Citations in New York
Statistics, citations and compliance trends for long-term care facilities in New York.
Statistics for New York (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in New York
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in New York
- Re-educated staff on recognizing and reporting abuse to reinforce required identification and reporting expectations (K - F0600 - NY)
- Educated staff on adhering to care plans and the care-card acknowledgement process (including identifying residents requiring no-male care, where it was documented, and signing off on care cards prior to providing care) (J - F0656 - NY)
- Verified unit assignment sheets and staff assignments against the no-male-caregiver list to prevent assigning male staff to residents care planned for no male care (J - F0656 - NY)
- Verified completion of care-card acknowledgement sign-off sheets against staff assignment sheets to ensure staff reviewed care cards prior to their shift (J - F0656 - NY)
- Provided in-service to the Director of Nursing and Assistant Director of Nursing on ensuring thorough investigations of all allegations to strengthen investigative practices (J - F0610 - NY)
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Failure to Protect Residents From Repeated Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from sexual abuse by another resident with Alzheimer’s disease, resulting in Immediate Jeopardy and actual harm. Facility policy required staff training on abuse prevention, recognition of abuse, and ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or sexually aggressive conduct. Despite this, the resident with Alzheimer’s disease (Resident #2), who had moderate cognitive impairment and ambulated independently, was repeatedly involved in sexually inappropriate situations with six other residents, most of whom had severe cognitive impairment and were dependent on staff for mobility and care. The facility did not consistently assess, care plan, or monitor at-risk residents or the aggressor in a way that prevented repeated incidents. In the first incident, a nurse documented that Resident #2 was found in another cognitively impaired resident’s bed with a hand moving inside that resident’s brief. Resident #2 was removed and moved to another unit, but the incident report lacked staff statements and did not document Resident #2’s activities prior to discovery or when either resident was last observed. There was no documented social work follow-up or updated interventions for the victim resident, despite a care plan noting trauma and anxiety related to prior traumatic events. The only documented care plan change for Resident #2 was a temporary unit move, medication review, and behavioral monitoring, and there was no documentation of care plan updates when Resident #2 was later moved back to the original floor or of specific interventions addressing sexually inappropriate behavior. Subsequent incidents showed a pattern of inadequate protection and follow-up. In one event, a severely cognitively impaired resident was found in Resident #2’s bed, naked from the waist down, while Resident #2 was completely unclothed; staff noted apparent fluid on the sheet, but there was no care plan update or new interventions for the victim, and Resident #2’s care plan was only revised to note that another resident had been found in the bed, with no new protective measures. In another incident, Resident #2 was observed in a dining room kissing a severely cognitively impaired resident and removing a hand from the resident’s thigh area; although staff separated them and documented the event, there was no care plan revision for the victim. In a further incident, a cognitively intact resident reported that it was not acceptable for Resident #2 to touch their breast when Resident #2 attempted to kiss and rub the resident’s breast; the only documented intervention was to keep the residents apart in the activity room, and there was no care plan revision or psychosocial follow-up for the victim. Additional incidents continued despite knowledge of Resident #2’s history. In one case, staff found Resident #2 at the bedside of a severely cognitively impaired resident with both hands under the sheet; the victim’s brief was almost completely unsecured, and the resident stated, “it hurts,” though no open skin areas were found. In another case, Resident #2 was found lying in the bed of a severely cognitively impaired resident who was yelling for help, and later sitting on the same resident’s bed holding their hand; staff noted that Resident #2 wandered frequently at night and that there were no safety measures in place to protect female residents aside from general monitoring. Interviews with social services staff and the DON confirmed prior knowledge of Resident #2’s sexually inappropriate behaviors with multiple female residents, acknowledged that there were no safety measures in place for several of the victim residents, and revealed that no psychosocial follow-ups or psychological evaluations were completed for the victims. The Medical Director reported being notified only recently about the pattern of inappropriate sexual behaviors, despite expecting to be informed of such incidents. These actions and omissions demonstrate that the facility failed to implement effective assessments, care plan revisions, monitoring, and protective interventions to prevent ongoing sexual abuse of residents.
Removal Plan
- Resident #2's care plan was revised to show 1:1 supervision at all times.
- All residents who resided on the first floor South Unit had their care plans revised to be at risk for a victim of abuse.
