Elcor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Horseheads, New York.
- Location
- 48 Colonial Drive, Horseheads, New York 14845
- CMS Provider Number
- 335053
- Inspections on file
- 17
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Elcor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that multiple resident rooms and shared bathrooms were not maintained in a sanitary, comfortable condition, with sticky, malodorous floors and a shared bathroom repeatedly observed with urine, liquid on the floor, and strong odor despite facility policies assigning daily cleaning to housekeeping and bodily fluid cleanup to nursing staff. A resident with dementia and severe cognitive impairment in a shared room was repeatedly observed in bed without a privacy curtain, even while other roommates had curtains and another resident was seated facing the bed, and staff acknowledged that privacy curtains are required and should not be absent for more than a day.
Two residents who were cognitively intact but dependent on staff for ADLs did not receive consistent grooming and hygiene assistance as required by facility policy and their care plans. One resident with necrotizing fasciitis, diabetes, and chronic pain was repeatedly observed with long chin hair and dirty fingernails, with no documented showers, facial hair removal, nail care, or hand hygiene before meals over an extended period, and no records of refusals or reattempts. Another resident with hemiplegia, heart failure, and diabetes, requiring two-person assistance for showers and hygiene, had multiple dates with no documented hygiene care or showers, reported unfulfilled requests for shaving, and was repeatedly observed with significant beard growth. Staff interviews described expectations for regular shaving offers, documentation of refusals, and reattempts of missed care, but the clinical records did not reflect that these practices occurred.
Two residents were exposed to accident hazards when staff did not follow facility policies for medication administration and smoking safety. For one resident with mild dementia, diabetes, COPD, and dysphagia, an LPN prepared multiple oral and inhaled medications and left them unattended at the bedside, despite no assessment or MD order for self-administration and policies requiring an IDT determination before bedside medications are allowed. For another resident with hemiplegia, hemiparesis, and dementia, the required interdisciplinary Smoking/Tobacco Safety Screen was incomplete, even though the care plan called for it and a prior note documented the resident leaving the building early in the morning to smoke and having half-smoked cigarettes on the room floor. Surveyors later observed a cigarette on the floor of this resident’s room, and the resident reported keeping cigarettes and a lighter in the room and going outside to smoke, while the OT and DON confirmed the smoking safety assessment had not been fully completed.
The facility failed to provide suitable, nourishing snacks consistent with resident needs and preferences, offering only limited items such as crackers, pudding, applesauce, and soda, with no meaningful alternatives. A resident with protein-calorie malnutrition and depression, for whom snacks between meals were very important, had a care plan that did not address snack interventions or preferences and reported only receiving pudding without options and not consistently receiving ordered double portions. Another resident with dysphagia, CHF, and hypertension reported that preferred snacks like sandwiches, cookies, and ice cream were no longer available, leaving only basic items. Multiple CNAs, an LPN, and dietary staff confirmed that snack choices had been reduced for cost reasons, residents complained daily, and staff sometimes bought snacks with personal funds. Resident Council and Food Committee records documented ongoing, unresolved complaints about limited snack variety and inconsistent stocking of items such as bread and peanut butter.
Surveyors found that the facility did not follow its own kitchen cleaning schedule, with damaged and ajar ventilation hood filters over the cook top, heavy grease and food debris on the oven and cook top surfaces, and a broken floor section under a steamer containing standing water and food debris. These unsanitary conditions persisted on re-observation. During meal service, disposable plates and utensils were used on the tray line for multiple units because of a shortage of non-disposable plates and silverware, which the Food Service Director attributed to missing items and back-ordered replacements. A resident reported that it would be preferable to have real silverware and plates during meals.
The facility did not implement an effective pest control program on one resident unit, as pest control records showed no documented inspection or treatment of resident rooms despite a policy stating that resident floors would be included in monthly and as-needed extermination rounds. On the Colonial Ridge South unit, surveyors observed multiple small black flies on the walls of two resident bathrooms, along with sticky floors and a foul odor. A family member reported that the flies had been present for some time and previously reported, and described using towels to swat them. The Director of Maintenance stated that the bathrooms lacked exhaust, was not aware of flies in resident rooms, and indicated reliance on the pest control vendor for all inspections and treatments.
Six cognitively intact residents with significant medical conditions were observed smoking on facility property, storing smoking materials in unsecured locations, and discarding cigarette butts outside, despite a facility policy prohibiting smoking. Facility staff did not conduct smoking safety assessments or care planning, and did not provide receptacles for cigarette disposal, contributing to an environment with accident hazards.
