Dumont Center For Rehabilitation And Nursing Care
Inspection history, citations, penalties and survey trends for this long-term care facility in New Rochelle, New York.
- Location
- 676 Pelham Road, New Rochelle, New York 10805
- CMS Provider Number
- 335271
- Inspections on file
- 14
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Dumont Center For Rehabilitation And Nursing Care during CMS and state inspections, most recent first.
The facility did not consistently review and revise comprehensive care plans or conduct required interdisciplinary care plan meetings. An abuse care plan for a resident with psychiatric and respiratory diagnoses was not updated after its last revision despite ongoing quarterly assessments. Another resident receiving IV hydration for weakness and poor oral intake had no corresponding update to the care plan to address IV therapy. A cognitively intact resident with diabetes and ESRD did not have a scheduled quarterly care plan meeting held, and reported not recalling any invitation or attendance. Staff interviews showed that social services, the MDS department, and the DON had differing understandings of who was responsible for updating care plans and scheduling care plan meetings.
Surveyors found that hot foods served on two units during lunch were not maintained at the facility’s required minimum of 140°F. Policy required all hot items to reach residents at or above this temperature, but test trays on both regular and puree diets showed food temperatures ranging from 90°F to 130°F after delivery to resident rooms. The Food Service Director confirmed that hot foods should be above 140°F to be palatable and acknowledged that the observed meal service did not meet this standard, despite prior efforts to address earlier food temperature concerns.
A cognitively intact resident with schizophrenia, DM, and a seizure disorder had expressed that it was very important for family or friends to be involved in care discussions, but the facility did not ensure that the resident’s group home representatives were included in person-centered care planning. The group home’s Resident Manager and Executive Director reported they wanted to be involved and were listed as contacts, yet they were not invited to care plan meetings and were sometimes denied information due to outdated contact information. The SW and Director of Social Services stated that representatives were only invited to initial, significant change, and discharge care plan meetings, not quarterly meetings, and the ADON, RN Manager, and DON all reported having no direct communication with the resident’s representatives, resulting in the representatives not being afforded the opportunity to participate in the resident’s care planning.
The facility did not report an allegation of verbal abuse to the state as required. An Ombudsman informed the DON that a resident with psychiatric and respiratory diagnoses, but intact cognition, alleged that a NP verbally abused them during an encounter in which the NP and an RN entered the room to provide requested lab results and the resident became agitated, verbally abusive, and refused to sign for receipt of the results. Despite facility policies requiring prompt reporting of suspected abuse to the Department of Health, there was no documentation that this allegation was reported.
A resident with intact cognition and psychiatric diagnoses alleged that a nurse practitioner verbally abused them during an encounter related to delivery of lab results. The facility’s abuse investigation policy required a thorough investigation of potential abuse, but the facility only obtained written statements from the NP and a supervising RN, who reported that the resident became agitated, verbally abusive, and refused to sign for the lab results. The facility did not interview the resident, other residents, or additional staff, nor did it document a complete investigative conclusion or related corrective actions, resulting in a failure to fully investigate the verbal abuse allegation.
A resident with moderately impaired cognition and a history of seizure disorder, hypothyroidism, and brain malignancy was discharged home after IV hydration orders were discontinued, but the IV access device was not removed and the discharge summary lacked instructions regarding IV access. Nursing notes indicated the resident was sent home with discharge medications, yet the facility’s discharge protocol requiring two-nurse verification of medications and removal of medical appliances was not followed, resulting in the resident being discharged with an IV access device still in place and a blister pack of medication that belonged to another resident.
A resident with seizure disorder, hypothyroidism, and brain malignancy received IV fluids for bradycardia and later for hypernatremia, but the facility failed to follow its own IV administration and line management policies. For both a peripheral IV and a midline catheter, there was no documentation of insertion date/time, site location, site assessments, resident tolerance, or verification of device placement, and nursing assessments were not consistently recorded each shift while IV fluids were infusing. The MAR showed multiple IV administrations, yet one shift lacked any documented IV administration or assessment, and nursing notes inconsistently described whether the access was a peripheral line or a midline. During interviews, an RN and the DON confirmed that required IV placement and monitoring documentation was missing, while the NP explained the ordering process and expectation for provider notification at completion of IV therapy.
A facility failed to report an alleged sexual abuse incident involving a resident with impaired cognition to the NYSDOH within the required 2-hour timeframe. The incident was reported by the resident's family, and the facility, after consulting with the Administrator, decided to report it within 24 hours, believing immediate reporting was only necessary if there was harm. This decision led to a deficiency in timely reporting.
