Clove Lakes Health Care And Rehab Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Staten Island, New York.
- Location
- 25 Fanning Street, Staten Island, New York 10314
- CMS Provider Number
- 335239
- Inspections on file
- 17
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Clove Lakes Health Care And Rehab Center, Inc during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment and adequate supervision for several residents, including one cognitively intact smoker on continuous O2 who repeatedly smoked in their room and entered the smoking area while still on oxygen, without effective intervention by the assigned smoking monitor or documented increases in safety checks or reassessment. Room searches of identified smokers revealed multiple residents with smoking materials and lighters, including residents on continuous O2, yet there was no documented evidence of follow-up smoking safety reassessments. Additionally, a severely cognitively impaired, high fall-risk resident experienced multiple falls with injuries over several months, while incident reports repeatedly recommended increased supervision and frequent checks that were not incorporated into the care plan or consistently documented in CNA task records, and nursing leadership acknowledged that supervision interventions and root cause analysis were lacking.
A resident with COPD requiring continuous O2, diabetes, heart failure, and a high fall risk was not given ordered evening medications, continuous oxygen, hourly safety checks, or a dinner meal over several hours. The assigned RN did not verify the resident’s whereabouts after being told the resident had a visitor, did not administer scheduled meds or ensure O2 use, and only began searching late in the shift, eventually finding the resident unresponsive on the floor beside the bed without oxygen in place. The assigned CNA did not perform ordered hourly checks, did not serve or confirm a dinner tray, and only checked the resident once more around mid-evening, despite care plans and task lists requiring close monitoring. Documentation of the incident omitted that the resident had been unaccounted for for hours, had missed medications, treatments, and a meal, and was not on oxygen when found, while leadership and the MD were not initially informed of these care gaps.
A resident with COPD on continuous O2, diabetes, heart failure, and multiple psychotropic and other meds had no documented administration of ordered medications or oxygen between late afternoon and late evening. The assigned RN assumed the resident was with a visitor, did not verify the resident’s location, did not administer 4 PM, 8 PM, or 9 PM meds, and did not notify the MD or RN supervisor of missed doses. For several hours, nursing and direct care staff were unaware of the resident’s whereabouts, and CNA safety checks and meal documentation stopped mid-afternoon. The resident was later found face down on the floor in the room, unresponsive, without O2 in place; CPR was initiated and EMS pronounced the resident deceased. Incident and nursing documentation did not reflect that the resident had been missing for hours, that medications and O2 were not provided, or that the resident was off oxygen when found, and leadership and the MD reported they were not informed of these facts at the time.
A resident with COPD, diabetes, heart failure, and depression had multiple scheduled medications and continuous O2 at 3 L/min ordered for the evening shift, but an RN did not administer the 4 PM, 8 PM, or 9 PM doses and did not ensure the resident received ordered oxygen, nor did the RN notify a supervisor or MD of the missed doses. The RN assumed the resident was with a visitor, did not verify the resident’s return, and only began looking for the resident later in the shift. The resident was ultimately found on the floor unresponsive without O2 in place, CPR was initiated, EMS assumed care, and the resident was pronounced deceased. Supervisory staff and the MD reported they were not informed during the shift that the resident was missing or that medications and oxygen had not been provided, and records showed no hourly safety checks or medication administration during the relevant period.
The facility failed to prevent neglect of a resident on continuous oxygen and at high fall risk when staff did not perform required hourly safety checks, administer medications, provide the dinner meal, or ensure oxygen therapy for several hours after the resident was noted missing, and leadership (including the DON and Administrator) were unaware for weeks that the resident had been unaccounted for prior to being found unresponsive and later pronounced deceased. The facility also failed to enforce smoking safety policies for residents with unsafe smoking behaviors and oxygen use by limiting smoking assessments to admission only, not reassessing after repeated incidents, not increasing monitoring, allowing residents to retain smoking materials, and not ensuring oxygen was removed before entry into the smoking room, while the Medical Director was not informed of ongoing noncompliant smoking behavior.
The facility failed to ensure accurate MDS coding of current tobacco use for multiple cognitively intact residents who were active smokers. Several residents with conditions such as COPD, pulmonary fibrosis, heart failure, schizophrenia, paraplegia, hypertensive heart disease, epilepsy, and depression were repeatedly observed smoking in the designated smoking room. Each had a signed smoking agreement, a smoking assessment identifying them as smokers, and a care plan addressing smoking in a designated area, yet their admission, annual, or significant-change MDS assessments did not reflect current tobacco use in Section J1300. The MDS Manager reported that Section J1300 is completed by the MDS department using resident assessments, staff interviews, medical record review, and a periodically updated smoking list from recreation, but was not aware of these specific discrepancies.
A resident with COPD, diabetes, and heart failure on continuous O2 was reported to have a visitor in the late afternoon, but an RN did not check on the resident for several hours and later could not locate the resident for medication administration. The resident was subsequently found on the floor unresponsive, with no pulse or respirations, and was pronounced deceased by EMS. Documentation showed no record that the resident was missing for several hours, no notification of the nursing supervisor or MD, and no documentation of dinner, hourly safety checks, or medication administration during that time. An internal investigation concluded the event was a medical incident and found no cause to believe abuse, mistreatment, or neglect had occurred, and the allegation was not reported to the State agency, despite facility policy requiring timely reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment.
A resident with COPD, respiratory failure, diabetes, intact cognition, and on continuous O2 was not checked by an RN for several hours after the RN was told the resident had a visitor. The resident was later found on the floor, face down and unresponsive, and was pronounced deceased by EMS. Facility documentation did not show that the resident was considered missing during the gap in monitoring, nor that a supervisor or MD were notified. The incident report concluded it was a medical event and noted environmental factors and a later-discovered facial skin tear, but omitted key details such as the resident’s reported missing status, the RN’s call to the resident’s family to look for the resident, and the exact position in which the resident was found. The ADON, DON, and Administrator all reported they were not informed of these critical facts until much later and stated that, had they known, the investigation’s conclusion would have been different, demonstrating that the facility failed to conduct a thorough abuse/neglect investigation.