Surveyors found that several cognitively intact residents experienced disrespectful and undignified treatment from staff, including being ignored during care, spoken to in a 'nasty' or uncaring manner, addressed with inappropriate terms, and exposed to staff using foul language or answering personal cell phones during care. Facility leadership acknowledged awareness of some of these behaviors, but staff did not consistently uphold residents' rights to dignity and respect.
Two residents with mental health diagnoses reported physical and verbal abuse by nursing staff, including one incident resulting in visible bruising. Facility leadership documented and investigated the allegations but did not report them to state authorities, relying on their interpretation of state guidelines that allowed them to rule out the allegations within two hours.
Unsanitary Resident Areas and Lack of Privacy Curtain in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, orderly, and comfortable environment in multiple resident units and bathrooms, contrary to its own cleaning policies. Observations on several dates showed sticky, malodorous floors in multiple rooms on Colonial Ridge South, and a shared bathroom used by a cognitively intact resident had brown liquid in the toilet bowl and large quantities of clear, malodorous liquid on the floor. Subsequent observations of the same shared bathroom revealed yellow liquid and paper in the toilet bowl, yellow liquid on the toilet seat, and persistent malodorous liquid on the floor, with the resident reporting that the bathroom was frequently in an unsanitary condition. Facility staff interviews revealed that housekeeping was responsible for once-daily cleaning and sanitizing of bathrooms and rooms, while nursing staff were expected to clean bodily fluids and unsanitary bathrooms and then notify housekeeping for disinfection. The deficiency also includes failure to ensure privacy and a homelike environment for a resident in a shared room who did not have a privacy curtain in place, despite facility policy stating residents have the right to privacy through the use of privacy curtains in shared rooms. This resident had dementia, severe cognitive impairment, and required assistance with personal hygiene and dressing. Over multiple observations, the resident was seen in bed or sleeping in a shared room without a privacy curtain, while other residents in the same room had curtains present, and at one point another resident was seated facing the bed. Staff, including a CNA, an LPN Unit Director, and the Administrator, acknowledged that residents in shared rooms should have privacy curtains and that a curtain should not be absent for more than a day, confirming that the resident’s lack of a privacy curtain was inconsistent with facility expectations and policy.
Failure to Provide and Document Required Grooming and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, to residents who were unable to perform these tasks independently. Facility policies required staff to assist with self-care needs such as hair combing, bathing, grooming, shampooing, shaving, and nail care, including soaking hands and using a nail brush to remove debris. Despite these policies, documentation and observations showed that required hygiene care, including showers, facial hair removal, nail care, and hand hygiene before meals, was not consistently provided or documented, and refusals or reattempts were not recorded. One resident, who had diagnoses including necrotizing fasciitis, type 2 diabetes, and chronic pain, was assessed as cognitively intact and needing substantial assistance with personal hygiene, including hair combing and shaving, without exhibiting rejection of care. The resident’s care plan called for staff assistance with baths or showers on specific evenings and with hygiene before and after meals. However, review of progress notes and Point of Care documentation over a one-month period revealed no evidence that the resident received showers, facial hair removal, or nail care, and there was no documentation of refusals or reattempts. Multiple observations showed the resident with approximately one-inch chin hair, visible debris under fingernails, and no hand hygiene offered before meals, while staff interviews indicated that the resident did not refuse grooming or nail care and would accept assistance if offered. Another resident, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic diastolic heart failure, and diabetes, was also cognitively intact and required staff assistance with showering and personal hygiene without rejecting care. The resident’s care plan and Kardex directed staff to provide showers and hygiene care with two-person assistance on a weekly schedule. Point of Care documentation over several weeks showed multiple dates with no recorded hygiene care and no documentation of refusals or reattempts, and the Treatment Administration Record showed no evidence that showers were provided during the review period. The resident reported requesting a shave several days earlier and again after a shower without receiving follow-up, and repeated observations showed approximately one-inch beard growth. Staff interviews confirmed expectations that residents be asked each shift about shaving, that refusals be documented, and that missed hygiene care be reattempted and reported, but records did not show that these expectations were met.