- All nursing staff working on South Unit were educated on Resident #2's revised care plan (confirmed by signature records).
- The Medical Director and Nurse Practitioner #29 assessed Resident #2's medications and made changes.
- A referral for a psychiatric evaluation of Resident #2 was made.
- All staff were re-educated on recognizing and reporting abuse.
- Education was verified through staff interviews across departments and review/verification of education signature sheets against a full staffing list.
- All residents on the South Unit were interviewed by members of the Interdisciplinary Team to rule out any further instances of unreported abuse; progress notes from the last 30 days were also reviewed for those residents (no concerns identified).
- Social Worker #14 followed up with Residents #3, #4, #5, #6, #7, and #8 to ensure no psychosocial/emotional harm was noted.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Supervise Elopement-Risk Residents and Implement Elopement/AMA Policies
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents at risk of elopement remained under adequate supervision and that the environment was free from accident hazards, resulting in two separate elopement incidents. Facility policies required that when a resident was discovered missing, staff conduct a thorough search of the building and premises, notify the Administrator, Director of Nursing Services, the resident’s legal representative, attending physician, and law enforcement, and, under the emergency preparedness missing resident procedure, initiate a Code Pink, search the facility and grounds, and notify police if the resident was not found within 10 minutes. The facility also had an Against Medical Advice (AMA) policy requiring that cognitively intact residents who leave against professional advice receive information about risks, be asked to sign AMA documentation, and that staff complete careful, comprehensive documentation of education, counseling, options, reactions, and all facility actions, including contacts with the physician and Adult Protective Services. One resident, admitted with alcohol abuse with withdrawal delirium, dysphagia, and opioid dependence, was assessed as cognitively intact with a Brief Interview for Mental Status score of 14/15 and identified as an elopement risk on the interdisciplinary assessment. The care plan for wandering and elopement risk set a goal for the resident to remain safely under supervision and within the facility unless escorted, with interventions including documenting and notifying providers of behavior intensity, duration, or frequency and redirecting the resident. The resident also had a care plan for substance use disorder history, including monitoring for signs of acute intoxication or potential substance use and promoting supportive communication. Progress notes documented that an electronic monitoring device was applied on admission for wandering tendency, that the resident repeatedly expressed a desire to leave due to pain and facility restrictions, and that the resident attempted to leave through the front door several times, yelling and being aggressive, but was calmed. There was no documented evidence that the medical provider was notified of the resident’s repeated statements about wanting to leave against medical advice or of the attempts to leave the facility. On the night and early morning when the elopement occurred, documentation and interviews showed the resident continued to complain of pain, paced the hallway, and was sweating, swearing, and talking fast. An LPN documented promising to speak to the physician about an extra dose of tramadol, offering a topical analgesic that the resident refused, and then allowing the resident to sleep in a chair in the front lobby because they were calm. Later, when staff attempted to administer medications, the resident was no longer in the chair or room, and a head count showed the resident was the only one unaccounted for. The resident’s health care proxy reported not being called until hours after the resident had already arrived at a local hospital emergency department and stated the facility asked if they knew the resident’s whereabouts. The proxy also reported being told the resident had cut off their electronic monitoring device and left it at the front desk and that the facility said the resident had the right to leave and there was no risk. The DON stated they reviewed camera footage showing the resident with all belongings in the lobby and then leaving through the front door, and asserted that because the resident was alert and oriented, the facility had no responsibility and the incident was not an elopement. There was no documentation of AMA education, counseling, options, or resident/responsible party reactions, and no evidence that AMA paperwork was discussed or signed, despite the resident being treated as an AMA discharge. A second resident, admitted with Alzheimer’s disease, cognitive communication deficit, and generalized muscle weakness, had severely impaired cognition and was care planned as at risk for wandering into unsafe areas or elopement without supervision. The care plan goal was for the resident to be maintained safely under staff supervision and remain away from unsafe areas and within the facility unless escorted, with interventions including identifying behavior patterns, documenting behavior intensity, duration, and frequency, orienting to daily routines, referring for psychiatric consult as ordered, and ensuring proper placement and functioning of an ankle electronic monitoring device. Treatment records showed electronic monitoring device checks every shift beginning on a specified date. On the day of the incident, an alarm sounded from a unit exit door, prompting staff to initiate resident accountability, and dietary staff observed the resident alone outside near the exit door in a wheelchair and returned the resident inside. Investigation statements indicated the resident had last been seen on the unit shortly before being observed outside. During interviews, the DON acknowledged that electronic monitoring device orders for this resident were never placed in the Medication or Treatment Administration Record when ordered, and that monitoring of residents’ electronic monitoring devices was only added to the record after a quality assurance audit following the elopement incident. The DON also stated that the door the resident exited was an emergency exit with an alarm but was not connected to the electronic monitoring device system. These actions and omissions resulted in one resident leaving the facility without staff knowledge and being located hours later at a hospital, and another resident with severely impaired cognition exiting through an alarmed emergency door and being found outside on facility grounds, constituting Immediate Jeopardy and substandard quality of care for the first resident and no actual harm with potential for more than minimal harm for the second resident.