The facility’s assessment failed to include required competencies for Activities staff assigned as smoking monitors. Activities personnel, including a Recreation Transporter, were responsible for assessing residents’ smoking practices and monitoring residents during smoking, including those on oxygen, but the facility-wide assessment did not specify the knowledge, training, or skills needed for safe smoking monitoring and oxygen safety. Although the Administrator reported that new smoking monitors receive training and are evaluated by demonstration, and that smoking was listed as a special care need in the assessment, the document did not detail the actual training requirements for this role, leading to a deficiency related to incomplete evaluation of staff competencies.
A resident with a documented mushroom allergy was served a meal containing mushrooms due to a failure to update dietary records and meal tickets. The resident experienced an allergic reaction, requiring immediate medical intervention. Staff interviews revealed gaps in communication and documentation regarding the allergy, leading to the deficiency.
A facility failed to develop a comprehensive care plan for a resident with macerated skin around the stoma, despite a Nurse Practitioner ordering treatment. The resident, with cognitive impairments and multiple diagnoses, did not have an updated care plan addressing skin issues. Interviews revealed that the responsibility for care plan development and updates was not fulfilled, leading to the deficiency.
A resident with intact cognition and multiple diagnoses was involved in an incident where a CNA roughly pulled incontinent briefs away from them, holding the resident's arm in the process. The resident reported feeling upset, and the facility's investigation was inconclusive. The CNA resigned after viewing the surveillance footage, and the incident was reported to the police. No injuries were reported, but the facility failed to protect the resident from abuse as per their policy.
A facility failed to report a sexual abuse allegation to law enforcement as required by section 1150B of the Act. A visitor observed a resident putting their hand in another resident's pajama pants, but the facility's policy did not include reporting such suspicions to local law enforcement. The facility concluded there was no reasonable suspicion of a crime, as the involved resident denied the allegation and claimed they were helping the other resident with their clothing. The incident involved two residents, one with intact cognition and the other with moderately impaired cognition.
A resident with psychiatric behaviors, including refusing medication and verbal aggression, was not accurately assessed in the MDS 3.0 assessments, despite staff awareness and documentation of these behaviors. The facility's Social Services department, responsible for inputting MDS information, failed to code these behaviors, leading to a deficiency in assessment accuracy.
A facility failed to coordinate PASARR assessments for a resident with a new serious mental disorder diagnosis. Despite exhibiting behaviors such as medication refusal and verbal abuse, the resident was not referred for a PASARR Level II evaluation. The facility's policy lacked procedures for such referrals, and staff interviews revealed awareness of the resident's psychological issues without action taken.
A resident with a history of encephalitis and moderate cognitive impairment did not receive their prescribed anti-seizure medication, Brivaracetam, on multiple occasions due to it not being available. The facility failed to notify the physician and did not reorder the medication in a timely manner, despite having a system in place to signal when a refill is needed. Interviews with nursing staff revealed a lack of communication and follow-up, contributing to the lapse in medication administration.
A resident with a thyroid disorder did not receive Levothyroxine Sodium at the prescribed time due to medication storage issues, leading to late administration on multiple occasions. The resident, who is cognitively intact, reported the issue, and staff interviews revealed that the medication was often missed by the night nurse due to its unusual packaging.
A resident did not receive Brivaracetam, a seizure medication, due to unavailability, and the physician was not notified. The resident, with a history of encephalitis and other conditions, missed doses on multiple occasions. Nursing staff failed to reorder the medication timely and did not communicate effectively, leading to a significant medication error.
A resident with End Stage Renal Disease and Hyperlipidemia, who primarily speaks Cantonese, was not provided with appropriate communication tools or interpreter services, leaving them unable to fully understand their health status. Despite the facility's policy to provide interpretive services, staff relied on simple English words and gestures, which the resident did not fully understand. Interviews revealed a lack of awareness and implementation of available communication resources.
Two residents in an LTC facility did not have comprehensive care plans developed and implemented to address their specific medical needs. One resident, with multiple diagnoses and on hemodialysis, antipsychotic, and anticoagulant medications, lacked care plans for these treatments. Another resident, identified as a smoker, did not have a smoking care plan despite being observed smoking. The facility's failure to create these care plans was acknowledged by staff as an oversight.
A facility failed to update comprehensive care plans for two residents, one with outdated Advance Directives and another with unreviewed plans for physical restraints and tracheostomy. The facility's policy requires quarterly reviews, but these were not conducted, leading to care plans that did not reflect the residents' current medical needs.
A resident with respiratory failure was administered an expired Serevent Diskus inhalation device due to the facility's lack of policy on checking medication expiration dates. The medication, delivered by a vendor pharmacy, was expired upon receipt and administration. An LPN acknowledged the oversight, and the DON confirmed the absence of a procedure for verifying expiration dates.