Failure to Prevent Medication and Smoking-Related Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for two residents. For one resident with mild dementia, diabetes, COPD, and a care plan noting risk for aspiration and choking related to dysphagia, surveyors observed multiple prepared medications left unattended on the overbed table, including gabapentin, metformin, duloxetine, iron, lactulose, Protonix, a nasal spray, and an inhaler. The resident’s record contained no assessment or physician order for self-administration of oral or inhaled medications, despite facility policies requiring an interdisciplinary assessment and physician order before medications may be left at the bedside. An LPN acknowledged leaving the medications with the resident and stated they should not have done so, and both the RN Manager and DON confirmed that medications should not be left with residents unless they are assessed and ordered for self-administration. The second issue concerns unsafe smoking practices and incomplete smoking safety assessment for a resident with hemiplegia, hemiparesis following a stroke, and dementia, who was documented as cognitively intact. Facility smoking policy required an interdisciplinary assessment deeming a resident safe to smoke unsupervised, secure storage of ignition devices, staff notification prior to smoking, and smoking only in designated areas at least 30 feet from the building. The resident’s care plan required completion of a Smoking/Tobacco Safety Screen, but the screen contained only one LPN manager’s electronic signature and was missing four required interdisciplinary signatures. A prior progress note documented that the resident exited the facility at 4:00 AM to smoke after obtaining the exit door code and had half-smoked cigarettes on the room floor with a smell of freshly lit cigarettes. During observations, a cigarette was seen on the floor of the resident’s room, and the resident reported keeping cigarettes and a lighter in the room and going outside to smoke. The OT and DON confirmed the Smoking/Tobacco Safety Screen was not completed and that the resident did not have a completed evaluation for safe smoking.
Failure to Provide Suitable, Nourishing Snacks Consistent With Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure suitable, nourishing snacks were available and provided in accordance with resident needs, preferences, and care plans. Surveyors found that snacks being distributed consisted primarily of pudding, graham crackers, saltine crackers, applesauce, and soda, with no meaningful alternatives when those items were not desired or appropriate. Observation of the nourishment room showed only limited beverages, crackers, and an almost empty freezer, confirming the restricted snack inventory. Staff interviews revealed that previously available items such as cookies, fig newtons, cheese crackers, and ice cream had been discontinued, and that residents complained daily about the lack of variety and availability. One resident with protein-calorie malnutrition, anxiety disorder, and major depressive disorder was cognitively intact and had an assessment indicating it was very important to have snacks between meals. The resident’s care plan addressed potential nutritional deficit with double portions at meals but did not include any interventions related to snacks or snack preferences. Dietary documentation showed a one-time update of food preferences without ongoing assessment or follow-up regarding snacks. This resident reported only receiving pudding for snacks without additional options, stated that no one had discussed snack preferences, and produced a meal ticket showing an order for two sandwiches when only one was received. Another cognitively intact resident with dysphagia, congestive heart failure, and hypertension reported that snacks were not regularly offered and that preferred items such as sandwiches, cookies, and ice cream were no longer available, leaving only crackers and applesauce as options. Multiple CNAs, an LPN, and the dietary clerk confirmed that snack choices were limited to crackers, pudding, applesauce, and similar items, and some staff stated they purchased snacks with personal funds due to the facility’s limited offerings. The administrator acknowledged that snack availability and resident preferences had been an ongoing concern, that snack options were reduced due to cost without exploring alternatives, and that prior efforts to obtain and follow up on resident preferences were ineffective. Resident Council and Food Committee documentation over several months showed repeated resident complaints about snack availability and variety, with inconsistent stocking of items such as bread and peanut butter and no documented effective resolution.
Failure to Maintain Sanitary Kitchen Conditions and Adequate Dishware for Meal Service
Penalty
Summary
Surveyors identified that the facility failed to follow its own kitchen cleaning schedule and maintain sanitary conditions in the main kitchen. Record review showed the facility had a written cleaning schedule requiring quarterly ventilation hood cleaning, daily floor cleaning, and semi-annual oven and range cleaning in May and November, but there was no documentation that these tasks were completed as required. During observations, the ventilation hood filters over the cook top were found damaged and ajar, allowing grease and vapors to bypass the filtration system, and there were significant soiled black areas of grease and food debris on the backsplash, front, and sides of the oven and cook top units. The Food Service Director reported not being aware that the hood filters were damaged or improperly fitted and was unsure how often deep cleaning of the cooking equipment was performed. Additional observations showed an approximately three-foot by three-foot area of broken floor tiles under the steamer with standing water and food debris present. On a subsequent observation date, the damaged ventilation hood filters, broken flooring with standing water and debris, and heavily soiled oven and cook top units remained unchanged. During meal service observations, disposable plates and utensils were being used on the kitchen tray line for meals delivered to two units because there were not enough non-disposable plates and silverware available. The Food Service Director stated that more plates had been ordered about a month earlier and were on back order, and estimated the kitchen was short about 60 pieces of silverware and 100 plates, noting that plates and silverware would go missing. A resident eating lunch at a nurses' station stated it would be nice to use real silverware and plates during meals.
