Troy Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, New York.
- Location
- 49 Marvin Avenue, Troy, New York 12180
- CMS Provider Number
- 335280
- Inspections on file
- 21
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Troy Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer covered in eschar. After an initial RN assessment and a high-risk team meeting noting referral to the in-house wound provider, there was no documented evidence of completed wound treatments on several ordered days and no ongoing interdisciplinary discussion of the wound. Due to a standing conflict between the wound provider’s single weekly visit and the resident’s dialysis schedule, the resident was never seen by the wound specialist or the NP, and no alternative arrangements (such as schedule changes or wound center referral) were made. Weekly wound evaluations were at times done by an LPN without RN oversight, and when the wound began to separate and show drainage, the RN notified a provider and obtained new orders but did not thoroughly document the worsening condition. When the resident later reported increased foot pain, there is no clear documentation that the dressing was removed or the wound fully assessed. The DON was unaware of the scheduling conflict, the physician’s admission note omitted the ulcer, and leadership did not ensure qualified weekly wound assessments. The wound ultimately progressed to sepsis, osteomyelitis, a pathological heel fracture, bacteremia, and a right BKA, causing actual physical and psychosocial harm and constituting neglect.
Surveyors found that the facility failed to provide timely and consistently documented pressure ulcer care for three residents admitted with existing pressure injuries. One resident’s unstageable heel ulcer was assessed on admission without any treatment order entered for two days, and later daily wound treatments were repeatedly undocumented or recorded as applied to both heels despite only one documented wound. Two other residents with stage 3 sacral ulcers had delays of several days between wound identification and initiation of treatment orders, and their Treatment Administration Records showed multiple blank entries on days when ordered dressings or Santyl applications were scheduled. Nursing staff and leadership acknowledged that blank TAR entries meant treatments were not done and that wound treatments were expected to be in place upon wound identification, but the documentation demonstrated missed or undocumented care in violation of facility wound care policy and care plans.
A resident with end stage renal disease and other chronic conditions, who was cognitively intact, changed their advance directive from full CPR to DNR after admission. Although this decision and the resident’s understanding of its consequences were documented in a physician note, the existing CPR order remained active in the EHR for several days, and pre-dialysis notes continued to list the code status as CPR. A DNR order and signed MOLST were not entered until a week later. Staff interviews revealed reliance on a manual order book process and a failure to immediately enter the code status change into the EHR, resulting in the resident’s expressed wishes not being promptly reflected in physician orders or communicated to care staff.
The facility failed to report the results of an internal investigation of a resident-to-resident abuse incident to the State Survey Agency as required by policy and state regulations. During an acute psychotic and aggressive episode, a resident with vascular dementia, depression, and anxiety threw objects at staff, climbed into another resident’s bed while that resident was in it, and entered another resident’s room, where a tray table struggle occurred and a thrown chair struck the resident’s foot. An internal investigation was completed and skin assessments were performed, but the event was not reported to the state. In interviews, the DON stated they did not consider the incident reportable and believed the administrator was responsible for state reporting, while the administrator indicated the DON completed investigations.
A resident with diabetes, CKD stage 3A, and a documented stage 3 sacral pressure ulcer was admitted, and an RN recorded the wound size and characteristics. Facility policies required the IDT and RN to develop a comprehensive, person-centered care plan with measurable objectives and timetables, including specific plans for new skin impairments. However, the comprehensive care plan lacked measurable goals and interventions for treatment of the stage 3 sacral ulcer, containing only a nutritional care plan that noted the pressure injury without detailed wound care measures, resulting in a deficiency in care planning standards.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency had a right heel pressure injury with eschar and an existing skin integrity care plan. Facility policy required the IDT and RN to revise care plans with significant changes and to address new or changing wounds. An LPN documented that the unstageable heel ulcer had deteriorated and that the wound care provider could not complete weekly assessments due to conflicts with the resident’s dialysis schedule, resulting in multiple missed wound assessments. Despite these documented changes and missed visits, the comprehensive care plan was not updated to reflect the deterioration of the pressure ulcer or the interruption in weekly wound care assessments, as confirmed in interviews with the DON and an RN manager.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer with 100% eschar, which was initially assessed by an RN and care planned with interventions including ordered treatment and referral to a wound specialist. Facility policy required weekly wound rounds and assessment by qualified staff, but a subsequent weekly wound evaluation was performed and documented solely by an LPN acting in a leadership role, without an RN or wound provider present. The LPN recorded wound measurements and characteristics and noted treatment response, yet there was no documentation that a wound provider or RN assessed the ulcer at that time. Interviews and state scope-of-practice guidance confirmed that LPNs may collect wound data but may not perform nursing assessments, and leadership and the wound provider acknowledged that the weekly assessment should have been completed by an RN, demonstrating that the resident’s pressure ulcer was not assessed by a qualified person as required by the care plan and regulations.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer that nursing staff and the IDT documented, including wound measurements and a plan to refer to an in‑house wound provider. At a required initial H&P visit, the attending physician documented no skin breakdown and described the skin as warm and dry, omitting any mention of the known heel ulcer and failing to document a plan of care or treatment for it, contrary to facility policy requiring review and documentation of the resident’s total program of care at each visit.