Failure to Ensure Smoking Safety and Fall Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents, particularly related to smoking safety and fall prevention. One cognitively intact resident with COPD and pulmonary fibrosis was identified as a smoker, had a physician’s order for continuous oxygen via nasal cannula, and a care plan indicating they would smoke safely in a designated area with supervision. Despite this, nursing notes documented three separate incidents in which this resident smoked in their room, including while oxygen was in use, and staff confiscated cigarettes and a lighter. On another occasion, the resident was observed entering the designated smoking room while still on oxygen, and the assigned smoking monitor did not stop the resident or remove the oxygen. The facility’s own smoking policy required staff to intervene when residents smoked in non-designated areas, remove smoking materials, and conduct searches, but there was no evidence of increased safety checks or reassessment for safe smoking after these repeated unsafe behaviors. The facility also failed to reassess and document safe smoking practices for multiple other residents after contraband smoking materials were discovered. During room searches of all identified smokers, 19 residents were found with smoking materials, and four residents were found with lighters. Two of these residents also had continuous oxygen orders. There was no documented evidence that these four residents received a smoking reassessment for safe smoking after the lighters were found. The report states that these circumstances subjected all 565 residents in the facility to the likelihood of serious adverse outcomes that constituted Immediate Jeopardy. In addition, the facility did not provide adequate supervision and interventions for a resident at high risk for falls who had severe cognitive impairment and a history of multiple falls. This resident had a documented high fall risk and required supervision or touching assistance for bed mobility and transfers, and could ambulate short distances. Between late August and late February, the resident experienced seven fall incidents, three of which resulted in injuries including lacerations and a hospital visit for suturing of a facial laceration. Incident reports repeatedly recommended increased supervision and frequent checks, and one incident recommended observation near the nurse’s station and another recommended frequent observation every 30 minutes. However, the comprehensive care plans for actual falls and the fall-risk care plan did not include specific interventions for increased or defined supervision, and task lists and CNA documentation often lacked evidence of the recommended monitoring. Nursing supervisors and the DON acknowledged that supervision frequency was not reflected in the care plan, that new interventions were not added after falls, and that no formal root cause analysis was conducted for the repeated incidents.
Resident Neglect Due to Missed Medications, Oxygen, Supervision, and Meal Leading to Unresponsive Event
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not providing ordered medications, continuous oxygen, supervision, and meals during an evening shift. The resident had chronic obstructive pulmonary disease requiring continuous oxygen at 3 L/min via nasal cannula, diabetes mellitus, heart failure, and major depressive disorder, and was cognitively intact but required supervision/touching assistance with activities of daily living. The resident was assessed as high risk for falls, had a history of falls, and had a care plan that included hourly visual safety checks, anticipation of needs, ensuring the call light was within reach, and providing physical and emotional support for safety. Physician orders included multiple scheduled medications and inhalers for COPD, diabetes, depression, and other conditions, with doses due at 4:00 PM, 8:00 PM, and 9:00 PM on the evening shift. On the date of the incident, the Medication Administration Record showed no documented evidence that any of the resident’s scheduled medications or treatments were administered between 4:00 PM and 9:00 PM. The Task List for CNAs showed the resident was to receive hourly visual checks for safety, but there was no documentation of hourly monitoring from 2:45 PM to 9:40 PM. The nutritional intake form also showed no evidence that the resident was served a meal or snack between 2:45 PM and 9:40 PM, and the visitor log contained no record of any visitor for the resident during that time. Despite the resident’s order for continuous oxygen, when the resident was later found, staff observed that the resident was not connected to oxygen. Registered Nurse (RN) #1 reported arriving on the unit at 4:15 PM and not seeing the resident during rounds, stating they had been told the resident had a visitor, but they did not verify the resident’s whereabouts and continued working without locating the resident. RN #1 did not administer the resident’s scheduled medications and did not ensure the resident received continuous oxygen. RN #1 stated they began looking for the resident around 9:40 PM, briefly checked the room, did not see the resident, and at approximately 9:43 PM called the resident’s adult child to ask if the resident had left with them. RN #1 then contacted the nursing supervisor to report the resident could not be located and subsequently found the resident at 9:49 PM lying face down on the floor beside the bed, unresponsive, with no pulse and no breathing. Certified Nursing Assistant (CNA) #1, assigned to the resident from 3:00 PM to 11:00 PM, stated they saw the resident in the room sitting on the bed at about 3:30 PM and did not see any visitor present. CNA #1 acknowledged they did not perform the ordered hourly safety checks and that the second time they checked on the resident was around 8:30 PM, when the resident was in the room and stated they were okay. CNA #1 also stated they did not serve a dinner tray to the resident because they were serving residents on the other side of the unit, did not know if the resident ate, and did not ask another CNA whether the resident had received a meal, despite being responsible for checking and documenting meal intake. Supervisory and leadership staff, including the RN supervisors, Infection Control Director, Director of Nursing, Administrator, and Medical Director, later confirmed they were not initially informed that the resident had been considered missing for several hours, had not received scheduled medications, treatments, or a meal, and that these facts were not documented in the incident report, which instead concluded the event appeared related to a medical event and that there was no cause to believe neglect had occurred. At 9:49 PM, the resident was found unresponsive on the floor beside the bed with no measurable vital signs, and CPR was initiated until EMS arrived at 10:07 PM and assumed care. The nursing progress note documented that the resident was found unresponsive with no pulse and no breathing, a STAT call was made, oxygen via nonrebreather mask at 15 L/min was applied, 911 was called, and IV fluids were started. EMS pronounced the resident expired at 10:24 PM. The Accident/Incident Investigation form documented that the call bell was within reach but had not been activated, the bed was in the lowest and locked position, and the floor was clean and dry. It also documented that the interdisciplinary team determined there was no cause to believe abuse, mistreatment, or neglect had occurred, and omitted that the resident had been unaccounted for from 4:15 PM to 9:48 PM, had not received evening medications, was not on oxygen when found, and that the nursing supervisor and physician were not notified of these circumstances at the time of the incident. During postmortem care, staff observed a large skin tear on the resident’s right cheek, described by the adult child as skin peeled off that looked like a burned skin injury. The adult child reported being called by RN #1 at about 9:43 PM and told the resident was missing, and then receiving another call that the resident had been found unresponsive beside the bed. The adult child stated that when they arrived, they were told the resident had expired at 10:24 PM and that a nurse supervisor attributed the facial injury to EMS. RN Supervisor #1 and RN Supervisor #2 both confirmed they responded to a report that the resident could not be found, but by the time they reached the unit, the resident had already been located on the floor unresponsive, and one supervisor noted that the resident was not connected to oxygen. The facility’s own policies defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required accident investigations and care plan revisions as needed, but the investigation documentation did not reflect the prolonged lack of monitoring, missed medications, missed meal, and absence of continuous oxygen that occurred prior to the resident being found unresponsive.