A resident was exposed to an odor from glue while maintenance staff repaired flooring in their room. The resident was not removed due to feeling unwell, and the maintenance staff did not inform nursing staff of the repairs. Facility staff acknowledged that residents should not be present during such repairs, and the maintenance staff's actions were against policy.
A resident was discharged from the facility without the completion and transmission of a Minimum Data Set (MDS) Discharge Assessment. The resident, who had conditions such as asthma and hyperlipidemia, was discharged home, but the MDS coordinator missed completing the necessary discharge assessment. The Director of Nursing was unaware of this oversight, as the MDS department functions separately from nursing.
A resident at risk for pressure ulcers was not provided with heel booties as per their care plan, leading to a deficiency in care. Despite orders to offload heels with booties, staff were unaware of this requirement, resulting in the resident's heels resting directly on the mattress. Interviews revealed a communication breakdown among staff regarding the resident's care plan.
The facility did not maintain sanitary conditions in the kitchen, as observed during a survey. Blue cup racks, claimed to be clean, were stored on the floor and later combined with other clean racks for use. This action violated the facility's policy on preventing contamination, as confirmed by the Director of Dietary Service.
The facility failed to implement proper infection control measures for a resident with C. difficile, who was placed in a shared room instead of a private one, and the infection was not tracked for five days. Additionally, another resident's ventilator tubing was not changed as per the facility's policy, being five days overdue. These lapses indicate deficiencies in infection prevention and equipment maintenance protocols.
Failure to Review, Revise, and Conduct Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment and failed to hold required quarterly care plan meetings with resident participation. For a resident with paranoid personality disorder, major depressive disorder, and COPD, an abuse care plan initiated in December 2023 and last revised in February 2024 showed no further documented evaluation or revision despite subsequent quarterly MDS assessments, contrary to facility policy requiring quarterly and periodic review. Social services staff acknowledged that the abuse care plan should have been updated quarterly and that their department was responsible for this task, noting that a consultant who normally audits care plans had been covering for another social worker. Another resident with seizure disorder, hypothyroidism, and malignant neoplasm of the brain experienced weakness and poor oral intake, leading to a physician order for IV hydration with 0.45% sodium chloride administered over several days; however, there was no documented evidence that the resident’s comprehensive care plan was reviewed and revised to address the IV fluid therapy. In addition, a cognitively intact resident with diabetes mellitus and end stage renal disease, whose MDS documented resident and family participation in assessment and goal setting, did not have a quarterly care plan meeting held as scheduled. Although the care plan meeting schedule showed two planned conference dates, there was no documentation in the medical record that the meeting occurred, and the resident reported not remembering being invited or attending. Staff interviews revealed confusion and differing understandings among the MDS department, social workers, and the DON regarding responsibility for scheduling and conducting these care plan meetings.
Failure to Maintain Hot Food at Required Serving Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that hot foods were served at palatable and appetizing temperatures during lunch meal service on two of six units observed. Facility policy titled "Food Temperatures" required all hot food items to be served to residents at a temperature of at least 140°F at the time the resident received the food. The meal delivery schedule showed that lunch for one unit was scheduled for 11:55 AM and another unit at 12:10 PM. On the day of observation, a food truck was delivered to the first floor at 11:50 AM, and staff distributed trays to residents in their rooms until 12:10 PM. Test trays conducted at 12:10 PM on the first floor with the Food Service Director showed that items on a regular diet tray (baked potato, turkey chili, green beans) measured between 90°F and 110°F, and items on a puree diet tray (mashed potato, puree green beans, puree turkey) measured between 122°F and 130°F, all below the required 140°F. On the second floor, the food truck arrived at 12:15 PM, and staff delivered trays to residents in their rooms until 12:39 PM. Test trays conducted at 12:39 PM with the Food Service Director showed that items on a puree diet tray (puree green beans, puree turkey, mashed potato) measured between 124°F and 130°F, and items on a regular diet tray (baked potato, green beans, turkey chili with beans) measured between 116°F and 123°F, again below the facility’s required hot food temperature. During an interview, the Food Service Director stated that hot foods should be served above 140°F to be palatable and acknowledged that hot foods were not maintained at the appropriate temperature range during the observed meal service. The Director also stated that food temperature issues had been brought up in the past and previously addressed by replacing equipment and conducting monthly temperature audits, and that no further issues had been reported since then.
