Carmel Richmond Healthcare And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Staten Island, New York.
- Location
- 88 Old Town Road, Staten Island, New York 10304
- CMS Provider Number
- 335455
- Inspections on file
- 26
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Carmel Richmond Healthcare And Rehab Center during CMS and state inspections, most recent first.
A resident with ESRD on hemodialysis, diabetes, and protein-calorie malnutrition was admitted with intact skin and later developed moisture-associated skin damage (MASD) to the sacrum and buttocks. Nursing staff requested a wound consult but did not document a wound assessment or physician notification, and treatment for MASD was delayed and inconsistently documented, with no clear evaluation of effectiveness. After transfer to the hospital, the resident was found to have multiple wounds, including a stage III sacral ulcer, hip pressure injuries, heel deep tissue injuries, gangrenous toes, and left bunion skin loss. On readmission, an RN documented sacral, hip, heel, and toe wounds but did not notify the MD or initiate care plans, and a subsequent MD order for collagenase did not specify the body site. The care plan and wound care RN’s assessment failed to reflect all hospital-documented wounds, and there was no documented treatment for several wounds, while interviews showed that staff deferred to the wound care RN, did not fully review hospital records, and did not consistently assess, report, or document wound progression.
A resident with ESRD on hemodialysis, diabetes, and severe malnutrition developed moisture-associated skin damage to the sacrum and buttocks, for which topical treatment was ordered but not clinically reassessed or documented for effectiveness over an extended period, despite later evidence of wound deterioration. After a hospital stay, the resident was readmitted with eight documented wounds, including a Stage III sacral ulcer, bilateral hip wounds, heel injuries, gangrenous toes, and a left bunion wound. On readmission, nursing documented multiple wounds, but the physician history and physical noted only sacral moisture-associated skin damage, and a debriding agent was ordered without specifying the body site. A wound nurse assessment documented findings that did not match the hospital discharge summary or nursing admission note, and subsequent orders addressed only sacral dermatitis and a left hip abrasion, with no documented physician orders, assessments, or treatments for the right hip wound, left bunion wound, or gangrenous toes, and no podiatry consult. The wound PA later assessed only selected areas directed by the wound nurse, while the readmitting MD, attending MD, and medical director each acknowledged limited or no direct examination of the resident and incomplete follow-through on the documented wounds, resulting in a failure of effective physician supervision of medical care.
A resident with multiple chronic conditions and moderately impaired cognition developed moisture associated dermatitis to the sacrum and bilateral buttocks, for which topical treatment was ordered and administered. A wound consult was requested by an RN, but there was no timely wound assessment or documentation of physician notification at that time, and later documentation by the wound care RN showed the skin condition and treatment orders. Despite facility policy requiring notification and documentation of contact with the responsible party when a change in condition occurs, there was no evidence in the EMR that the resident’s designated representative was informed of the new skin condition. The resident’s representative confirmed they were unaware of the issue, while the unit manager RN, wound care RN, and DON each described differing understandings of who was responsible for notifying families about skin changes.
A resident with multiple complex medical conditions, including cellulitis, bacteremia, and numerous documented wounds (e.g., Stage III sacral ulcer, deep tissue injuries to hips and heels, unstageable hip wound, gangrenous toes, and a left bunion wound), was admitted and readmitted with detailed hospital records and facility admission notes describing these skin issues. Despite this, MDS assessments in two separate assessment periods documented no skin problems or only moisture-associated skin damage, omitting the full-thickness wounds, pressure injuries, and gangrene. The MDS coordinator and MDS director reported relying on the wound nurse’s documentation and the medical record without physically assessing the resident or reconciling discrepancies between hospital discharge information and internal wound assessments, resulting in inaccurate MDS coding of the resident’s skin condition.
A resident with severe cognitive impairment and a care plan requiring two-person assistance for transfers was repeatedly moved by single CNAs, contrary to documented instructions. The resident was later found with a left hip fracture, with no reported fall or trauma, indicating that staff did not follow established transfer protocols.
A resident with cognitive impairment was involved in an incident where a CNA threw melted ice cream at them after the resident initially threw it at the CNA. The facility's investigation confirmed abuse, leading to the CNA's suspension and termination.