Failure to Administer Ordered Medications, Maintain Continuous Oxygen, and Monitor Resident Whereabouts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality for one resident with multiple chronic conditions, including COPD requiring continuous oxygen, diabetes mellitus, heart failure, major depressive disorder, and use of antipsychotic, antidepressant, and hypoglycemic medications. Physician orders directed that the resident receive multiple scheduled medications between 4:00 PM and 9:00 PM, including inhaled medications for COPD, Metformin for diabetes, Sertraline, Varenicline, Atorvastatin, Quetiapine, Trazodone, and continuous oxygen at 3 L/min via nasal cannula. The facility’s own policies required medications to be administered as ordered within one hour before or after the scheduled time, with documentation of administration or refusal, and prompt reporting and documentation of medication errors and physician notification. On the evening in question, the Medication Administration Record for the 3:00 PM–11:00 PM shift showed no evidence that any of the resident’s scheduled medications or continuous oxygen treatment were administered between 4:00 PM and 9:00 PM. RN #1, who was responsible for the resident’s care during that shift, stated they arrived on the unit at 4:15 PM, did not see the resident during rounds, and were told by unknown staff that the resident had a visitor. RN #1 reported they did not look for the resident, assuming the resident was with the visitor, and acknowledged that the 4:00 PM medications were not given for that reason. RN #1 further stated they were aware that the 4:00 PM, 8:00 PM, and 9:00 PM medications were not administered and did not recall notifying the RN supervisor or the physician, despite knowing they were required to do so when medications were not given. From approximately 4:15 PM until 9:49 PM, nursing and direct care staff were unaware of the resident’s whereabouts. The CNA accountability record for the 3:00 PM–11:00 PM shift contained no hourly safety checks or meal documentation for the resident after 2:45 PM. At about 9:49 PM, the resident was found on the floor beside the bed, face down, unresponsive, with no pulse and no respirations, and not connected to any oxygen source. A stat was called, CPR was initiated, and EMS arrived at 10:07 PM and later pronounced the resident deceased at 10:24 PM. The incident report and nursing progress note did not document that the resident had been missing for several hours, that staff were unaware of the resident’s whereabouts from 4:15 PM to 9:49 PM, that no 4:00 PM, 8:00 PM, and 9:00 PM medications were administered, or that the resident was not on oxygen when found. The Medical Director, DON, Administrator, and attending physician all reported they were not informed at the time that the resident had been missing for hours or that the evening medications and continuous oxygen had not been provided, and the Medical Director stated they did not review the chart and were not made aware of the missed medications until days later. The facility’s investigation documentation concluded the incident appeared related to a medical event and initially indicated there was no cause to believe abuse, mistreatment, or neglect had occurred. However, the investigation form did not include the fact that the resident’s whereabouts were unknown for several hours, that the resident did not receive ordered medications and treatments during the evening shift, or that the resident was not connected to oxygen when found. Supervisory nursing staff who responded to the emergency confirmed that when they arrived, the resident was already on the floor unresponsive and that no oxygen was connected. The Medical Director and other leadership staff stated they were not made aware that the resident had been missing or that medications and treatments were not administered as ordered during the relevant time period. These omissions in monitoring, medication administration, treatment provision, and timely, accurate reporting and documentation formed the basis of the cited deficiency under 10 NYCRR 415.11(c)(3)(i).
Failure to Administer Ordered Medications and Oxygen or Monitor Resident Whereabouts
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and received ordered oxygen therapy as prescribed. The resident had diagnoses including COPD, diabetes mellitus, heart failure, and major depressive disorder, and was ordered multiple medications, including inhaled bronchodilators and steroids, metformin, sertraline, varenicline, atorvastatin, quetiapine, trazodone, and continuous oxygen at 3 L/min via nasal cannula. The facility’s own policies required medications to be administered as ordered within one hour before or after the scheduled time, with documentation of administration or reasons for omission and physician notification, and required that significant medication errors be reported as soon as recognized. On the date in question, the resident was scheduled to receive medications at 4:00 PM, 8:00 PM, and 9:00 PM on the 3:00 PM–11:00 PM shift, but the Medication Administration Record showed no evidence that any of these medications or the ordered continuous oxygen were provided. RN #1 reported arriving on the unit at 4:15 PM, not seeing the resident during rounds, and being told by unknown staff that the resident had a visitor. RN #1 did not look for the resident at that time and continued working on the unit, did not verify the resident’s return, and did not administer the 4:00 PM medications within the allowed time frame. RN #1 acknowledged being aware that the 4:00 PM, 8:00 PM, and 9:00 PM medications were not given and did not recall notifying the nursing supervisor or the physician, despite knowing this was required. RN #1 stated they began looking for the resident at about 9:40 PM and briefly checked the resident’s room without finding them. At 9:49 PM, the resident was found on the floor, face down, unresponsive, with no pulse and no breathing; CPR was initiated and EMS was called, and the resident was pronounced expired at 10:24 PM. Supervisory staff reported they were not aware during the shift that the resident had missed scheduled medications or that the resident had been missing for several hours. The Medical Director and the resident’s attending physician both stated they were not informed at the time that the resident had been missing or that medications from 4:00 PM through 9:00 PM had not been administered, and the Medical Director stated they could not opine whether missing one cycle of medications caused the resident’s collapse and death. The DON confirmed there was no documentation of hourly safety checks or meal consumption for the resident after 2:45 PM and no medications administered from 4:00 PM to 9:49 PM.