Failure to Involve Resident Representative in Person-Centered Care Planning
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that a cognitively intact resident and the resident’s chosen representatives were able to participate in all aspects of person-centered care planning. The resident, admitted with schizophrenia, diabetes mellitus, and seizure disorder, had an admission MDS documenting that it was very important for family or friends to be involved in discussions about their care. The facility’s policy stated that residents and/or family would be invited to interdisciplinary care plan meetings for comprehensive assessments. However, the quarterly MDS documented the resident as cognitively intact, and there was no documented evidence that the resident’s representatives were invited to initial or quarterly care plan meetings. The Social Worker reported that if a resident refused to attend, the IDT met without the resident or representative, and that representatives were only invited to initial, significant change, and discharge care plan meetings, not quarterly meetings. The resident’s group home, where the resident had lived prior to admission, reported that the facility refused to discuss the resident’s care with them or other group home representatives. The group home Resident Manager stated that one listed contact was outdated, and that current contacts included a group home RN and the Executive Director, none of whom were invited to care plan meetings or involved in the resident’s care despite their expressed desire to be involved. The Executive Director confirmed wanting to attend care plan meetings but not receiving invitations. The ADON and a unit RN Manager both stated they had not communicated with the resident’s representatives and indicated that the Social Worker was responsible for updating contacts and inviting representatives. The Director of Social Services confirmed that representatives were not invited to quarterly care plan meetings and was unaware that the resident’s representatives wanted to be involved, and the DON stated they were not aware that the representatives felt excluded and had not personally communicated with them. These actions and inactions resulted in the resident’s representatives not being afforded the opportunity to participate in the resident’s care planning process, in violation of 10 NYCRR 415.11(c)(2)(i-iii).
Failure to Timely Report Allegation of Verbal Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported to the New York State Department of Health within the required time frames. During a recertification and abbreviated survey, record review and interviews showed that an Ombudsman informed the Director of Nursing that Resident #35 alleged a Nurse Practitioner verbally abused them. Despite this allegation, there was no documented evidence that the incident was reported to the Department of Health as required by regulation and by the facility’s own abuse reporting policies. Resident #35 had diagnoses of Paranoid Personality Disorder, Major Depressive Disorder, and Chronic Obstructive Pulmonary Disease, with a recent assessment indicating intact cognition and a need for supervision to moderate assistance with ADLs and mobility. Documentation from the Nurse Practitioner and supervising Registered Nurse described an encounter in which they entered the resident’s room to provide requested lab results, after which the resident became agitated, verbally abusive, and refused to sign for receipt of the results, ultimately yelling at them to leave the room. This encounter formed the basis of the resident’s allegation of verbal abuse, yet the facility did not initiate the required external report of this alleged abuse to the state authority.
Failure to Thoroughly Investigate Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by a resident against a nurse practitioner. The facility’s abuse investigation policy required that a staff nurse initiate an incident report, notify a supervisor, and that the supervisor and Director of Nursing (DON) determine the need for an investigation and possible reporting to the Department of Health. On 01/05/2026, the Ombudsman notified the facility that Resident #35 alleged that Nurse Practitioner #1 verbally abused them. Resident #35 had diagnoses including Paranoid Personality Disorder, Major Depressive Disorder, and Chronic Obstructive Pulmonary Disease, and a recent MDS documented intact cognition with a need for supervision to moderate assistance for activities of daily living. The facility collected written statements from Nurse Practitioner #1 and the supervising Registered Nurse #4 describing an encounter on 12/26/2025 in which the resident became agitated when awakened, refused to sign for laboratory results, and was verbally abusive toward the nurse practitioner and RN, repeatedly yelling for them to leave the room. Despite the Ombudsman’s report of alleged verbal abuse and the facility’s policy requiring investigation of potential abuse, the facility’s investigation was limited to the two staff statements and did not include an interview or statement from the alleged victim, other residents on the unit, or other staff who might have witnessed the incident or had knowledge of interactions between the nurse practitioner and other residents. During a later interview, the resident stated that the nurse practitioner is “bad” and yells and screams at them. The DON reported that they concluded there was no evidence of abuse and that the resident was actually abusive to the nurse practitioner, noting that the resident tends to confabulate, but there was no documented evidence of a thorough investigation, no documented conclusion of the investigation, and no documented determination of appropriate corrective action if the allegation had been verified. This failure to conduct and document a complete investigation of an alleged verbal abuse incident constituted noncompliance with the requirement to respond appropriately to all alleged violations.