A resident with a history of stroke, hypertension, and diabetes mellitus was identified with an unstageable pressure injury and a deep tissue pressure injury. The facility failed to complete a Significant Change in Status Assessment within the required 14 days after this change in condition. The Minimum Data Set Coordinator did not complete the assessment due to not receiving the wound tracker report from the Wound Care Nurse.
A resident with cognitive impairment was found on the floor with head injuries, including a nasal bone fracture, after an unwitnessed fall. Despite the facility's policy requiring immediate reporting of such incidents, the event was not reported to the New York State Department of Health. The facility's investigation concluded no abuse or neglect occurred, but the Director of Nursing acknowledged the reporting failure.
The facility failed to store and prepare food according to safety standards, with expired bratwurst found in storage and sandwiches not maintained at safe temperatures. Staff interviews revealed a lack of awareness and monitoring of food expiration and temperature compliance.
A resident with cognitive impairment was found on the floor with head injuries, including a nasal bone fracture, after an unwitnessed fall. The facility did not report the incident to the New York State Department of Health as required, despite the policy stating that such incidents must be reported within 2 hours if they involve serious bodily injury.
A resident with a history of stroke, hypertension, and diabetes mellitus was identified with new pressure injuries, but the facility failed to complete a Significant Change in Status Assessment within the required 14 days. The Minimum Data Set Coordinator did not receive the necessary wound tracker report, leading to the oversight.
The facility failed to store and prepare food according to safety standards, with expired bratwurst found in storage and sandwiches not maintained at safe temperatures. Staff interviews revealed a lack of awareness and monitoring of food expiration and temperature compliance.
Failure to Assess, Treat, and Document Multiple Wounds and MASD
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders to maintain a resident’s highest practicable physical well-being. The resident was admitted with diagnoses including end-stage renal disease on hemodialysis, diabetes mellitus, and protein-calorie malnutrition, and was assessed on admission with intact skin and no pressure ulcers. A Braden Scale assessment identified the resident as at moderate risk for pressure injury. Despite a wound care consultation request being entered by a nurse, there was no documented wound assessment, no description of the wound, and no evidence that the attending physician was notified at that time. Moisture-associated dermatitis of the sacrum and bilateral buttocks was not formally assessed until days later by the wound care RN, who documented moisture-associated dermatitis and obtained a physician order for topical treatment. Between the initiation of treatment and the resident’s subsequent transfer to the hospital, there was a lack of consistent documentation of treatment application and wound progression. The treatment record showed the last documented treatment on one date with no further documentation of treatment or evaluation of effectiveness for several days. A nurse practitioner later documented moisture-associated skin damage to the sacrum and issued a new order for hydrophilic cream, followed by another change in treatment to Medi-honey and calcium alginate, but there was no documented evidence that the effectiveness of these treatments was evaluated. The resident was then transferred from dialysis to the emergency room with increased leukocytosis. Hospital records documented multiple wounds, including moisture-associated skin damage to the sacrum/coccyx, stage I and II pressure injuries to the trochanters, deep tissue injuries to both heels, and other wounds to the left bunion and toes. On hospital discharge back to the facility, the resident was documented with a stage III sacral ulcer, unstageable and deep tissue injuries to the hips, deep tissue injuries to both heels, dry gangrene of toes, and partial thickness skin loss at the left bunion. Upon readmission to the facility, the admitting nurse documented a pressure wound to the sacrum, wounds to bilateral hips, gangrene to all toes, and bilateral heel wounds, but did not notify the physician or nursing supervisor and did not initiate care plans, instead expecting the wound care nurse to reassess. The physician’s readmission note mentioned only moisture-associated skin damage to the sacrum and did not identify the stage III sacral ulcer or other wounds listed in the hospital discharge summary. A subsequent physician order for collagenase ointment did not specify the body site, and the treatment administration record showed it was given on only two days before being discontinued. The impaired skin integrity care plan addressed only moisture-associated skin damage to the sacrum and did not include the multiple additional wounds documented by the hospital. The wound care RN’s post-readmission assessment documented only a right hip superficial abrasion and sacral moisture-associated dermatitis, with bilateral lower extremities and feet described as unremarkable, which did not correlate with the hospital’s documentation of bilateral heel deep tissue injuries, gangrenous toes, and left bunion skin loss. There was no documented evidence of treatment for four wounds: the right hip, left bunion full thickness skin loss, and bilateral gangrenous toes. Interviews with facility staff and the wound care consultant confirmed that hospital skin assessments were not fully reviewed, that unit nurses deferred to the wound care nurse for skin issues, that some wounds were not assessed or reported, and that treatment effectiveness and wound progression were not consistently