Failure to Prevent Resident Neglect and Enforce Smoking Safety Policies
Penalty
Summary
The deficiency involves the facility’s failure to administer operations in a way that ensured residents were free from neglect and that required systems for monitoring and care were functioning. For one resident with continuous oxygen use and a high fall risk, staff became aware around 4:15 PM that the resident could not be located on the unit, yet the facility did not ensure required hourly safety checks, medication administration, oxygen therapy, or provision of the dinner meal from approximately 4:00 PM to 9:00 PM. There was no timely staff communication, physician notification, or escalation of concern despite the resident not being seen for several hours. The resident was later found unresponsive on the floor at 9:49 PM, a STAT call was made, CPR was initiated, EMS took over, and the resident was pronounced deceased at 10:24 PM. The report notes that the DON recalled learning of the event through a hospitalization group chat message sent between 2:00 AM and 3:00 AM, which stated that the resident had been found unresponsive on the floor the prior evening. The DON stated they were not informed that the resident had been reported missing prior to being found and only became aware weeks later that the resident had reportedly been missing for several hours before discovery. The DON also stated that the Infection Control Director knew the resident had initially been reported missing, but this was not discussed in the morning meeting. The Administrator similarly reported first learning of the incident via a hospitalization group chat message after midnight and was unaware that the resident had been reported missing, had not been monitored hourly, had no documented dinner intake, and had not received medications between 4:00 PM and 9:00 PM. A second deficiency concerns the facility’s failure to enforce smoking safety policies for residents with known unsafe smoking behaviors and oxygen use. The Director of Recreation stated that smoking assessments were conducted only upon admission, not reassessed after repeated smoking incidents, and that they continued to provide education without clearly identifying further interventions. The Director of Recreation indicated that a smoking monitor should have removed oxygen before a resident on oxygen entered the smoking room and that residents should not have smoking materials, yet residents were found with such materials, which were then confiscated. The DON stated that one resident on hourly safety checks was not reassessed for safe smoking after each incident and that monitoring frequency was not increased despite repeated noncompliance. The DON also stated they were unaware that other residents had smoking materials or that there were smoking issues until surveyors arrived. The Medical Director reported not knowing about the resident’s noncompliant smoking behavior, acknowledged that smoking in a room with continuous oxygen is dangerous, and could not determine whether the resident was a safe smoker.
Failure to Accurately Code Current Tobacco Use on MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected residents’ current tobacco use status, as required by facility policy and regulation. The facility’s policy on Accuracy of Assessment, last reviewed in October 2025, required that assessments be accurate and based on direct observation and communication with residents and staff on all shifts. Despite this, surveyors found that for five cognitively intact residents, the MDS Section J1300 (Current Tobacco Use) did not document that these residents were active smokers. For one resident with COPD, benign prostatic hyperplasia, and diabetes, surveyors observed the resident smoking in the designated smoking room on multiple occasions. The resident had a signed Smoking Regulation Agreement identifying him as a smoker, a smoking assessment documenting smoking status, and a care plan titled “Known Smoker” directing that he smoke safely in the designated area. However, his annual MDS dated 12/29/2025 did not indicate current tobacco use in Section J1300. Another resident with COPD, pulmonary fibrosis, and testicular cancer was repeatedly observed smoking in the smoking room, had a signed Smoking Regulation Agreement, a smoking assessment, and a “Known smoker” care plan, and a nursing note documented that he was found smoking in his room while on oxygen. His annual MDS also failed to document current tobacco use in Section J1300. Similarly, three additional residents with diagnoses including hypertension, schizophrenia, paraplegia, heart failure, chronic pancreatitis, hypertensive heart disease, epilepsy, and depression were each observed smoking in the smoking room on multiple occasions. Each had a signed Smoking Regulation Agreement identifying them as smokers, a smoking assessment documenting smoking status, and a care plan titled “Known Smoker” indicating they would smoke safely in the designated smoking area. For these residents, their admission, annual, or significant change MDS assessments, all of which documented them as cognitively intact, did not record current tobacco use in Section J1300. In an interview, the MDS Manager stated that Section J1300 was completed by the MDS department using resident assessments, staff interviews, and medical record review, and that a smoking list was obtained from the recreation department about every two weeks, but acknowledged unawareness of the discrepancies for these residents.
Failure to Report Alleged Abuse/Neglect After Resident Found Unresponsive and Deceased
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving potential abuse, neglect, or mistreatment, as required by policy and 10 NYCRR 415.4(b)(1)(i). The facility’s policy required all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property to be reported immediately, but not later than two hours if abuse or serious bodily injury was involved, or within 24 hours otherwise, to the New York State Department of Health. Despite this policy, the facility did not report an allegation related to a resident who was missing for several hours and later found unresponsive and pronounced deceased. The resident involved had diagnoses including COPD, diabetes mellitus, and heart failure, and was receiving continuous oxygen. The resident’s MDS documented intact cognition and a need for supervision/touching assistance with ADLs, and the care plan for risk of abuse/neglect included interventions to allow the resident to express fear or anxiety and to provide physical and emotional support for safety. On the day of the incident, an RN arrived on the unit at 4:15 PM and was informed by staff that the resident had a visitor. The RN did not check on the resident until 9:40 PM, at which time the resident could not be located for medication administration. At 9:49 PM, the resident was found on the floor, face down, unresponsive, with no pulse or breathing, and was later pronounced expired by EMS at 10:24 PM. Record review showed no documentation that the resident was missing from 4:15 PM until 9:48 PM, and no documentation that the nursing supervisor or physician were notified. The Accident/Incident Investigation form documented that the incident appeared related to a medical event, with the resident found on the floor beside the bed, no measurable vital signs, and no visible injuries on initial assessment, though a large skin tear on the right cheek was noted during postmortem care. The call bell was within reach but not activated, the bed was in the lowest locked position, and the room floor was clean and free of clutter. The interdisciplinary team concluded there was no cause to believe abuse, mistreatment, or neglect had occurred, and therefore the allegation was not investigated or reported to the Department of Health. Subsequent interviews with the DON and Administrator revealed they were not made aware that the resident had been initially missing, not monitored hourly, and had no documented dinner or medications during the 4:00 PM–9:00 PM period, and that this information had been left out of the initial investigation, contributing to the failure to report the allegation.