The facility failed to provide sufficient nursing staff, resulting in long waits for call lights, missed showers, and delays in morning care. Residents reported inadequate assistance with activities of daily living, and observations confirmed these issues. The staffing schedule often showed insufficient staff to meet resident needs.
The facility failed to provide a functional nurse call system in three resident rooms on the North Unit. Observations and interviews confirmed that the call bells did not activate, and residents were using tap bells instead. Repair requisitions were documented, and a quote for repairs was obtained, with the repairs completed by the end of the survey period.
The facility failed to report allegations of abuse involving a resident to the New York State Department of Health in a timely manner. Incidents on two separate occasions were not reported promptly, despite being witnessed and acknowledged by staff. The facility's policy mandates immediate reporting, which was not followed.
The facility failed to develop comprehensive care plans for two residents, neglecting to address an indwelling urinary catheter for one and dental care for another. Interviews with staff confirmed these omissions, indicating a lapse in adherence to care planning policies.
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene. One resident was not provided with adequate incontinence supplies, another lacked clean clothing and timely assistance, and a third did not receive scheduled showers. Staff were unaware of these issues, and the facility's policies were not followed, resulting in significant deficiencies in resident care.
Neglect of Wound Care for Dialysis Patient Leading to Amputation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to the assessment and management of a known right heel pressure ulcer. The resident was admitted with significant comorbidities including end stage renal disease requiring dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency. On admission/readmission, an RN documented an unstageable pressure ulcer on the right heel with 100% black/brown eschar and an existing treatment. Facility policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or distress, and the wound policy required identification, assessment, and management of wounds in accordance with current standards of practice, including RN assessment and provider notification when wounds worsened. Following the initial assessment on 09/18/2025, there was no documented evidence that ordered wound treatments were completed on multiple dates, including 09/22/2025, 09/23/2025, 09/25/2025, and 09/29/2025. A high-risk team meeting on 09/19/2025 documented that the resident was being referred to the in-house wound provider for the right heel pressure ulcer, but there was no further documented discussion of this wound by the interdisciplinary team after that date. There was also no documented assessment of the right heel pressure ulcer by a qualified person after the 09/19/2025 team meeting through the period leading up to the resident’s subsequent decline. The designated in-house wound care provider only came to the facility one day per week, on a day that consistently conflicted with the resident’s dialysis schedule, and no alternate arrangements were made for wound evaluation, such as changing dialysis times, arranging virtual visits, or sending the resident to a wound care center. Nursing staff interviews revealed that weekly wound evaluations were sometimes performed by an LPN without an RN present, despite the expectation that initial and weekly wound assessments be completed by an RN. On 09/25/2025, the LPN conducted wound rounds without an RN and did not refer the resident to the wound care provider, stating there was no change in the wound, and the nurse practitioner who was notified should have seen and assessed the resident but did not. On 10/02/2025, the LPN and an RN observed that the wound bed had started to separate, remained covered with eschar, was pulling away from the edges, and had serosanguineous drainage; the RN notified the provider and obtained a new treatment order but did not thoroughly document the change in the wound or measurements. The resident was not seen by the wound care provider that day due to dialysis. On 10/06/2025, when the resident reported increased right foot pain, the RN did not recall removing the dressing or assessing the wound status, although the medical provider and physiatrist were contacted. The nurse practitioner later stated they never saw the resident because their schedule also conflicted with dialysis, and the medical director and wound care provider both indicated that the lack of weekly RN wound assessments and failure to arrange alternative wound care access were unacceptable. Ultimately, the resident was transferred from dialysis to the hospital with sepsis, a right pathological calcaneal fracture with acute osteomyelitis, and bacteremia, resulting in a right below-knee amputation and psychosocial trauma, which the surveyors determined constituted actual harm from neglect, though not Immediate Jeopardy. Additional interviews highlighted systemic failures in oversight and communication. The DON stated they were unaware of the conflict between the wound care provider’s schedule and the resident’s dialysis schedule and acknowledged missing documentation of a wound assessment on 10/09/2025. The DON also confirmed that LPNs could measure but not assess wounds and were expected to document observations in progress notes, and that the physician’s admission evaluation did not document the pressure ulcer. The administrator, who