documented. This deficient practice resulted in actual harm to the resident, though it was not cited as Immediate Jeopardy. Additional interviews further detailed the actions and inactions contributing to the deficiency. The nurse practitioner acknowledged not following up on the sacral moisture-associated skin damage, relying on unit nurses to notify them if the wound healed or required additional treatment, and did not recall gangrenous feet and toes. The RN who first requested the wound consult admitted there was no documentation of their assessment or physician notification and stated that unit nurses were responsible for providing treatment and notifying the wound care RN of deterioration, while the wound care RN was responsible for monitoring and documenting effectiveness. The readmitting RN acknowledged unwrapping the resident’s leg dressings, observing necrotic heels and toes, but failing to notify the physician or supervisor or initiate care plans. The wound care RN stated they did not review the hospital skin assessment because they preferred to assess with their own eyes, and asserted that the resident did not develop pressure ulcers in the facility. The unit manager stated they saw documentation of wounds in the hospital record but did not notify the wound care nurse and did not get involved with skin assessments. The wound care specialist PA reported assessing only the areas directed by the wound care RN and was unaware of some documented wounds. The DON and Administrator acknowledged that the nurse who first noted skin changes should have notified the physician and that the wound care nurse should have reviewed hospital discharge documentation and compared it to the resident’s condition on readmission.
Failure of Physician Supervision and Wound Management for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical care was effectively supervised by a physician, in accordance with facility policy and regulatory requirements. The resident had multiple serious comorbidities, including end stage renal disease on hemodialysis, diabetes mellitus, and protein calorie malnutrition, and was assessed as having moderately impaired cognition and a moderate risk for pressure injury. Initially, the resident had no documented skin problems, but on 08/12/2025 an RN requested a wound care consultation without documenting an identified wound or notifying the attending physician. No wound assessment was documented until 08/14/2025, when the wound care nurse identified moisture associated dermatitis to the sacrum and bilateral buttocks and a physician ordered topical treatments for 30 days. Although a subsequent nursing note on 08/15/2025 documented skin openings to the bilateral buttocks and indicated that the wound nurse and physician were to evaluate, there was no documented evidence of wound progression, effectiveness of treatment, or clinical reassessment between 08/14/2025 and 11/29/2025, despite a later surgical note on 12/17/2025 describing a sacral wound with serosanguinous exudate and specific measurements. After the resident was transferred to the hospital and later discharged back to the facility, the hospital discharge record documented eight wounds, including a Stage III sacral ulcer, unstageable and deep tissue injuries to both hips, deep tissue injuries to both heels, dry gangrene of the left toe, a necrotic right great toe, gangrene of all toes, and a left bunion with partial thickness skin loss. On readmission, the facility nurse documented pressure wounds to the sacrum, bilateral hips, gangrene to all toes, and bilateral heels, but the physician’s history and physical documented only moisture associated skin damage to the sacrum and did not identify the Stage III sacral ulcer or the other seven wounds listed in the hospital discharge summary. A physician order for collagenase was written without specifying the body site, and the treatment administration record showed the treatment as given on two days without identifying where it was applied. The wound care nurse’s assessment on 01/05/2026 documented only a right hip superficial abrasion, moisture associated dermatitis to the sacrum, and unremarkable lower extremities and heels, which did not correlate with the hospital discharge assessment or the nurse’s admission/readmission note. Subsequent physician orders on 01/05/2026 addressed Medi-honey treatment for irritant contact dermatitis and Triad cream for a left hip abrasion, but there was no documented evidence of physician orders or treatment for four of the wounds: the right hip wound, left bunion partial thickness skin loss, and bilateral gangrenous toes. There was also no documented evidence of a podiatry consultation. The wound care physician assistant later documented assessments of the sacrum and left hip (identified as a Kennedy terminal ulcer) but did not assess the gangrenous toes or left bunion wound, stating they only examined areas directed by the wound care nurse. The readmitting physician stated they reviewed the hospital discharge record and saw moisture associated skin dermatitis but did not observe the hip wounds, attempted but did not document a refused lower extremity exam, and did not order podiatry because they did not assess the bandaged extremities. The attending physician for the unit reported never seeing the resident after readmission and was unaware of the multiple wounds and gangrenous toes, relying on the wound care team and unit nurses for communication. The medical director acknowledged reviewing the hospital discharge notes and seeing the list of wounds, stated that the readmitting physician should have ordered treatments for all wounds, and confirmed they did not physically examine the resident. Collectively, these documented omissions and incomplete assessments demonstrate that the resident’s medical care, particularly wound management, was not effectively supervised by a physician as required by facility policy and regulation.