Failure to Thoroughly Investigate Resident Death and Missing Status
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an alleged incident of possible abuse, neglect, or mistreatment related to a resident’s death. The facility’s abuse/neglect policy required that all alleged or suspected incidents be thoroughly investigated, documented, and reported. On the date of the incident, a registered nurse (RN) arrived on the unit at 4:15 PM and was informed by staff that the resident had a visitor. The RN did not check on the resident again until 9:40 PM when attempting to administer medications and was unable to locate the resident. At 9:49 PM, the resident was found on the floor, face down, unresponsive, with no pulse and no respirations, and was later pronounced deceased by Emergency Medical Services. The resident had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and diabetes mellitus, with intact cognition and a need for supervision/touching assistance with ADLs, and was on continuous oxygen therapy. Nursing progress notes and the accident/incident investigation form showed no documentation that the resident was missing between 4:15 PM and 9:48 PM, and there was no evidence that the nursing supervisor or physician were notified during that period. The accident/incident form concluded the event appeared related to a medical event and documented that the resident was found lying on the floor beside the bed, unresponsive, with no measurable vital signs, and that CPR and EMS were initiated. It also documented that the call bell was within reach but not activated, the bed was in the lowest locked position, the floor was clean and dry, and that no visible injuries were initially noted, although a large skin tear on the right cheek was later observed during postmortem care. Interviews revealed that key information about the incident was not included in the investigation or communicated to leadership. The Assistant DON, who was responsible for incident completion and accuracy, stated they first learned from the incident report and a statement the next day and that it was their first time hearing that the resident had been reported missing, that the adult child had been called by the RN to look for the resident, and that the position in which the resident was found on the floor should have been included. The DON stated they were not notified that the resident had been reported missing prior to being found and only learned this information the day before the interview; they also noted that the facial injury and explanation that it may have occurred during EMS intubation attempts were not documented in the nursing notes. The Administrator similarly reported first learning of the incident via a hospitalization chat after midnight and was not aware that the resident had been initially missing, not monitored hourly, had no record of dinner intake, and had not received medications between 4:00 PM and 9:00 PM, or that the RN had contacted the adult child and RN supervisor about the resident being missing. Leadership stated that, had all this information been known and investigated, the conclusion of the investigation would have been different, demonstrating that the facility did not conduct a thorough investigation into how the resident was found unresponsive.
Failure to Include Smoking Monitor Competencies in Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that evaluated staff competencies necessary to meet resident needs, as required by regulation. Surveyors found that the facility’s assessment, dated 09/2025, did not include the specific knowledge, training, and skills required for Activity Aides who were assigned to monitor residents who smoke. Although the facility’s policy and assessment referenced identifying resident acuity levels, providing continuous care through consistency, and basing staffing plans on resident population and needs, the assessment did not address competencies related to safe smoking monitoring and oxygen safety for the Activities staff who were functioning as smoking monitors. During the abbreviated survey, it was determined that one of four smoking monitors lacked documented evaluation of competencies necessary to provide the level and type of care needed for residents who smoke. The facility had designated Activities staff, including a Recreation Transporter, to assess residents’ smoking practices and to monitor residents during smoking activities, including residents using oxygen. In an interview, the Administrator stated that newly hired smoking monitor staff receive specific training and are evaluated by demonstration on proper monitoring of residents in the smoking room and residents with oxygen, and that noncompliant resident smoking behavior prompts ongoing staff re-education. The Administrator also stated that smoking was identified as a special care need in the facility assessment and referenced under other special needs and services related to buildings, but acknowledged that the assessment did not elaborate on the actual training required for safe smoking monitoring, resulting in a deficient facility assessment under 10 NYCRR 415.5(h)(2).