Failure to Implement Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program for one of eight resident units reviewed, specifically the Colonial Ridge South unit. The facility’s undated pest control policy stated that a technician from a contracted licensed extermination service would make monthly and as-needed visits, including rounds to resident floors, administrative offices, common areas, pantries, day rooms, utility areas, and complaint sites. However, review of weekly pest control records from late November through early April showed no documented inspection or treatment of resident rooms, and there was no additional pest control documentation available after early April. During observations on the Colonial Ridge South unit, surveyors noted multiple small black flies in resident bathrooms. In one resident room bathroom, four small black flies were seen on the wall, the bathroom floor was sticky, and there was a foul odor. A resident’s family member reported that the flies had been present for an ongoing period, had previously been reported to the facility, and that they used towels in the bathroom to swat the flies. In a shared bathroom between two other resident rooms, three small black flies were observed on the wall, with similarly sticky floors and a foul odor. The Director of Maintenance stated that the residents’ bathrooms in the Colonial Ridge building did not have exhaust, that they were not aware of flies in resident rooms, and that the pest control vendor was expected to handle all treatments and inspections.
Failure to Assess and Care Plan for Resident Smoking in Violation of Facility Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for six residents identified as cigarette smokers. Despite the facility's policy prohibiting smoking on campus, observations revealed that these residents were smoking on facility property, including areas near entrances and dumpsters. Cigarette butts and smoking paraphernalia, such as lighters and cigarettes, were found in residents' rooms and on the ground outside. Some residents stored cigarette butts in their pockets and later disposed of them offsite. The facility did not provide cigarette receptacles, and staff reported that safety assessments and care planning for smoking were not conducted because the facility is designated as smoke-free. Interviews with facility leadership confirmed that no smoking assessments or care plans were in place for the identified residents, and that smoking materials were not consistently secured as required by the facility's admission agreement. The residents involved had medical conditions such as peripheral vascular disease, congestive heart failure, cerebral infarction, and conversion disorder with seizures, and were documented as cognitively intact. The lack of assessment, care planning, and secure storage of smoking materials contributed to the deficiency, as did the absence of designated smoking areas or receptacles for cigarette disposal.
Failure to Ensure Respectful and Dignified Treatment of Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect, as required by policy and regulation. Multiple residents, all cognitively intact, reported negative interactions with staff across several units. One resident stated that staff do not like them and are not nice, while another reported being repeatedly ignored by a registered nurse during care, with their questions about the care process going unanswered. Another resident's family member overheard staff using foul language in the resident's presence. Additional residents described staff as speaking to them in a disrespectful or 'nasty' manner, being short or uncaring, and using inappropriate terms such as 'sweetie,' 'honey,' or 'baby.' One resident reported that staff talked down to them and answered personal cell phones during care, including while changing incontinence briefs. Interviews with facility leadership confirmed awareness of some of these issues, with the Director of Resident Care Services acknowledging that staff should not use terms like 'honey' or 'baby' and that staff had been spoken to about their demeanor. The Assistant Director of Nursing stated that new employees receive a handbook covering resident rights, including the right to be treated with dignity. Despite these policies, the observations and resident interviews demonstrated that staff did not consistently uphold residents' rights to respectful and dignified treatment.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by policy and regulation. For two residents, one with schizoaffective and bipolar disorders and another with bipolar and conversion disorders, allegations of physical and verbal abuse were made against nursing staff. In one case, a resident reported being dragged down the hall by a nurse, resulting in visible bruising to the knees. In the other case, a resident reported feeling verbally abused by a nurse. Both allegations were documented by staff and discussed with supervisory personnel. Despite these reports, facility leadership, including the Administrator, Director of Resident Care Services, Assistant Director of Nursing, and Director of Nursing, determined that the allegations were not reportable to the New York State Department of Health. They based this decision on their interpretation of the 2016 state complaints manual, concluding that if an allegation is ruled out within two hours, it does not require reporting. As a result, the facility did not report the allegations to the appropriate authorities as required by state law and facility policy.
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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