was not present at the time of admission, stated that high-risk meetings should have been held weekly for residents with wounds and that the DON and corporate nurse consultant were responsible for nursing oversight, while the physician or nurse practitioner were responsible for overall care. The nurse practitioner reported not realizing that the staff member performing weekly wound assessments was an LPN rather than an RN. The wound care provider and medical director both stated that the resident should have had weekly RN wound assessments and that alternative arrangements, including virtual visits or wound center referrals, could have been made when the resident was unavailable due to dialysis. The medical director emphasized that the resident’s frequent dialysis schedule did not excuse the lack of assessment by a qualified person. These combined failures—missed and undocumented wound treatments, lack of ongoing interdisciplinary review, absence of timely RN wound assessments, failure to coordinate provider schedules with dialysis, and failure to arrange alternative wound care access—resulted in the resident’s right heel pressure ulcer not being adequately monitored or managed. The resident’s condition progressed to sepsis, osteomyelitis, a pathological calcaneal fracture, bacteremia, and the need for a right below-knee amputation, causing both physical and psychosocial harm. The surveyors cited this as neglect under the facility’s abuse and neglect policy and cross-referenced deficiencies related to pressure ulcer treatment, use of qualified persons, and physician supervision and visits.
Failure to Provide Timely and Consistent Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards of practice and care-planned interventions, for three residents who were admitted with existing pressure injuries. Facility policy titled “Wound Identification and Wound Rounds” required that new admissions and newly discovered pressure ulcers receive a complete skin assessment by an RN, notification of the health care provider, and prompt treatment orders based on wound care guidelines. For Resident #1, the admission assessment on 09/18/2025 documented an unstageable right heel pressure ulcer with 100% black/brown eschar measuring 2.5 cm by 2.2 cm, with the wound bed not visible. Although the assessment noted that a treatment was in place, there was no corresponding treatment order in the medical record on 09/18/2025, and no order was entered until 09/20/2025. This gap meant the resident’s documented wound existed without an active physician order or documented treatment for at least two days. Once a treatment order for TheraHoney Gel to the right heel was entered for Resident #1, the Treatment Administration Record (TAR) showed multiple missed or undocumented treatments. The ordered daily dayshift treatment was not documented as administered on 09/22, 09/23, 09/25, and 09/29/2025. On several other dates (09/26, 09/27, 09/30, 10/01, and 10/02/2025), the TAR documented the treatment as being applied to both heels, even though there was no documented evidence of a wound on the left heel. A subsequent order starting 10/03/2025 for Anasept gel with collagen powder and an island dressing to the right heel was also not consistently carried out as ordered. The TAR showed that this treatment was not documented as administered until 10/04/2025, despite a start date of 10/03/2025, and was not documented on 10/06/2025. For several days (10/04, 10/05, 10/07, 10/08, and 10/09/2025), the location of administration was not recorded. Resident #6 and Resident #7 also had documented pressure ulcers present on admission that did not receive timely or consistently documented treatment. For Resident #6, an admission evaluation on 02/24/2026 documented a stage 3 sacral pressure ulcer measuring 2 cm by 2 cm by 0.1 cm, but there was no treatment order until 02/27/2026, creating a delay of several days between identification and initiation of ordered care. When a daily dayshift order for a calcium alginate-silver dressing to the sacrum began on 02/27/2026, the March TAR showed blank entries on 03/03, 03/08, and 03/18/2026, indicating the treatment was not documented as administered on those days. For Resident #7, an admission nursing evaluation on 02/18/2026 documented a stage 3 sacral pressure ulcer measuring 2.5 cm by 2.5 cm by 0.2 cm, and the care plan called for treatment per order. A Santyl ointment treatment every shift to the sacrum was ordered starting 03/06/2026, but the March TAR contained blank entries on 03/08 and 03/12/2026, again indicating missed or undocumented treatments. Interviews with nursing leadership and staff confirmed that blank entries on the TAR indicated treatments were not done and that a treatment should be in place whenever a wound is identified. The RN manager stated they were not aware that Resident #1 had no treatment order until 09/20/2025 and that missed treatments should have been reported. The DON acknowledged that Resident #1’s unstageable heel ulcer was documented on admission but that no treatment order appeared in the record until two days later, and they observed missing treatments on the TAR. LPNs and RNs interviewed described the expectation that wound care be completed during their shifts, documented in the electronic record, and communicated via nursing notes and 24-hour reports if not completed. Despite these stated expectations and the facility’s wound care policy, the records for Residents #1, #6, and #7 showed delays in obtaining initial treatment orders and multiple days where ordered pressure ulcer treatments were not documented as administered.
