Colonial Park Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rome, New York.
- Location
- 950 Floyd Avenue, Rome, New York 13440
- CMS Provider Number
- 335233
- Inspections on file
- 21
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Colonial Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not consistently provide accurate, palatable meals at proper temperatures. Six residents reported that their food was often cold and did not match the meal tickets. During two observed lunch meals, one resident received hot and cold items measured outside the facility’s required temperature ranges, and another resident’s original tray was missing multiple ordered food items and adaptive equipment. The replacement tray for that resident also lacked ordered gravy, did not have the turkey cut as specified, provided a divided plate instead of a scoop plate, and included regular milk instead of a prescribed diet shake. The Food Service Director confirmed that staff were responsible for checking trays against meal tickets, acknowledged ongoing resident complaints about missing items, and stated the required temperature standards for hot and cold foods.
A resident with serious infections did not receive or have documented several scheduled IV antibiotic doses, as required by physician orders. MAR entries were left blank for multiple administrations, and there was no evidence in progress notes or provider notification regarding the missed doses. Staff interviews revealed confusion about responsibility for IV medication administration and documentation, and facility leadership confirmed that blank MAR entries constituted medication errors, but no investigation or provider notification was documented.
A resident receiving IV vancomycin for serious infections did not have required vancomycin trough levels drawn as ordered, and the only recorded trough was not performed at the correct time. Staff interviews revealed confusion about lab scheduling and timing, and there was no documentation that the necessary labs were completed or communicated to the pharmacy or consultant pharmacist.
A resident with multiple health conditions did not receive critical medications as ordered due to delays in corporate approval and communication failures within the facility. The resident's medications, including those for Parkinson's, diabetes, and respiratory issues, were unavailable on multiple occasions, and there was no evidence that providers were notified. This deficiency in medication management led to worsening symptoms for the resident.
The facility failed to ensure a proper grievance process, as residents were unaware of the grievance officer and did not receive follow-up on grievances. A resident with cerebral palsy reported discomfort with CNAs' behavior, but the grievance resolution was incomplete, with only one CNA re-educated and the resident's care preferences not fully addressed. Staff interviews revealed inconsistencies in grievance handling, highlighting a deficiency in the process.
The facility failed to adhere to food safety standards, with improper cooling of hot food, a malfunctioning dishwasher, and outdated food in the cooler. Observations revealed rice and other items not cooled properly, incomplete cooling logs, and a dishwasher with inadequate temperatures and sanitizer levels. Outdated food items were also found, indicating lapses in monitoring and adherence to protocols.
A survey revealed that a facility failed to properly label and store medications, including insulin pens and eye drops, across multiple medication carts. Medications lacked resident-specific identifiers and opened/discard dates, and some were expired. Staff interviews indicated a lack of knowledge about medication expiration and inadequate documentation of checks, contributing to these deficiencies.
A facility failed to maintain effective infection control practices for a resident with clostridium difficile. Staff did not consistently wear required PPE or perform hand hygiene when entering or exiting the resident's room, despite signage indicating contact precautions. Interviews revealed a lack of understanding and adherence to protocols, with the DON confirming the importance of following isolation room procedures.
A resident with a history of stroke and infections was prescribed antibiotics for an elevated white blood cell count, but the facility failed to notify the resident's representative as required by their policy. Despite the initiation of Doxycycline and Ceftriaxone treatments, there was no documentation of notification, and interviews confirmed the lapse.
A resident with visual impairment and depression was not provided with a large print Bible or glasses, which were necessary for their participation in activities. The resident's care plan documented these needs, but staff were unaware of the missing items. The Activities Director acknowledged the oversight, and the deficiency was noted during the survey.
Two residents with pressure ulcers did not have their low air loss mattresses set according to their current weights, and the settings were not documented in their care plans or physician orders. One resident with a Stage 4 ulcer had their mattress set too firm, while another resident with an unstageable ulcer had unclear mattress settings. Staff interviews revealed confusion about responsibility for setting and monitoring the mattresses.