Resident Discharged Home With IV Access Device and Another Resident’s Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality when a resident was discharged home with an intravenous (IV) access device still in place and with medications that belonged to another resident. The resident had diagnoses including seizure disorder, hypothyroidism, and malignant neoplasm of the brain, and an admission MDS documented moderately impaired cognition. A physician’s order dated 03/14/2025 authorized a midline IV and 0.45% sodium chloride IV solution at 50 cc/hour every shift for nine doses for hydration, and this order was discontinued on 03/17/2025. On the same day, nursing notes documented that the resident was discharged home with medications taken and with discharge medications provided. The facility’s Day of Discharge Protocol and Procedure required licensed nurses to verify discharge medications with two nurses for accuracy and to remove all medical appliances, such as IV lines, per physician’s order prior to discharge. Despite these requirements, the resident’s interdisciplinary discharge summary did not include any discharge plan or care instructions related to the IV access device. An occurrence report investigation documented that the facility was notified by a hospice nurse that the resident had been discharged home with an IV access device still in place and a blister pack of medication that did not belong to the resident. The Director of Nursing’s review of the incident found that the nurse responsible for the discharge disconnected the IV line but did not remove the IV access device, and that the resident was given discharge medications that included another resident’s blister pack. These actions and omissions occurred during the discharge process conducted by the nursing staff on the unit.
Failure to Document and Monitor IV and Midline Therapy per Professional Standards
Penalty
Summary
Surveyors identified a failure to ensure parenteral fluids were administered consistent with professional standards of practice for one resident who received IV therapy for bradycardia and later for hypernatremia. The facility’s IV policies required verification of provider orders, proper labeling and setup, monitoring of infusions, and documentation of IV insertion, site assessments, and dressing and tubing changes, as well as every-shift monitoring for signs of infection or infiltration. Despite these requirements, the resident’s medical record lacked documentation of the date and time of IV insertions, site assessments, the resident’s tolerance, and verification of device placement for both a peripheral IV and a midline catheter. For the first IV course, a physician ordered 0.9% sodium chloride at 75 cc/hr for three doses to support hemodynamic stability after bradycardia was noted. A nursing note confirmed a peripheral line order, but there was no documentation of when or where the IV was inserted, nor any site assessment or tolerance. The MAR showed two administrations of the ordered IV solution across two shifts, but there was no documented administration or assessment during the intervening shift. Additionally, there was no documentation that the resident was evaluated to determine whether the IV access device should be maintained or removed after completion of the ordered IV therapy. A later nursing note documented that the peripheral IV in the left hand became dislodged and was bleeding, at which time the line was removed and the site cleaned and dressed. For the second IV course, following lab results showing elevated sodium, a physician ordered a midline via an IV vendor and 0.45% sodium chloride at 50 cc/hr every shift for nine doses for hydration. A nurse documented two unsuccessful peripheral IV attempts and that a midline was ordered, and a later note documented that IV fluids were started, but there was no documentation of the midline placement, including date and time, site assessment, resident tolerance, or verification of insertion. The MAR showed that the IV solution was administered over multiple shifts, but nursing notes from this period did not consistently document assessments and monitoring of the IV site. The notes inconsistently described the device as a peripheral line in the left arm or left hand and as a midline in the left upper arm. During interviews, an RN and the DON acknowledged that documentation of IV placement and ongoing assessment was missing, and the NP described the ordering process and expectation that providers be notified upon completion of IV therapy for reevaluation of treatment or removal of the access device.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged incident of sexual abuse involving a resident to the New York State Department of Health (NYSDOH) within the required 2-hour timeframe. The incident involved a resident with moderately impaired cognition and no behavioral symptoms, who was admitted with diagnoses including diabetes, muscle weakness, difficulty walking, and a displaced comminuted fracture of the right femur. On February 10, 2024, the resident's family informed the facility that the resident had reported being molested by an unknown male who entered their room at midnight. The family and police were notified, but the family declined to send the resident to the hospital. The Director of Nursing and the Administrator reviewed the incident and decided to report it within 24 hours, believing that immediate reporting was only necessary if there was harm. The incident was reported to the NYSDOH on February 11, 2024, at 11:21 AM, which was beyond the required 2-hour reporting window. This decision was based on the Administrator's interpretation of the guidelines, which was incorrect as per the regulation 10NYCRR 415.4 (b)(2)(3), leading to a deficiency in timely reporting of alleged abuse.