Failure to Promptly Implement and Document Resident Code Status Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s advance directive and code status change were promptly converted into a physician order and accurately documented and communicated to staff. A cognitively intact resident with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency initially requested full resuscitation at admission but later changed their mind and chose not to be resuscitated in the event of cardiorespiratory arrest. An encounter note documented that advance care planning was voluntarily discussed, the resident was alert, oriented, competent, and understood the consequences of choosing do not resuscitate (DNR). Despite this documented decision, there was no corresponding physician order entered to change the resident’s code status at that time. Record review showed that the electronic health record continued to carry an active order to attempt cardiopulmonary resuscitation (CPR) for several days after the resident’s decision to change to DNR. The Order Recap Report reflected an order to attempt CPR with an end date that extended seven days beyond the date of the documented change in the resident’s wishes. Pre-dialysis notes on multiple subsequent dates also documented the resident’s code status as CPR: attempt resuscitation, directing staff to “please see MOLST,” even though the resident had already expressed a desire not to be resuscitated. A DNR order and a completed and signed Medical Orders for Life-Sustaining Treatment (MOLST) form were not documented until a week after the resident’s decision. Interviews with staff confirmed that the process for implementing code status changes relied on the physician writing orders in a book and handing it to nursing or medical records staff, who were then responsible for entering the orders into the electronic medical record. The RN interviewed acknowledged that the code status change to DNR was documented in the physician’s note but did not recall an order being entered at that time and stated that a seven-day delay for a code status change should never occur. The Medical Director stated that a verbal order for a code status change was valid and that the facility should not have waited for the MOLST form to be completed and signed before entering the DNR order, noting that some nursing homes mistakenly believe code status is not official until the MOLST is finalized. This sequence of events resulted in the resident’s expressed change in advance directive not being promptly reflected in physician orders or in the clinical record, contrary to facility policy and regulatory requirements.
Failure to Report Resident-to-Resident Abuse Incident to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report the results of an investigation of resident-to-resident abuse to the State Survey Agency within the required timeframe. Facility policy, last reviewed on 07/18/2025, required the Administrator and Director of Nursing to investigate and report alleged or suspected abuse, neglect, or misappropriation to the appropriate State Agency immediately, and no later than two hours after identification of the allegation. On 10/14/2025 at 8:30 PM, a resident with vascular dementia, depression, anxiety, moderate cognitive impairment, and documented psychotic and aggressive behaviors threw objects, including a chair, during an escalated behavioral and psychotic episode. During this episode, the resident threw soda cans and an object at a nurse, climbed into another resident’s bed while that resident was lying in it, and then entered a third resident’s room, pushed a tray table, and threw a chair that struck the third resident’s right foot. The facility completed an internal investigation and documented that the event was the result of an acute psychosis episode in which the resident became belligerent, aggressive, violent, and at very high risk of harm to others. The investigation noted that two CNAs were present when the chair was thrown and that both affected residents received RN skin assessments. The investigation concluded there was no evidence of abuse, neglect, exploitation, mistreatment, or intentional misconduct by staff. However, there was no documented evidence that the facility reported this resident-to-resident abuse incident to the New York State Department of Health as required. During interviews, the DON stated they did not believe the incident was reportable because no one was hurt and indicated that the Administrator was responsible for reporting to the State Agency, while the Administrator stated that the DON completed investigations. The surveyors cited this as a failure to report the results of all investigations to the resident’s representative and to other officials in accordance with State law, including the State Survey Agency, within five working days of the incident.