A resident with dysphagia was observed eating alone in their room without supervision, despite being care planned for line-of-sight supervision during meals. Facility policies required supervision for residents on altered diets to ensure safety, but staff failed to adhere to these protocols, as confirmed by interviews with a CNA, RN Unit Manager, and Speech and Language Pathologist.
A resident requiring BiPAP therapy did not receive proper respiratory care as the facility failed to clean and maintain the equipment per professional standards. Observations showed the mask was dirty and improperly maintained, with no documented cleaning schedule or physician orders. Staff interviews confirmed the lack of proper documentation and adherence to care protocols, potentially leading to respiratory infections.
A resident with end-stage renal disease did not receive proper pre- and post-dialysis evaluations at an LTC facility. The facility failed to document vital signs and access site assessments, and the communication book with the dialysis center was incomplete and outdated. Staff interviews revealed confusion over documentation responsibilities, compromising the resident's safety.
The facility failed to provide meals at appropriate temperatures and with adequate flavor, as observed during a survey. Meals served on two occasions were below temperature standards, bland, and contained foreign substances. Residents reported missing items and unappetizing food. Staff interviews revealed issues with menu changes and communication, leading to inaccurate meal service.
Failure to Provide Accurate, Palatable Meals at Proper Temperatures
Penalty
Summary
The facility failed to provide residents with nourishing, palatable, well-balanced diets that met their daily nutritional needs, as evidenced by multiple issues with meal temperatures, tray accuracy, and missing adaptive equipment during surveyor observations and resident interviews. Facility policy required that all meals be checked for accuracy against meal tickets, that hot foods be maintained above 140°F and cold foods below 41°F, and that trays be verified before leaving the kitchen. During a resident group meeting, six anonymous residents reported that their food was often cold and that the items on their trays did not match the meal tickets. These resident reports were corroborated by direct observations of two lunch meals. During a lunch observation on one unit, a resident’s tray was the last served and food temperatures were measured and verified with the Regional Director of Food Operations: the ziti was 133°F, the broccoli 110°F and cool to taste, the garlic bread 100°F, the coffee 133°F, and the pineapple 68°F, all outside the facility’s stated acceptable ranges for hot and cold foods. On another unit during a separate lunch observation, a resident’s tray was identified by a CNA as incorrect and missing multiple ordered items, including turkey, gravy, creamed spinach, cottage cheese, chilled peaches, a diet house shake, Mrs. Dash seasoning, margarine, and a scoop plate; measured temperatures showed stuffing at 125.1°F, carrots at 110.2°F, and water at 62.8°F. When a replacement tray was delivered, it was still missing gravy, the turkey was not cut as directed on the meal ticket, the resident received a divided plate instead of the ordered scoop plate, and regular milk was provided instead of the diet house shake. In an interview, the Food Service Director acknowledged that all dietary staff were responsible for meal ticket accuracy, that residents had been complaining of missing items for months, and confirmed the required temperature standards for hot and cold foods.
Failure to Administer and Document IV Antibiotics as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including osteomyelitis of the thoracic vertebrae, local skin infection, and sepsis did not receive several prescribed intravenous antibiotic doses. Physician orders required administration of cefepime and vancomycin every 12 hours, but the Medication Administration Record (MAR) showed blank entries for multiple scheduled doses, indicating they were either not given or not documented. There was no evidence in the nursing progress notes of missed doses or provider notification regarding these omissions. Interviews with nursing staff revealed confusion and inconsistency regarding responsibility for intravenous medication administration and documentation. LPNs and RNs described different processes for being alerted to medication times, and some staff were unsure why MAR entries were left blank. Supervisory staff acknowledged that a blank MAR box meant the medication was unaccounted for, and that this constituted a medication error. However, there was no documentation of any investigation into the missing administrations, nor was there evidence that the provider was notified as required by facility policy. The physician responsible for the resident's care confirmed that they were not notified of any missed antibiotic doses, which they considered a significant medication error. Facility leadership, including the DON and Assistant DON, stated that all MAR entries should be completed and that missed or undocumented doses should be investigated and reported. Despite this, no such actions were documented, and the missed doses remained unaccounted for.