Removal Plan
- Confirmed by review of camera footage and interviews with six staff of various titles that the front door to the facility was manned.
- Revised the elopement policy to add that when a resident is found missing from the facility, staff are to follow the missing person policy.
- Revised the missing person policy to add steps for residents who have not signed or declined to sign Against Medical Advice paperwork, including immediately notifying the Administrator or Director of Nursing, notifying the police, and notifying the New York State Department of Health.
- Educated employees on the revised elopement and missing person policies, with rosters and education sign-off sheets.
- Verified via interviews with staff members of various titles that they had been educated on the revised elopement and missing person policies.
Failure to Follow No-Male-Caregiver Care Plan Resulting in Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan consistent with resident rights for a resident with a documented restriction against male caregivers. The resident had diagnoses including traumatic brain injury and anxiety, with a Minimum Data Set dated 01/22/2026 indicating severely impaired cognition, verbal and behavioral symptoms directed toward others, and a need for moderate assistance or dependence for most ADLs. The comprehensive care plan dated 01/23/2026 documented behaviors related to traumatic brain injury, including verbal and physical aggression toward staff, and included specific interventions: two caregivers for care, no male caregivers, and 1:1 supervision during the night shift due to falls. Undated care instructions also documented two staff for all care and no male caregivers. Despite these documented interventions, multiple CNA assignment sheets showed male CNAs being assigned to the resident. Assignment sheets dated 02/01/2026, 02/09/2026, and 02/12/2026 listed a male CNA assigned to the resident on the 7:00 AM–3:00 PM shifts. The 02/03/2026 CNA assignment sheet documented a male CNA assigned as the resident’s 1:1 during the 11:00 PM–7:00 AM night shift, contrary to the care plan specifying no male caregivers. Interviews with the Assistant DON and other staff confirmed that the resident was more agitated and aggressive toward males, that the spouse agreed with this, and that the care plan had been updated to include no male caregivers, with this information also placed on the care card accessible to CNAs. On the night shift when a male CNA was assigned 1:1, an incident of abuse occurred. According to the 02/04/2026 incident report and witness statements, during morning care at the end of the night shift, the resident became combative while being assisted by the male CNA assigned as 1:1 and another CNA. One CNA interlocked hands with the resident to de-escalate, and the resident spat at the male CNA. The male CNA was then witnessed forcefully pushing the resident’s face down into a pillow, causing scratches over the resident’s face and neck. Multiple staff interviews, including with an LPN, a unit manager, the RN supervisor, the NP, and the Medical Director, confirmed that the resident was care planned to have no male caregivers, that male caregivers triggered the resident, and that the care plan should have been followed. The DON acknowledged that the care card directed care and that CNAs, LPNs, and the RN supervisor were supposed to review it at the beginning of their shift, but the male CNA was nonetheless assigned and involved in the resident’s care, in violation of the care plan.
Removal Plan
- Review Resident #1's care plan to ensure all interventions, including the no-male caregivers requirement, are clearly documented and communicated to all staff.
- Educate all in-house staff on adhering to care plans, identifying residents who require no male care and where it is documented, and reviewing care cards for their assignment prior to starting care with care card acknowledgement sign-off.
- Complete an immediate review to identify individuals with the specific need for no male care.
- Verify unit assignment sheets clearly identify residents requiring no male caregivers by comparing against the facility master list.
- Review and verify the staff education list against the post-test and staff listing to ensure accuracy.
- Verify staff assignments against the no male caregiver list to ensure residents who are care planned to not have male care are not assigned male staff.