Failure to Develop Measurable Care Plan for Stage 3 Pressure Ulcer
Penalty
Summary
Surveyors found that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident with a stage 3 pressure ulcer on the sacrum. The resident was admitted with diagnoses including right tibia/fibula orthopedic surgery aftercare, diabetes, and stage 3A chronic kidney disease, and was documented as cognitively intact and able to communicate. On admission/readmission evaluation, an RN documented a stage 3 sacral pressure ulcer measuring 2 cm by 2 cm by 0.1 cm. Facility policies required that the IDT, in conjunction with the resident and representative, develop a comprehensive care plan with measurable objectives and timetables to meet the resident’s needs, and that an RN/IDT develop a care plan for new skin impairments, including prevention interventions as necessary. Despite these policies and the documented presence of the stage 3 sacral pressure ulcer, the resident’s comprehensive care plan did not contain measurable goals and interventions specifically addressing the care and treatment of this wound to promote healing and prevent infection. The only related documentation was a nutritional care plan noting the presence of a sacral pressure injury, without evidence of detailed, measurable wound care goals or interventions. During interviews, the DON and an RN stated that care plans were initiated by an RN or the IDT and updated when a wound or status change was identified, but the record review showed that this process did not result in a comprehensive, measurable care plan for the resident’s stage 3 sacral pressure ulcer, in violation of facility policy and 10 NYCRR 415.11(c)(1).
Failure to Revise Care Plan After Deterioration of Pressure Ulcer and Missed Wound Assessments
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised and updated according to professional standards for one resident with complex medical conditions, including end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency. The facility’s policies required that comprehensive care plans be revised as residents’ conditions changed, that the IDT review and update care plans with significant changes, and that RNs/IDT develop and initiate care plans for new skin impairments. The resident had an actual pressure injury on the right heel with eschar, and a care plan for alteration in skin integrity was created and initiated with interventions such as applying treatment per order, and referrals to PT/OT and a wound care specialist as needed. On a weekly wound evaluation dated 10/02/2025, an LPN documented an unstageable right heel pressure ulcer with 100% black/brown eschar, scant serous drainage, no odor, and that the wound had deteriorated, with treatment re-evaluated or changed and a note that the wound care provider was unable to see the resident due to a dialysis schedule conflict. The resident was not seen by the wound care provider for weekly wound assessments on three separate dates when the resident was out of the facility for scheduled dialysis. Despite these missed weekly wound assessments and the documented deterioration and significant change in the pressure ulcer, there was no evidence that the comprehensive care plan was updated or revised to reflect these changes. Interviews with the DON and an RN Manager confirmed that care plans were expected to be initiated and updated when resident status changed, but the care plan for this resident’s pressure ulcer was not revised in response to the missed wound care visits and deterioration of the wound.
Unqualified Wound Assessment for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s pressure ulcer was assessed by a qualified person in accordance with the written plan of care and facility policy. The resident was admitted with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency, and had an unstageable pressure ulcer with 100% black/brown eschar on the right heel identified on admission by a registered nurse. The care plan for alteration in skin integrity documented an actual pressure injury to the right heel with eschar and included interventions such as applying treatment per order and referring to a wound care specialist as needed. Facility policy on Wound Identification and Wound Rounds required that residents with pressure injuries be identified, assessed, and managed in accordance with current standards of practice, with the Wound Nurse/Designee, wound care provider, and registered dietitian notified and the resident scheduled for weekly wound rounds. On 9/19/2025, an interdisciplinary high-risk meeting was held for the resident, during which it was documented that the resident had a right heel pressure ulcer and would be referred to the in-house wound provider. The initial wound evaluation on 9/18/2025 was completed by a registered nurse, who documented the unstageable right heel ulcer with 100% eschar and no visible wound bed. However, the weekly wound evaluation dated 9/25/2025 was documented by an LPN, who recorded the same measurements, 100% black/brown eschar, no exudate or odor, and noted that treatment was in place with an improved response, adding a comment to refer to the wound care provider. There was no documented evidence that the in-house wound care provider or any other qualified person, such as a registered nurse, assessed the resident’s right heel pressure ulcer on that date. Interviews confirmed that the LPN who completed the 9/25/2025 weekly wound evaluation was functioning as a travel resource nurse and acting Assistant Director of Nursing, and that a registered nurse was not present with them during the wound assessment for this resident. The LPN stated they evaluated the wound alone, documented what they observed, and did not refer the resident to the wound care provider on that date because there was no change in the wound, although they indicated the nurse practitioner should have been notified and should have assessed the resident. The DON acknowledged that LPNs could measure but could not assess wounds and were supposed to document observations in a nursing progress note, and the wound care provider stated it was unacceptable for there to be no weekly assessment by a registered nurse when the wound care provider did not see the resident. Information from the New York State Education Department clarified that LPNs may collect and report clinical data but may not perform nursing assessments or determine nursing diagnoses, and that RNs are responsible for assessing wounds and determining the plan of care, underscoring that the 9/25/2025 wound assessment was not performed by a qualified person as required.