Failure to Obtain Timely and Accurate Vancomycin Trough Levels
Penalty
Summary
The facility failed to ensure timely and accurate laboratory services for one resident who was receiving intravenous vancomycin for osteomyelitis, discitis, and sepsis. Physician orders required regular monitoring of vancomycin trough levels and other laboratory tests to assess the effectiveness and safety of the antibiotic therapy. Despite these orders, there was no documented evidence that the required vancomycin trough levels were obtained on the specified dates, and the only recorded trough was not performed at the appropriate time relative to the dosing schedule. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that laboratory draws were scheduled on specific days of the week, and there was confusion or lack of clarity regarding the timing of the vancomycin trough draws. The registered nurses were responsible for drawing blood from the resident's peripherally inserted central catheter, but the records did not show that the required labs were completed as ordered. The pharmacy and consultant pharmacist were not contacted with the necessary lab results, and the facility failed to communicate effectively regarding the resident's laboratory needs. The failure to obtain timely and accurate vancomycin trough levels was confirmed through record review and staff interviews. The physician stated that the trough levels should have been drawn every three days and prior to the next scheduled dose, and that delays or missed draws were not acceptable. The lack of appropriate laboratory monitoring was not explained by the staff, and there was no documentation to support that the required tests were performed as ordered.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure that Resident #2 received medications as ordered, leading to a deficiency in providing treatment and care according to professional standards and the resident's care plan. Resident #2, who had diagnoses including depression, diabetes, chronic obstructive pulmonary disease, and Parkinson's Disease, did not receive several critical medications on multiple occasions. These medications included Rytary for Parkinson's, Novolog for diabetes, Pulmicort for respiratory issues, and vilazodone for depression. The absence of these medications was documented by various Licensed Practical Nurses over several days, with no evidence that a provider was notified about the unavailability of these medications. The facility's policy required that any medication not administered should be documented, and the medical professional should be informed to obtain further orders. However, this protocol was not followed, as there was no documented evidence that the provider was notified about the missing medications. The facility's practice of requiring corporate approval for medications over $50 contributed to delays in medication availability. This process led to significant delays in obtaining necessary medications for Resident #2, who experienced worsening symptoms, including dysarthria and chest pain, potentially related to the missed medications. Interviews with facility staff, including Licensed Practical Nurses, the Corporate Pharmacy Liaison, and the Director of Nursing, revealed systemic issues in medication management and communication. Staff reported that medications were often unavailable for extended periods, and there was confusion about the process for obtaining medications from the Cubex or notifying providers. The Medical Director emphasized the importance of timely medication administration, particularly for conditions like Parkinson's Disease, where missing doses can lead to symptom recurrence. The deficiency highlights a failure in the facility's medication management system, impacting the resident's health and well-being.