Failure to Notify Resident Representative of New Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a designated resident representative of a change in a resident’s condition, as required by facility policy and state regulation. The facility’s policy on Notification of Resident’s Change in Condition (dated 04/2020) states that when a change in condition is detected, the nurse must notify the physician, resident, or responsible party and document the date, time, name, method of notification, actions taken, and resident’s response in the medical record. Resident #1, admitted with multiple diagnoses including dementia with moderately impaired cognition, anemia, end stage renal disease on hemodialysis, diabetes mellitus, atrial fibrillation, coronary artery disease, heart failure, COPD, malnutrition, and respiratory failure, experienced a change in skin condition. On 08/12/2025, RN #3 requested a wound care consultation, but there was no documentation of an identified wound, no documentation that the attending physician was notified, and no wound assessment documented at that time. On 08/14/2025, RN #2 (wound care nurse) completed a wound assessment and documented moisture associated dermatitis to the sacrum and bilateral buttocks, described as moist, pink/red, with no odor, no drainage, and no pain, and treatment with Triad cream mixed with A&D ointment was ordered and administered every shift through the end of the month. The electronic medical record and treatment administration record contained no documentation that Resident #1’s designated representative was notified of this new moisture associated skin damage. In an interview, the resident’s representative stated they were not aware of the skin condition. RN #3 stated they did not notify the representative because they believed the wound care nurse was responsible for notifying families of skin problems and reported being not very involved with wounds due to the presence of a full-time wound nurse. RN #2 acknowledged usually notifying families of skin issues but stated they missed notifying this resident’s representative, and also stated that unit nurses could have notified the family. The DON stated the full-time wound nurse is responsible for notifying families of skin changes and that on weekends or holidays the unit nurse is responsible for such notifications.
Inaccurate MDS Coding of Resident Skin Conditions and Wounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Minimum Data Set (MDS) assessments accurately reflected a resident’s skin condition and wounds. During an abbreviated survey, it was identified that one sampled resident had cellulitis and multiple wounds documented in hospital discharge records and facility admission notes, but these conditions were not captured on the resident’s MDS assessments. An MDS dated in July 2025 documented no skin problems or pressure ulcers, despite hospital records and a Patient Review Instrument from mid-July 2025 indicating bacteremia with cellulitis, a full-thickness wound on the lower right extremity, and the need for wound care for stasis ulcers. Further record review showed that when the resident was discharged again from the hospital in late December 2025, the hospital discharge summary listed multiple significant wounds, including a Stage III sacral ulcer, deep tissue injuries to the left hip and both heels, an unstageable right hip wound, dry gangrene of toes, black necrosis of the right great toe, and a partial-thickness wound at the left bunion. A nursing admission/readmission note from early January 2026 documented pressure wounds to the sacrum, wounds to both hips, and gangrene to all toes and both heels. However, a wound/skin assessment by the facility’s wound care nurse on January 5, 2026, described only a right hip superficial abrasion, moisture-associated dermatitis to the sacrum, and unremarkable bilateral lower extremities, heels, and feet, which did not correlate with the hospital discharge assessment. An MDS dated January 9, 2025, recorded the resident as having moderately impaired cognition and documented only moisture-associated skin damage in the skin condition section, with no evidence that the unstageable right hip ulcer, gangrenous toes, or left bunion wound were assessed or coded. Interviews with the MDS coordinator revealed that they reviewed the hospital discharge records and were aware of multiple wounds but relied on the wound nurse’s assessment without physically assessing the resident’s skin or reconciling discrepancies between hospital and facility documentation. The MDS director stated that MDS completion is based on assessments documented in the medical record and acknowledged that ulcers in the hospital records may have been overlooked. These actions and inactions resulted in MDS assessments that did not accurately reflect the resident’s actual skin status, contrary to the facility’s MDS Completion Policy and regulatory requirements.