions resulted in inaccurate and incomplete medical records, not in accordance with accepted professional standards.
Failure to Adhere to Enhanced Barrier Precautions During Resident Care
Penalty
Summary
During a complaint investigation, surveyors identified that the facility failed to maintain infection prevention and control practices in accordance with its own policy for enhanced barrier precautions for one resident. The resident in question had multiple active diagnoses, including sepsis, chronic osteomyelitis, gastrostomy malfunction, and several unhealed pressure ulcers, and was under enhanced barrier precautions as indicated by signage outside their room. The resident's care plan and medical orders specifically required the use of enhanced barrier precautions, including gown and glove use during high-contact care activities. On three separate occasions, staff members provided hands-on care to the resident without wearing gowns, despite the posted signage and facility policy. Observations included a respiratory therapist adjusting respiratory equipment and physically assisting the resident while only wearing gloves, and a registered nurse manager assisting with changing the resident's gown without donning a new gown after having removed it to leave the room. The resident was noted to be diaphoretic and minimally clothed during these interactions, increasing the likelihood of direct contact with bodily fluids and skin. Interviews with the involved staff revealed a lack of awareness or lapses in adherence to the enhanced barrier precautions policy. The respiratory therapist, who was new to the facility, did not notice the signage and believed a gown was unnecessary for auscultating breath sounds. The registered nurse manager was unaware that a gown was required upon returning to the bedside, and the LPN acknowledged noticing the lapse but did not intervene. Leadership staff, including the DON and medical director, confirmed that gowns are required for all hands-on care for residents on enhanced barrier precautions, regardless of the specific task.
Failure to Update Care Plan Leads to Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that the comprehensive care plans were reviewed and revised in a timely manner for a resident with a history of accusatory behaviors. The resident, who was diagnosed with depression, paranoid schizophrenia, and morbid obesity, required a two-person assist for all care due to their behavioral symptoms, which included verbal aggression and accusations towards staff. However, the care plan was not updated to reflect this requirement in the Certified Nurse Aide (CNA) documentation, leading to a CNA providing care alone without the necessary assistance. On January 7, 2024, the resident accused a CNA of alleged abuse after care was provided without a second staff member present. The CNA was unaware of the two-person assist requirement because it was not documented in the CNA Kardex. The Assistant Director of Nursing and the Director of Nursing confirmed that the care plan was not properly updated to include the two-person assist requirement in the CNA documentation, which was a critical oversight. The incident highlights a failure in the facility's process for updating and communicating care plans to all relevant staff. The care plan, initiated in April 2022, was not revised to include the necessary interventions for CNAs until after the incident occurred. This lack of timely updates and communication led to the CNA being unaware of the resident's specific care needs, resulting in the alleged incident.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial tour of the kitchen, a chest freezer used as a refrigerated unit was found to be heavily soiled with various colored grime and mold. The Food Service Director (FSD) admitted that the freezer was not in a sanitary condition for food storage. Additionally, a walk-in refrigerated unit contained a heavily soiled grocery bag and unlabeled, defrosted ground beef, which the FSD could not confirm was safe to eat and subsequently decided to discard. The FSD also failed to produce cooling logs for meatloaf prepared the previous week, indicating a lack of proper documentation and monitoring of food cooling processes. Further observations revealed that two nourishment refrigerators were not maintained at safe temperatures for food safety. The Team 7 refrigerator had a thermometer reading of 45 degrees Fahrenheit, while the Team 3 refrigerator had a reading of 46 degrees Fahrenheit. Both refrigerators contained various food items, including meatloaf, yogurt, pudding, and milk, with temperatures exceeding safe limits. The FSD acknowledged the issue and decided to discard the foods and inform maintenance and administration. Additionally, during meal service, two food service staff members did not follow safe food handling practices while recording food temperatures. One cook was observed sanitizing a thermometer probe with gloves that had touched unsanitary surfaces, and the FSD assisted by handling alcohol wipes with bare hands. These deficiencies highlight significant lapses in food safety practices within the facility, including improper storage, inadequate temperature control, and poor hygiene practices by food service staff. The FSD's inconsistent statements and inability to provide necessary documentation further underscore the lack of adherence to professional standards for food service safety.
Failure to Provide Ongoing Activities Program
Penalty
Summary
The facility did not provide an ongoing program of activities for a resident diagnosed with Multiple Sclerosis and optic neuritis. The resident, who was cognitively intact and had expressed preferences for daily activities such as music, keeping up with the news, and getting fresh air, was not consistently provided opportunities to participate in independent activities of their choice. The resident's Care Plan, which was updated in April 2023, documented a preference for self-directed activities and included interventions to encourage these activities. However, observations and interviews revealed that the resident was not visited by Activities staff and did not have any activities in their room. The Director of Activities confirmed that the resident had expressed a preference not to attend group activities and preferred to watch TV and movies in their room. Despite this, the Director was unable to provide evidence of the resident's participation in independent activities since February 2023. This lack of documentation and follow-through on the resident's preferences led to the deficiency noted in the survey report.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility did not ensure that a resident was provided the appropriate treatment to improve and/or prevent a further decline in range of motion (ROM). Specifically, a resident with diagnoses including encephalopathy, stroke, and generalized muscle weakness was not provided soft booties as recommended by physical therapy. The resident's care plan did not include the use of soft booties or monitoring their effects, despite a physical therapy evaluation and discharge summary indicating the necessity of soft booties to prevent pressure sores and contractures. Observations revealed that the resident was not wearing the soft booties on multiple occasions, and there was no documented evidence in the physician's orders or CNA task reports directing their use. Interviews with the Director of Rehabilitation confirmed that the resident was referred to the rehabilitation department due to contracture of the bilateral ankles and that soft booties were to be used at all times to maintain neutral alignment of the ankles. However, the review of the resident's chart revealed no physician's order, care plan documentation, or CNA task assignment directing the use of soft booties. This deficiency was identified during the recertification survey and was based on observations, record reviews, and interviews.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident #82 received continuous oxygen therapy as per the physician's order of 3L/min via nasal cannula. The resident, who had diagnoses including cerebral infarction, respiratory failure, and anxiety, was observed multiple times without the nasal cannula in place. On 11/14/2023 at 01:38 PM, the resident was seen in their wheelchair without the nasal cannula, with the oxygen tubing and cannula by the nightstand. Again, at 03:20 PM the same day, the resident was observed sleeping in the wheelchair without the nasal cannula, which was found on the floor by the nightstand table near the window. The oxygen concentrator was on during both observations. On 11/15/2023 at 09:59 AM, the resident was again seen without the nasal cannula, with the tubing wrapped around the tube feeding pole and the cannula in the nightstand drawer. During an interview on 11/15/2023 at 09:29 AM, the physician stated that the oxygen was intended to maintain the resident's saturation rate and that staff were expected to check the oxygen saturation rate if the resident removed the oxygen, ensuring it remained above 88%. An LPN interviewed on 11/15/2023 at 10:08 AM confirmed that staff would check the oxygen saturation level and consult with the nurse manager if a resident removed their oxygen to ensure the resident's well-being.
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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