Physician Failed to Address Documented Pressure Ulcer in Required Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure the attending physician reviewed a resident’s total program of care, including medications and treatments, and documented an appropriate plan at a required visit. A cognitively intact resident with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency was admitted with an unstageable pressure ulcer on the right heel. Nursing documentation on admission noted the heel ulcer measured 2.5 cm by 2.2 cm with 100% black/brown eschar and an existing treatment in place. An interdisciplinary team meeting the following day, attended by nursing, social services, rehab/therapy, dietary, administration, and a nurse practitioner, documented that the resident had a right heel pressure ulcer and would be referred to the in‑house wound provider. Despite this, when the attending physician conducted the initial history and physical visit several days later, the progress note documented no rashes or skin breakdown in the review of systems and described the skin as warm and dry on physical exam. The physician’s note did not mention the known unstageable right heel pressure ulcer and did not include any documented plan for its care or treatment, contrary to the facility’s Physician Visits policy requiring review of the resident’s total program of care and appropriate documentation at each visit. During interviews, the medical director stated that the physician, who was preparing to retire, did not always write notes about all resident concerns and that the medical team needed to be aware of residents’ wound status and review wound care notes. The administrator stated that the physician/nurse practitioner was responsible for residents’ overall care and that the physician was not resident centered.
Insufficient Nursing Staff Leads to Unmet Resident Needs
Penalty
Summary
The facility did not ensure sufficient nursing staff to provide necessary care to residents, resulting in unmet needs in activities of daily living. Multiple residents reported long waits for call lights to be answered, delays in receiving showers, and not being assisted out of bed and dressed until late morning. Observations confirmed that residents were often left in bed wearing hospital gowns and waiting for assistance with morning care. One resident was noted to have breakfast remnants on their face and disheveled hair, indicating a lack of timely personal care. Another resident, who required assistance with activities of daily living due to limited mobility and other health conditions, filed a grievance about waiting an hour and a half for assistance during the night. Observations showed that the resident's call light remained on for 20 minutes without being answered, despite staff being in the vicinity. The resident also reported waiting for hours on the toilet and not receiving showers or overnight care. During an interview, a Licensed Practical Nurse initially claimed the resident refused their hearing aids, but later found and applied them, which the resident appreciated. The facility's daily staffing schedule revealed that the number of staff on duty was often insufficient to meet the needs of the residents. Interviews with staff and residents indicated that there were missed showers, long wait times for assistance, and inadequate care during the night shift. Residents expressed frustration with the lack of timely response to call lights and the insufficient number of staff available to provide necessary care. The facility's policies on staffing and call light response were not effectively implemented, leading to significant deficiencies in resident care.