Deficiency in Grievance Process and Resident Rights
Penalty
Summary
The facility failed to ensure a proper grievance process was in place for residents, as evidenced by the lack of awareness among residents about the grievance officer and the handling of grievances. During a Resident Council Meeting, twelve anonymous residents expressed that they were unaware of who the grievance officer was and did not receive follow-up on their grievances. Additionally, the facility did not have visible postings of the grievance officer's contact information, which is a requirement according to their policy. Resident #16, who has cerebral palsy, anxiety disorder, and depression, reported feeling uncomfortable with the behavior of two Certified Nurse Aides (CNAs) during care. The resident filed a grievance about the CNAs being inappropriately touchy with each other and not assisting with unlocking the door for visitors. The grievance was documented, but the resolution was incomplete, as only one CNA received re-education, and the resident's request to not be cared for by the involved CNAs was not fully addressed. Interviews with facility staff revealed inconsistencies in the grievance handling process. The Social Worker and Registered Nurse Unit Manager acknowledged the resident's dissatisfaction and the incomplete resolution of the grievance. The Director of Nursing and the Administrator confirmed that grievances should be resolved within 72 hours and that residents have the right to refuse care from certain staff members. However, there was a lack of documentation and follow-through in addressing Resident #16's concerns, highlighting a deficiency in the facility's grievance process.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, it was observed that hot food was improperly cooled, the mechanical dishwasher was not functioning as designed, and outdated foods were present in the walk-in cooler. Specifically, a pan of rice was found in the walk-in cooler at a temperature of 123 degrees Fahrenheit, which did not meet the required cooling standards. The rice was not properly monitored for temperature reduction, and similar issues were noted with other food items like turkey and pork loin, which had incomplete cooling records. The mechanical dishwasher was also found to be malfunctioning, with wash temperatures recorded below the required 150 degrees Fahrenheit and final rinse temperatures below the necessary 180 degrees Fahrenheit. The chlorine sanitizer levels were also inconsistent, with measurements as low as 10 parts per million, far below the required levels. The Maintenance Director confirmed that the dishwasher had been operating with a broken heating element for an extended period, and the facility had been using chemical sanitization as a workaround. Additionally, outdated food items were found in the walk-in cooler, including a pan of chicken labeled from 7/11 and a bag of cooked potatoes dated 7/3. Staff interviews revealed a lack of a specific person responsible for reviewing cooler contents, leading to the presence of outdated items. The Temporary Food Service Director acknowledged that these items should not have been in the cooler, indicating a lapse in monitoring and adherence to food safety protocols.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. On Unit 1, medication cart 1 contained several medications, including multidose insulin pens, eye drops, and ointments, that were not labeled with resident-specific identifiers or opened/discard dates. Additionally, an unopened insulin pen was not stored in the refrigerator as required. Licensed Practical Nurse #18 admitted to administering an undated insulin pen to a resident without checking for an opened date, which is necessary to determine expiration. On Unit 2, medication cart 1 had a multidose insulin pen without resident-specific information or an opened/discard date, and another insulin pen for a specific resident also lacked an opened/discard date. Medication cart 2 contained expired stock medications. Licensed Practical Nurse #1 acknowledged that they would not use medications without knowing the intended resident or expiration status. The Assistant Director of Nursing had previously checked the carts for expired medications, but these issues were not identified. Interviews with nursing staff revealed a lack of knowledge regarding the duration insulin is viable after opening and the absence of documentation for weekly expiration checks. The Assistant Director of Nursing stated that night shift nurses were responsible for checking expiration dates weekly, but it was unclear if these checks were documented. The facility lacked an educator, and staff were unsure when they last received education on medication storage, contributing to the oversight of expired and improperly labeled medications.
Inadequate Infection Control Practices for Resident on Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to transmission-based precautions for a resident diagnosed with clostridium difficile. The facility's policy required staff to wear gloves and gowns when entering the room of a resident on contact precautions, and to perform hand hygiene before leaving the room. However, observations revealed that staff members, including a Certified Nurse Aide, a Registered Nurse Unit Manager, and a Licensed Practical Nurse, did not consistently follow these protocols. Resident #59, who had a history of recurrent enterocolitis due to clostridium difficile, was placed on contact precautions upon readmission to the facility. Despite the presence of signage indicating the need for contact precautions, staff were observed entering and exiting the resident's room without the required personal protective equipment. Additionally, staff failed to perform hand hygiene after leaving the room, and contaminated items were handled inappropriately, increasing the risk of infection transmission. Interviews with staff members revealed a lack of understanding and adherence to the facility's infection control protocols. The Registered Nurse Unit Manager acknowledged the need for gowns and gloves when entering the resident's room and admitted to not following proper procedures. The Director of Nursing/Infection Preventionist confirmed that staff were expected to follow the signage and that there was no appropriate time to enter an isolation room without the required protective equipment. This deficiency highlights a significant lapse in the facility's infection control practices, particularly in protecting residents and staff from communicable diseases.