Failure to Accommodate Documented Food Allergy Results in Resident Reaction
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to mushrooms was served a meal containing mushrooms. The resident's medical records, including the Minimum Data Set, dietary assessment, care plan, and physician orders, all indicated an allergy to mushrooms. However, the resident's meal tickets did not reflect this allergy, and the resident was served chicken with mushrooms hidden underneath, which led to the resident consuming the allergen. Following the ingestion, the resident experienced an allergic reaction, including a red rash on both arms, swelling of the lips, and tingling of the tongue. Nursing staff responded by administering Solumedrol and Benadryl as ordered by a physician. The incident was observed and documented by multiple staff members, who confirmed the presence of mushrooms on the resident's tray and the resident's symptoms after eating the meal. Interviews with facility staff revealed inconsistencies in the communication and documentation of the resident's allergy. The dietician stated that the allergy was not initially reported and that the meal ticket was only updated after the incident. The electronic medical record system did not generate an alert for the allergy, and the dietary supervisor was responsible for ensuring meal tickets matched resident needs. Despite the care plan and orders indicating a mushroom allergy, the failure to update the meal ticket and communicate the allergy resulted in the resident being served an unsafe meal.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which was evident during an abbreviated survey. The deficiency was identified for a resident who was noted with macerated skin around the stoma. Despite the Nurse Practitioner evaluating the resident and ordering Maalox suspension to be applied to the affected area, there was no documented evidence of a care plan being developed to address this issue. The facility's policy on Comprehensive Person-Centered Care Planning requires the development of an individualized interdisciplinary care plan based on Care Area Assessment, but this was not adhered to in this case. The resident, who was admitted with diagnoses including malignant neoplasm of the colon, ileostomy, and diabetes, also had documented short and long-term memory problems and severely impaired cognitive decision-making. Despite these conditions, the care plan was not updated when the resident was noted with maceration around the stoma and later with a rash on the abdomen. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed that the responsibility for developing and updating the care plan was not fulfilled, leading to the deficiency.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by a nursing home staff member. The incident involved a resident with diagnoses including Hypertensive Heart Disease, Chronic Kidney Disease, and Depression, who had intact cognition. On the specified date, surveillance footage captured a Certified Nursing Assistant (CNA) roughly pulling incontinent briefs away from the resident, who was seated in a wheelchair in the hallway. The CNA was seen holding the resident's arm while attempting to retrieve the briefs, which the resident was reluctant to relinquish. The facility's policy on abuse prevention, last updated in November 2022, mandates that residents must not be subjected to abuse by anyone, including staff. Despite this, the incident occurred, and the resident reported feeling upset and expressed a desire to retaliate physically against the CNA, although no injuries or pain were reported. The facility's investigation into the incident was inconclusive, and the CNA involved resigned after being shown the surveillance footage. The incident was reported to the police, and the facility conducted interviews with other residents, who reported no issues with the CNA. The Director of Nursing reviewed the video and confirmed the physical contact between the CNA and the resident. Despite the lack of visible injuries, the incident highlights a failure in the facility's duty to protect residents from abuse, as outlined in their policies.
Failure to Report Sexual Abuse Allegation to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility did not report a sexual abuse allegation involving two residents to local law enforcement. On February 18, 2024, a visitor reported to a Certified Nursing Assistant (CNA) that they observed one resident putting their hand in another resident's pajama pants. The facility's policy did not include reporting such suspicions to local law enforcement, and the incident was not reported to them. The facility's investigation concluded there was no reasonable suspicion of a crime, as the resident involved denied the allegation and claimed they were helping the other resident with their clothing. The incident involved two residents, one with intact cognition and the other with moderately impaired cognition due to dementia and depressive disorder. The CNA who witnessed the incident immediately intervened and reported the situation to a nurse. The Director of Nursing stated that there was no evidence to support that sexual abuse had occurred, and the resident with impaired cognition could not recall the incident. The facility's policy required reporting suspicions of crimes resulting in serious bodily injury within two hours and those without injury within 24 hours, but it did not address reporting to law enforcement, leading to the deficiency.
Inaccurate MDS Assessments for Resident with Psychiatric Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessments accurately reflected the psychiatric behaviors of a resident, leading to a deficiency in assessment accuracy. The resident, who was admitted with diagnoses including a fracture, anxiety disorder, and depression, exhibited numerous psychiatric behaviors such as refusing medication, hiding medications, calling the police, talking to themselves, and displaying agitated and verbally abusive behavior. Despite these behaviors being documented in behavior notes and a psychiatric assessment diagnosing the resident with psychosis, the MDS assessments consistently failed to reflect these behaviors, indicating a significant oversight in accurately assessing the resident's status. Interviews with facility staff, including registered nurses, a certified nursing assistant, and the Director of Nursing, confirmed that the resident's behaviors were well-known and frequently discussed in staff meetings. The MDS Coordinator and the Director of Social Services acknowledged that the Social Services department was responsible for inputting MDS information related to mood and behavior, yet the behaviors were not coded in the assessments. This oversight suggests a breakdown in communication and documentation processes within the facility, as the staff were aware of the resident's behaviors but failed to ensure they were accurately reflected in the MDS assessments.
Failure to Coordinate PASARR Assessments for Resident with Serious Mental Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident with a new diagnosis of a serious mental disorder. Specifically, a resident who was admitted with diagnoses including a fracture, anxiety disorder, and depression, later exhibited behaviors indicative of a serious mental illness. Despite these behaviors, which included medication refusal, agitation, and verbal abuse, the facility did not refer the resident for a PASARR Level II evaluation. The facility's policy did not include procedures for referring residents with new serious mental health diagnoses for such evaluations. The resident's psychiatric condition was documented in multiple behavior notes and a psychiatric assessment, which diagnosed the resident with psychosis. Despite this, the facility did not conduct a PASARR Level II screen, as the Director of Social Services stated that such screens are only completed if a resident is transferred to a psychiatric hospital. Interviews with staff revealed awareness of the resident's psychological issues, yet no referral was made, highlighting a gap in the facility's process for handling psychiatric changes in residents.