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and ensure a safe environment for a resident, resulting in an accident. A resident with severe cognitive impairment, dementia, and anxiety disorder, who was assessed as requiring total dependence on two-person assistance for transfers using a stand pivot technique, was repeatedly transferred by a single Certified Nursing Assistant (CNA) on multiple occasions. The resident's care plan and CNA instructions clearly documented the need for two-person assistance for all transfers between bed and chair. Despite these documented requirements, three different CNAs transferred the resident by themselves over several days, without the required assistance. One CNA admitted to transferring the resident alone both before and after breakfast, and only noticed a discoloration on the resident’s left inner thigh after returning the resident to bed. Another CNA, who was not regularly assigned to the resident, also transferred the resident alone, stating they believed the care plan required only one-person assistance. A third CNA, new to the job, was unaware of how to access the resident’s care instructions and also transferred the resident alone. None of the CNAs reported any immediate difficulty during the transfers, and none observed any falls or trauma at the time. The resident was later observed to have a purplish discoloration on the left inner thigh, and an x-ray revealed an acute intertrochanteric fracture of the left hip. The incident was classified as an injury of unknown origin, as there was no observed fall or trauma. The facility’s policies required staff to review and follow the resident’s plan of care and to provide care in a safe manner, but these were not followed by the involved CNAs, leading to the resident sustaining a significant injury.
Resident Abuse Incident Involving CNA and Ice Cream
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. On the specified date, a Licensed Practical Nurse (LPN) reported to a Registered Nurse Supervisor that a CNA threw a cup of melted ice cream at a resident. The incident was captured on surveillance video, which showed the resident taking a cup of melted ice cream from a medication cart and subsequently throwing it at the CNA. In response, the CNA threw the ice cream back at the resident, resulting in a wet stain on the resident's clothing. The resident involved in the incident was admitted to the facility with diagnoses including Dementia with behavior, Anxiety, and Major Depression. The resident's cognitive impairment was documented, with a score indicating moderate cognitive impairment. A care plan for victimization was in place, which included interventions such as involving the resident in social activities and using a calm approach. Despite these measures, the incident occurred, highlighting a failure in the facility's abuse prevention policy. Interviews with staff members, including the CNA involved, revealed that the CNA admitted to throwing the ice cream back at the resident as a reflex reaction. The facility's investigation confirmed the occurrence of abuse, as the CNA's actions were contrary to the facility's policy prohibiting abuse. The incident was reported to the police, and the facility concluded that abuse had occurred, leading to the suspension and termination of the CNA involved.
Failure to Complete Significant Change Assessment for Resident with Pressure Injuries
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment within 14 days after a significant change in condition was identified for a resident. Specifically, on June 30, 2024, a resident was found to have an unstageable pressure injury to the sacrum and a deep tissue pressure injury to the left heel. Despite this significant change in the resident's condition, the facility did not complete the required assessment within the mandated timeframe. The facility's policy requires that the Minimum Data Set Coordinator determine if a resident has experienced a significant change in condition and, if so, notify the team and proceed with a Significant Change assessment. However, in this case, the Minimum Data Set Coordinator did not complete the assessment, citing a lack of receipt of the wound tracker report from the Wound Care Nurse as a reason for the oversight. The resident, who had diagnoses including stroke, hypertension, and diabetes mellitus, was noted to have severely impaired cognition and no pressure ulcers in a previous assessment, highlighting the significance of the change in condition.