Failure to Notify Resident's Representative of Antibiotic Treatment
Penalty
Summary
The facility failed to immediately inform the resident's representative about the initiation of a new treatment for a resident, which is a requirement according to their policy. Specifically, a resident with a history of stroke, sacral pressure ulcer, and infections was prescribed antibiotics due to an elevated white blood cell count indicating an infection. Despite the facility's policy mandating notification within 24 hours of a change in the resident's medical condition, the resident's representative was not informed about the antibiotic treatment. The resident's medical records showed that antibiotics, Doxycycline and Ceftriaxone, were prescribed on consecutive days to address the infection. However, progress notes by the registered nurse did not document any signs or symptoms of infection, the use of antibiotics, or the notification of the resident's representative. Interviews with the resident's representative and the Director of Nursing confirmed that the family was not notified about the antibiotic therapy, which was acknowledged as a lapse in procedure.
Failure to Provide Necessary Equipment for Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of Resident #3. The resident, who had diagnoses including left-sided hemiplegia, unspecified visual loss, and depression, was not provided with a large print Bible or glasses, which were necessary for their participation in activities. The resident's care plan indicated a preference for independent activities and 1:1 visits, and it was documented that they required visual aids to participate in activities. However, during the survey, it was found that the resident's glasses were missing, and they did not have access to a large print Bible, which was part of their documented interests. Interviews with facility staff revealed a lack of awareness regarding the resident's missing glasses and Bible. The Activities Director and Activity Aide were responsible for ensuring residents' interests were met, but they were not aware of the resident's needs for glasses and a large print Bible. The Activities Director acknowledged that the resident's care plan documented these needs, but the resident did not have glasses in their room, and the Bible provided was not large print. The facility's failure to ensure the resident had the necessary equipment and supplies for their preferred activities led to the deficiency.
Failure to Ensure Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, two residents with pressure ulcers did not have their low air loss mattresses set according to their current weights, and the settings were not documented in their care plans or physician orders. This oversight was observed during a recertification survey, where it was found that the mattresses were not monitored to ensure appropriate settings for the residents' weights. Resident #27, who had a Stage 4 pressure ulcer, diabetes, and morbid obesity, was found to have their low air loss mattress set on static at 325 pounds, despite weighing 211 pounds. The mattress settings were not documented in the physician orders or care plan, and the Treatment Administration Record indicated that checks were not consistently performed every shift. Observations revealed that the resident experienced pain from the pressure ulcer, and the mattress settings were not adjusted to provide optimal pressure relief. Resident #67, who had a history of surgery and an intellectual disability, was at risk for impaired skin integrity and had an unstageable pressure ulcer on the left buttock. The resident's low air loss mattress was set on alternating at 250 pounds, but the settings were not documented in the care plan or physician orders. Interviews with staff revealed a lack of clarity regarding who was responsible for setting and monitoring the mattresses, leading to inconsistencies in ensuring the mattresses were set according to the residents' weights.
Failure to Supervise Resident with Dysphagia During Meals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with dysphagia, a condition that makes swallowing difficult. The resident was care planned for line-of-sight supervision during meals, with specific strategies to ensure safe swallowing, such as consuming small, single bites and maintaining an upright position during and after meals. Despite these requirements, the resident was observed eating alone in their room without any staff supervision, which was contrary to the care plan and facility policies. The facility's policies on meal observation and assistance with meals required staff to supervise residents during mealtime, especially those on altered diets, to ensure safety and meet individual needs. The resident in question had a comprehensive care plan that included supervision during meals due to their limited mobility and risk of swallowing difficulties. However, during an observation, the resident was found eating lunch alone, with their back to the door, and no staff present to provide the necessary supervision. Interviews with facility staff, including a CNA, RN Unit Manager, and Speech and Language Pathologist, confirmed that the resident should have been supervised during meals. The staff acknowledged that residents on altered diets, like the one in question, were at risk for aspiration or choking and required supervision. The RN Unit Manager and Speech and Language Pathologist both stated that the resident should have been either in the dining room or accompanied by a staff member while eating in their room, highlighting a lapse in following the care plan and facility protocols.