Non-Functional Nurse Call System in Resident Rooms
Penalty
Summary
The facility did not adequately provide for residents to call for staff assistance through a communication system on one of the two units. Specifically, the nurse call system was non-functional in resident rooms 5, 7, and 11 on the North Unit. During observations, it was noted that the call bell did not activate when tested in room 5 for beds A and B. Additionally, rooms 7 and 11 were using tap bells and did not have nurse cords to activate the nurse call system. A resident confirmed that they would use the nurse call cord if one were provided. Record reviews indicated that repair requisitions for the nurse call systems in rooms 5, 7, and 11 were documented on 12/26/2023 and 12/30/2023. A quote for repairs was obtained on 1/09/2024. Interviews with the Maintenance Life Safety Consultant and the Administrator confirmed that the facility had contracted with a vendor to repair the systems and was awaiting the scheduling of the repairs once the replacement parts were available. The repairs were reported to be completed by 2/12/2024.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse involving a resident to the New York State Department of Health in a timely manner. Specifically, the facility did not report an incident on 8/09/2023 where a staff member made derogatory comments to a resident, which was witnessed by two individuals. The Administrator ruled out verbal abuse because the resident did not hear the comments, and no report was made to the State Agency until 8/21/2023. Additionally, another incident on 12/05/2023 involving a resident-to-resident verbal altercation and a physical threat was not reported to the State Agency until 2/08/2024. The Administrator did not believe the incident rose to an abuse situation since no physical contact was made, and the resident did not feel uncomfortable. The facility's policy on abuse, last revised in 2/2019, mandates immediate reporting of any alleged violations of abuse, neglect, or mistreatment to the appropriate State Agency. Both the Administrator and the Director of Nursing acknowledged that the incidents should have been reported according to the facility's policy. The failure to report these incidents in a timely manner constitutes a deficiency in the facility's compliance with state regulations regarding the reporting of abuse, neglect, or mistreatment.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical and dental needs. Resident #327, who was admitted with metabolic encephalopathy, severe sepsis with septic shock, and cirrhosis of the liver, had an indwelling urinary catheter placed by an outside provider. Despite this, the facility did not include the presence or maintenance of the urinary catheter in the resident's comprehensive care plan. Interviews with nursing staff and the Director of Nursing confirmed that the care plan should have addressed the urinary catheter but did not, indicating a lapse in the facility's adherence to its own policies and procedures for comprehensive care planning. Resident #14, admitted with diagnoses of Diabetes type 1 and partial limb amputation, had multiple missing and broken teeth and expressed a desire to see a dentist. However, the resident's comprehensive care plans did not include dental care, and no dentist appointment had been made. Interviews with the Director of Nursing and a Registered Nurse revealed that the care plan should have been updated to include dental care but was not, further highlighting the facility's failure to ensure all aspects of the residents' needs were addressed in their care plans.
Deficiency in Providing Necessary Services for Activities of Daily Living
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Resident #2, who was admitted with diagnoses including urinary tract infection, diabetes mellitus type 2, and hypertension, was observed multiple times in a hospital gown, unwashed, and with leftover food on their face. The resident reported that staff only provided care once a day, if at all, and that there was a shortage of extra-large incontinence briefs, leading to inadequate care. Interviews with staff revealed a lack of awareness about the resident's needs and the shortage of supplies, with the Medical Records/Supply Officer confirming that briefs were rationed and locked after hours to prevent misuse by staff for other residents who did not require them. The Director of Nursing and Registered Nurse also stated they had no knowledge of the issues reported by the resident and their family members. The resident's son had to bring in personal supplies to ensure the resident could be changed when needed. The facility's policy on Activities of Daily Living Support was not followed, resulting in the resident not receiving the necessary assistance for personal hygiene and incontinence care. The facility's failure to provide adequate care and supplies for Resident #2 highlights a significant deficiency in meeting the resident's needs and maintaining their dignity and comfort. Resident #32, admitted with diagnoses including osteoarthritis, difficulty walking, chronic obstructive pulmonary disease, weakness, and depression, was observed waiting for assistance with personal hygiene and wearing a hospital gown due to a lack of clean clothing. The resident reported waiting hours for assistance, especially during the night, and not receiving showers or care overnight. The resident's hearing aids were not applied, and staff did not assist in applying them despite the resident's requests. Interviews with staff revealed that the resident's grievances about waiting for assistance and not having clean clothing were known but not adequately addressed. The facility's new laundry service had issues, resulting in residents not receiving their clothing back, and the facility had recently hired an in-house laundry person to address these concerns. The facility's failure to provide timely assistance and clean clothing for Resident #32 demonstrates a deficiency in meeting the resident's needs and ensuring their comfort and dignity. Resident #327, admitted with diagnoses including metabolic encephalopathy, severe sepsis with septic shock, and cirrhosis of the liver, did not receive their scheduled weekly showers. The Kardex Report documented that the resident was to receive a shower or bath every Tuesday and Thursday, but the Bathing document showed that no bath or shower was given on the specified dates. Interviews with staff revealed that the Certified Nurse Aide was expected to inform the nurse if a resident refused a shower, and the nurse was to check at the end of the shift to ensure tasks were completed. The Director of Nursing stated that audits should be performed to ensure resident care was completed, but this was not done for Resident #327. The facility's failure to provide the scheduled showers for Resident #327 indicates a deficiency in meeting the resident's hygiene needs and ensuring their 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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