Failure to Report Unwitnessed Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed incident involving a resident who was found on the floor with lacerations to the forehead and nose bridge, which later resulted in a nasal bone fracture. The incident occurred on 07/21/2024, and the resident was sent to the emergency department for evaluation. Despite the injuries sustained, the facility did not report the incident to the New York State Department of Health as required by their policy and state regulations. The policy mandates that all alleged violations involving abuse, neglect, or injuries of unknown source be reported immediately, but not later than 2 hours after the allegation is made. The resident involved had diagnoses of Atrial Fibrillation, Heart Failure, and Benign Prostatic Hyperplasia, and was assessed to have moderately cognitive impairment. The facility's investigation concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred, which led to the decision not to report the incident. However, the Director of Nursing acknowledged that any injury of unknown origin should have been reported within the required timeframe, highlighting a failure to adhere to reporting protocols.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. During a kitchen task observation, it was found that two boxes containing 20 packages of bratwurst were stored beyond their best by date in both the kitchen refrigerator and the freezer in the emergency food area. Interviews with the Patient Food Services Utility Worker and the Chef Manager revealed a lack of awareness regarding expired food items, despite daily rounds being conducted to check for such items. Additionally, potentially hazardous foods were not maintained at an acceptable temperature to limit the growth of pathogens. Observations on the 2nd and 6th floors showed that egg salad and tuna sandwiches were stored at temperatures significantly above the required 41 degrees Fahrenheit. The sandwiches were prepared earlier in the day and were not adequately chilled before being served. Interviews with the Chef Manager and Food Service Director indicated that sandwiches are made daily and placed in the freezer to lower their temperature, but there was no evidence of temperature checks being conducted to ensure compliance with food safety standards.
Failure to Report Unwitnessed Fall Incident
Penalty
Summary
The facility failed to report an unwitnessed incident involving a resident who was found on the floor with lacerations to the forehead and nose bridge, which later resulted in a nasal bone fracture. The incident occurred on 07/21/2024, and the facility did not report it to the New York State Department of Health as required by their policy and state regulations. The policy mandates that all alleged violations involving abuse, neglect, or injuries of unknown source must be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. Resident #132, who has diagnoses of Atrial Fibrillation, Heart Failure, and Benign Prostatic Hyperplasia, was found on the floor beside their bed with injuries. The resident, who has moderately cognitive impairment, could not recall how they ended up on the floor. Despite the injuries and the unwitnessed nature of the fall, the facility concluded that there was no cause to believe abuse, mistreatment, or neglect had occurred and did not report the incident. The Director of Nursing acknowledged that the incident was not reported because it was determined to be a fall, even though it was unwitnessed.
Failure to Complete Significant Change Assessment for Resident with Pressure Injuries
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment within 14 days after a significant change in condition was identified for a resident. Specifically, on June 30, 2024, a resident was found to have an unstageable pressure injury to the sacrum and a deep tissue pressure injury to the left heel. Despite this significant change in the resident's condition, the facility did not complete the required assessment within the mandated timeframe. The facility's policy requires that the Minimum Data Set Coordinator determine if a resident has experienced a significant change in condition and, if so, notify the team and proceed with a Significant Change assessment. However, in this case, the Minimum Data Set Coordinator did not complete the assessment, citing a lack of receipt of the wound tracker report from the Wound Care Nurse as a reason for the oversight. The resident, who had diagnoses including stroke, hypertension, and diabetes mellitus, was noted to have severely impaired cognition and no pressure ulcers in a previous assessment, highlighting the significance of the change in condition.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. During a kitchen task observation, it was found that two boxes containing 20 packages of bratwurst were stored beyond their best by date in both the kitchen refrigerator and the freezer in the emergency food area. Interviews with the Patient Food Services Utility Worker and the Chef Manager revealed a lack of awareness regarding expired food items, despite daily rounds being conducted to check for such items. Additionally, potentially hazardous foods were not maintained at an acceptable temperature to limit the growth of pathogens. Observations on the 2nd and 6th floors showed that egg salad and tuna sandwiches were stored at temperatures significantly above the required 41 degrees Fahrenheit. The sandwiches were prepared earlier in the day and were not adequately chilled before being served. Interviews with the Chef Manager and Food Service Director indicated that sandwiches are made daily and placed in the freezer to lower their temperature, but there was no evidence of temperature checks being conducted to ensure compliance with food safety standards.
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.
Trusted by long-term care providers and associations.