- Verify care card acknowledgement sign-off sheets against staff assignment sheets to ensure they are being completed.
- Review care plans and care cards for residents identified as not wanting male care to ensure the information is clearly documented.
- Re-educate staff on reviewing the care card prior to their shift, ensuring the no-male designation is clearly identified on the care plan, and completing the care card acknowledgement sheet process.
Failure to investigate abuse allegation and protect cognitively impaired resident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse and to protect a resident from potential further abuse after the allegation was reported. The facility’s abuse policy required that all alleged or suspected incidents of abuse, neglect, mistreatment, or misappropriation of resident property be thoroughly investigated, with findings documented and reported, and that residents be protected from abuse. Resident #1, who had non-Alzheimer’s dementia, muscle weakness, difficulty walking, and severely impaired cognition per the most recent MDS, was the subject of the alleged abuse. Video surveillance from the unit on the date of the incident showed Resident #1 ambulating with an unsteady gait, using hallway handrails, and then rolling a cart with personal protective equipment into two residents’ rooms. Certified Nursing Assistant (CNA) #1, who was pushing another resident up the hallway, followed Resident #1 into a room, rolled the cart back into the hallway, and was then seen pulling Resident #1 by the arm into the hallway. CNA #1 held Resident #1 under the left armpit and pulled the resident up the hallway toward their wheelchair while the resident resisted. CNA #1 then seated Resident #1 on the edge of the wheelchair; as the resident resisted sitting, CNA #1 held the resident under the armpit and by the pants and dragged the resident fully back into the wheelchair. CNA #1 then pushed the resident’s upper body forward while their right hand moved back and forth at the resident’s lower back, appearing to hit the resident on the buttock, with the resident’s body jerking forward. A visitor for another resident was observed in a nearby doorway looking toward CNA #1 and Resident #1, and the visitor and CNA #1 appeared to exchange words and hand gestures. Later that day, the visitor reported the incident to the Director of Nursing (DON). The facility’s undated internal summary of the incident documented that the visitor demanded discipline for CNA #1 due to a verbal altercation and described hearing a commotion, coming out to observe, and asking CNA #1 what they were doing with Resident #1. The DON stated in interview that the visitor only reported rudeness by CNA #1 and did not report rough handling or hitting. The DON reviewed the video footage but stated they did not identify CNA #1’s actions as abusive or excessively rough and, based on CNA #1’s denial, did not further investigate the matter as abuse. CNA #1 was suspended for one day for poor customer service and then reassigned to another unit, but was not removed from resident care or access to residents in response to an abuse allegation, and no thorough abuse investigation was initiated at that time. Registered Nurse Supervisor #1 reported that the DON informed them that a family member had complained that CNA #1 was cursing at them after they questioned what CNA #1 was doing with Resident #1. The DON told the supervisor that video review showed CNA #1 attempting to put Resident #1 into their wheelchair and instructed the supervisor to perform a body assessment on Resident #1. The supervisor stated that they and the DON assessed Resident #1 and found no redness, discoloration, or visible injury, and that the resident was smiling and in good spirits with no complaints of pain or discomfort; however, this assessment was not documented in the resident’s chart, and the physician was not notified. There was no documented RN assessment of Resident #1 related to the alleged incident, and the attending physician later stated they were not made aware of any allegation of rough handling or abuse involving Resident #1 until more than a week after the event. The facility did not initiate a formal abuse investigation until after the state surveyor’s onsite visit, during which it was confirmed that CNA #1 had continued to work on other units after the date of the alleged abuse.
Removal Plan
- Certified Nursing Assistant #1 was removed.
- Resident #1 was assessed.
- Facility wide in-service was conducted.
- Administration rounding on all units was conducted.
- Resident #1's care plan was reviewed and updated.
- Audit log for Accident/Incidents was reviewed for the past 30 days.
- Facility reviewed and assessed 52 residents for abuse and mistreatment.
- Nurse Practitioner assessed Resident #1.
- The Director of Nursing and Assistant Director of Nursing received in-service on ensuring a thorough investigation of all allegations.
- Interdisciplinary Meeting was held.
- Facility investigation was reviewed.
- Facility reviewed Policy and Procedure on Abuse Prevention.
Trusted by long-term care providers and associations.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