Failure to Administer Seizure Medication as Ordered
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the case of a resident who did not receive their prescribed anti-seizure medication, Brivaracetam, in accordance with the physician's orders. The resident, who had a history of encephalitis, non-traumatic brain dysfunction, respiratory failure, and tracheostomy status, was moderately cognitively impaired. The medication was not administered on 10 out of 36 occasions due to it not being available, and there was no documented evidence that the physician was notified of this issue. The facility's policy requires that any medication not administered be documented, including the reason and physician notification, which was not adhered to in this case. Interviews with nursing staff revealed a lack of communication and follow-up regarding the medication's unavailability. The Registered Nurse Supervisor acknowledged that the physician should have been notified and that the medication should have been reordered before the supply was depleted. Despite a system in place to signal when a refill is needed, the medication was not reordered in a timely manner, leading to a lapse in administration. The Director of Nursing stated that all staff are responsible for reordering medications, but this responsibility was not fulfilled, resulting in the resident missing their medication for several days.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This deficiency was identified for a resident with a diagnosis of Hyperlipidemia and Thyroid Disorder, who had a physician's order to administer Levothyroxine Sodium at 6 AM daily. However, the medication was administered late on multiple occasions, sometimes as late as 1 PM, contrary to the facility's policy and the physician's order. The resident, who is cognitively intact, expressed concerns about the late administration of the medication and reported the issue to the Department of Health. Interviews with staff revealed that the medication was often missed by the night nurse because it was stored in an orange container rather than the usual blister pack, leading to confusion and delays. The Day shift Registered Nursing Supervisor and other staff members were aware of the issue and attempted to administer the medication as soon as they were informed of the oversight. Despite these efforts, the medication was not consistently given at the prescribed time, resulting in a failure to meet the resident's needs as per the professional standards of practice.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Brivaracetam, a medication for seizures. The resident, who had a history of encephalitis, non-traumatic brain dysfunction, respiratory failure, and tracheostomy status, did not receive the medication as ordered by the physician due to its unavailability. The Medication Administration Record indicated that on 10 out of 36 occasions, the medication was not administered, and there was no documented evidence that the physician was notified about the unavailability of the medication. Interviews with nursing staff revealed a lack of communication and follow-up regarding the medication's availability. A family member reported the absence of the anti-seizure medication for three days, and the nursing staff acknowledged the oversight in notifying the physician and reordering the medication in a timely manner. The Director of Nursing stated that medications should be reordered when supplies are running low, but this protocol was not followed, leading to the deficiency.
Failure to Provide Language-Appropriate Communication for Resident
Penalty
Summary
The facility failed to ensure that a resident was fully informed of their health status in a language they understood, as required by their policy. This deficiency was identified during a recertification survey, where it was observed that a resident with End Stage Renal Disease and Hyperlipidemia, who primarily speaks Cantonese, was not provided with appropriate communication tools or interpreter services. Despite the facility's policy to provide interpretive services and communication boards, the resident was left to communicate with staff using simple English words, body language, and gestures, which they did not fully understand. Interviews with staff revealed a lack of awareness and implementation of available communication resources. A Certified Nurse Aid admitted to not using a communication board for the resident, and a Registered Nurse Manager was unaware of the communication tools available. The facility's administrator acknowledged the importance of using interpreters and mentioned alternative solutions like Google translator and phone services, but these were not effectively utilized for the resident in question. The oversight in providing necessary communication support led to the resident not being fully informed of their health care status.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in meeting their specific medical needs. Resident #147, who was admitted with multiple diagnoses including anemia, hypertension, renal failure, and bipolar disorder, was on hemodialysis, antipsychotic, and anticoagulant medications. Despite these complex medical needs, the facility did not have documented care plans for hemodialysis, psychotropic medications, or anticoagulant therapy. This oversight was confirmed by the Registered Nurse Manager, who acknowledged the absence of these care plans and could not provide an explanation for the omission. Similarly, Resident #391, who was admitted with conditions such as asthma, COPD, and tobacco use, did not have a care plan addressing their smoking habits. The resident was observed smoking in the designated smoking room, and this behavior was documented by the recreation staff. However, the care plan for smoking was not initiated upon admission or after the smoking assessment, as confirmed by the Director of Nursing. The lack of a smoking care plan was attributed to an oversight, despite the resident being compliant with the facility's smoking rules. The deficiencies highlight a failure in the facility's process for developing and updating care plans to address residents' specific needs. Both the Registered Nurse Manager and the Director of Nursing acknowledged the lapses in care planning, which were not rectified despite previous discussions about care plan delays. The facility's policy requires individualized care plans with measurable objectives, but these were not implemented for the residents in question, leading to the identified deficiencies.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised to reflect the current status of residents, as evidenced during a recertification and complaint survey. Specifically, one resident's care plan related to Advance Directives was not updated to reflect a change in orders from Full Code to Do Not Resuscitate and trial of non-invasive intubation and mechanical ventilation. This oversight was acknowledged by the social worker responsible for updating the care plans, who admitted that the care plan should have been revised and documented in the progress notes. Another deficiency was identified for a resident whose care plans related to physical restraints and tracheostomy were not reviewed and revised after the completion of the Minimum Data Set Assessment. The care plans had not been updated since February 2024, despite the requirement for quarterly reviews and updates when there are changes in the resident's condition. The Registered Nurse Supervisor and Director of Nursing both confirmed that care plans should be reviewed quarterly and updated as needed, but this was not done for the resident in question. The facility's policy on Comprehensive Person-Centered Care Planning mandates that care plans be reviewed and updated at least quarterly or as needed. However, the survey revealed that this policy was not adhered to, resulting in outdated care plans that did not accurately reflect the residents' current medical directives and needs. This lack of timely updates in care plans could potentially impact the quality of care provided to the residents.
Expired Medication Administered Due to Lack of Expiration Date Checks
Penalty
Summary
The facility failed to ensure that medications provided by the pharmacy were not expired, as evidenced by the delivery and administration of an expired Serevent Diskus inhalation device to a resident. The resident, who was admitted with acute and chronic respiratory failure with hypoxia, was prescribed the inhalation device for shortness of breath. The medication, which had an expiration date of September 2024, was delivered and opened for administration in October 2024. The facility's policy on medication administration did not include procedures for checking expiration dates before accepting or administering medications. During the survey, it was observed that a Licensed Practical Nurse retrieved the expired medication from the medication cart, and upon interview, stated that the error was due to a pharmacy mistake. The nurse acknowledged the responsibility of checking expiration dates before administration but noted that the nurse who received the medication likely assumed the pharmacy would not send expired medications. The Director of Nursing confirmed that the facility did not have a policy for checking expiration dates upon receipt and that medications were delivered directly to the floor by the pharmacy. The Vendor Pharmacy Supervising Pharmacist was informed of the issue and stated that both the pharmacy technician and pharmacist are required to check expiration dates, but could not confirm if their policy was followed in this instance.
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.