Inadequate Respiratory Care for Resident Using BiPAP
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #19, who required the use of a bilevel positive airway pressure (BiPAP) machine. The facility's policy required the BiPAP machine to be cleaned weekly and the mask, nasal pillow, and tubing to be cleaned daily. However, there was no documentation of a cleaning schedule for the device, and the comprehensive care plan did not include maintenance or cleaning instructions for the BiPAP equipment. Observations revealed that the resident's BiPAP mask was found on the floor and had visible white and black specks inside, indicating it was not cleaned regularly. The mask harness was frayed, and surgical tape was used to secure the tubing, suggesting inadequate maintenance. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse Manager, confirmed that there were no physician orders for cleaning the equipment, and the task was not consistently documented in the treatment administration record. The Director of Nursing and a physician acknowledged the lack of proper orders and documentation for cleaning and changing the BiPAP equipment. They noted that the resident had experienced respiratory infections, which could have been linked to the unclean equipment. The facility's failure to adhere to professional standards of practice for respiratory care resulted in a deficiency, as the resident's equipment was not maintained or cleaned as required, potentially compromising the resident's health.
Deficiency in Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis services received care consistent with professional standards. Resident #59, who had end-stage renal disease and required hemodialysis, did not receive ongoing assessments and oversight before and after dialysis treatments. The facility's policy required pre-dialysis evaluations, including vital signs and access site assessments, to be documented in a communication book and the resident's medical chart. However, there was no documented evidence of these evaluations being completed for the resident during the specified period. The resident's communication book, which was supposed to facilitate information exchange between the facility and the dialysis center, was incomplete and outdated. It lacked current medication lists and recent evaluations, and there was no documentation of pre-dialysis or post-dialysis evaluations for several dates. Interviews with facility staff revealed a lack of clarity and responsibility regarding the documentation and communication process, leading to incomplete records and potential gaps in care. The facility's failure to document and communicate essential information about the resident's dialysis treatments and access site assessments compromised the resident's safety. Staff interviews highlighted the importance of monitoring vital signs and the dialysis access site for signs of infection or complications, yet these evaluations were not consistently documented. The lack of proper documentation and communication between the facility and the dialysis center raised concerns about the resident's care and the facility's adherence to professional standards.
Deficiency in Meal Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, flavorful, and served at appetizing temperatures. During the recertification survey, it was observed that meals served on two separate occasions were not at the appropriate temperatures and lacked flavor. Specifically, the lunch meals on 7/16/2024 and 7/18/2024 were served at temperatures below the required standards, with hot foods not being hot enough and cold foods not being cold enough. Additionally, the meals were described as bland and unappetizing by residents and staff. The survey also revealed that the facility's meal service was inconsistent and inaccurate. During a Resident Council meeting, 12 anonymous residents reported that their meals often had missing items and were not served at the correct temperatures. A test tray on 7/18/2024 contained a foreign substance, identified as parchment paper, which was mixed with the food, posing a potential choking hazard. The facility's policies on dining experience and tray line service were not adhered to, as meals were not checked for accuracy and quality before being served. Interviews with staff highlighted issues with menu changes and communication. The Acting Food Service Director and Dietary Supervisor acknowledged that the menu was changed without proper updates to meal tickets, leading to missing items like apple slices. The Registered Dietitian was unaware of the availability of certain foods and did not conduct test trays to ensure meal quality. The facility's failure to maintain proper food temperatures and ensure meal accuracy resulted in a deficiency in providing a satisfactory dining experience for residents.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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