Resident Exposed to Odor During In-Room Maintenance
Penalty
Summary
During a recertification survey, it was observed that a resident's right to a safe, clean, comfortable, and homelike environment was not maintained. Specifically, a maintenance staff member was repairing the flooring in a resident's room using glue that emitted an odor while the resident was present. The resident was lying in bed, and the bed had been moved to allow access to the flooring. The maintenance staff did not inform the nursing staff about the repair work, and the resident was not removed from the room despite the presence of the odor. Interviews with facility staff revealed a lack of communication and adherence to policy regarding maintenance work in resident rooms. A Licensed Practical Nurse and the Registered Nurse Unit Manager both acknowledged that residents should not be present during such repairs. However, the resident was not moved due to an episode of emesis. The Maintenance Director confirmed that residents should not be in the room during repairs unless there is a special circumstance, which was not the case here. The facility's Administrator stated that the maintenance staff's actions were against policy, and the staff member was subsequently written up.
Failure to Complete and Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure the completion and transmission of a Minimum Data Set (MDS) Discharge Assessment for a resident who was discharged from the facility. The resident, who had diagnoses including asthma, glaucoma, and hyperlipidemia, was discharged to home on February 16, 2024. However, the MDS Discharge Assessment was not completed or submitted at the time of the survey conducted from April 24, 2024, through May 1, 2024. This oversight was identified during a review of the resident's electronic medical record, which revealed the incomplete status of the discharge assessment. Interviews conducted during the survey revealed that the MDS coordinator acknowledged missing the completion of the MDS Discharge Assessment for the resident. The last assessment completed for the resident was a Comprehensive MDS 5-day assessment on December 1, 2023. The Director of Nursing was unaware of the incomplete discharge assessment, noting that the MDS department operates separately from the nursing department. This deficiency was cited under 10 NYCRR 415.11(a).
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received appropriate care to prevent pressure ulcers, as observed during a recertification survey. The resident, who was admitted with diagnoses including Non-Alzheimer's Dementia, muscle weakness, and schizophrenia, was identified as being at risk for pressure ulcers. Despite having a care plan intervention and physician's order to offload heels with heel booties while in bed, the resident was repeatedly observed in bed without the heel booties and with their heels resting directly on the mattress. There was no documentation indicating that the resident refused to wear the heel booties. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's care plan. A Certified Nurse Assistant stated they were not aware that the resident was supposed to use heel booties and had never seen them on the resident. Similarly, a Licensed Practical Nurse was unaware of any order for heel booties and mentioned that new orders are typically communicated through a 24-hour report, which they might have missed. This lack of adherence to the care plan and communication breakdown contributed to the deficiency in providing necessary pressure ulcer prevention care.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen area, specifically in the dishwasher section. During the recertification survey, it was observed that blue cup racks, which were claimed to be clean, were stored on the floor. These racks were later picked up and combined with other clean racks for further use. The facility's policy on the storage of utensils, trays, and racks to prevent contamination states that clean equipment should be stored in a clean, dry location to protect them from contamination. However, during an observation, a Dietary Aide was seen loading blue cup racks onto a cart and then picking up two racks from the floor, which were stored under the dishwasher transporter, and combining them with other racks. The Director of Dietary Service confirmed that this action was incorrect and that the clean racks were contaminated and should not be used.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the mishandling of a Clostridium Difficile (C. difficile) infection case. Resident #101, who was ventilator-dependent, was readmitted from the hospital with a C. difficile infection. Despite physician orders for contact precautions and the facility's policy requiring a private room for such infections, Resident #101 was placed in a shared room with another ventilator-dependent resident, Resident #27, who did not have a C. difficile infection. The Infection Preventionist was unaware of Resident #101's infection for five days post-readmission, resulting in a lack of proper tracking and monitoring. Additionally, the Infection Preventionist admitted to forgetting about the infection, which contributed to the oversight in infection control measures. Furthermore, the facility failed to adhere to its policy regarding the maintenance of respiratory care equipment. Resident #113, who was in a persistent vegetative state and dependent on a ventilator, had their ventilator tubing overdue for replacement by five days. The facility's policy required ventilator circuits to be changed every two weeks, but the tubing for Resident #113 was not changed as scheduled. The Director of Respiratory confirmed the oversight, acknowledging that the tubing should have been replaced earlier. These deficiencies highlight lapses in the facility's infection control practices and equipment maintenance protocols.
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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