Epic Rehabilitation And Nursing At White Plains
Inspection history, citations, penalties and survey trends for this long-term care facility in White Plains, New York.
- Location
- 120 Church Street, White Plains, New York 10601
- CMS Provider Number
- 335878
- Inspections on file
- 13
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Epic Rehabilitation And Nursing At White Plains during CMS and state inspections, most recent first.
A resident with chronic constipation did not receive a recommended medication after a GI consult due to a breakdown in communication and documentation. The LPN who received the resident after the appointment did not identify or act on the new order, and the consult documentation was not properly reviewed or filed. As a result, the recommended treatment was never initiated.
A resident with chronic constipation did not receive a recommended medication after a GI consult, as the consult documentation was missing from the chart and the medication was never ordered. Interviews with the DON, LPN, and NP revealed inconsistent processes for reviewing and filing consults, leading to incomplete documentation and failure to implement the consultant's recommendation.
Two residents experienced significant medication errors due to lapses in following medication administration protocols. One resident was given Lasix and Losartan without a physician's order, leading to hypotension and requiring medical intervention. Another resident was nearly given an incorrect dose of Tizanidine, but the error was caught before administration. The LPN involved admitted to not verifying the orders properly.
The facility failed to store medications securely, with two residents found with unauthorized medications at their bedside and medication carts left unlocked. One resident had no care plan for self-administration, while another was distressed by the removal of their inhaler. Staff acknowledged the carts should be locked, highlighting a deficiency in safety protocols.
A facility failed to ensure nursing staff had the necessary competencies to provide adequate care, as evidenced by missing competency assessments in personnel files for CNAs and licensed nurses. Communication issues between HR and Nursing departments, along with the removal of the Inservice Educator position, contributed to inconsistent training and evaluations. The DON and ADON acknowledged the inadequacy of the current system for evaluating staff competencies, with evaluations only conducted in response to specific incidents.
The facility failed to conduct annual performance reviews and provide required in-service training for CNAs, as evidenced by missing documentation in personnel files. The facility's assessment required staff competencies in areas like abuse and dementia care, but these were not included in orientation or annual training. Communication issues between HR and Nursing, along with the absence of an Inservice Educator, contributed to the deficiency. Interviews revealed inconsistencies in competency evaluations and training, with the Administrator unsure of compliance with required evaluations.
During a survey, three nurses at a facility were observed failing to follow infection control practices during medication administration. An RN did not sanitize hands or equipment between residents and touched a resident's eyelid with an eye dropper. An LPN failed to sanitize hands or clean a blood pressure cuff, while another LPN's long hair came into contact with medication cups and a nebulizer box. The facility's Assistant DON confirmed that nurses were trained on infection control, but these practices were not consistently followed.
The facility did not ensure staff wore identification badges, leading to confusion among residents with cognitive impairments and concern among visitors. Despite policies and efforts by the DON and Administrator, compliance was inconsistent, partly due to a non-functional badge machine and inconsistent staff education.
The facility did not ensure residents were informed of their rights during their stay, as resident rights were not reviewed during monthly Resident Council meetings. The Director of Social Services acknowledged that while rights information was provided upon admission and posted in day rooms, it was only available upon request thereafter, with no routine or annual discussions documented.
A facility failed to develop a comprehensive care plan for a resident self-administering an albuterol inhaler. The resident, with chronic conditions, was observed using the inhaler without a documented care plan. The facility's policy requires care plans to be developed by the Interdisciplinary Team, but the Director of Nursing confirmed that registered nurses did not initiate the necessary care plan in a timely manner.
A resident with cerebral infarction, anxiety disorder, and dementia exhibited distressing behaviors without receiving necessary non-pharmacological interventions or staff interaction. Despite having a comprehensive care plan, the facility failed to review or revise it to address the resident's behaviors. Observations showed the resident was often left alone and distressed in the dayroom, with staff failing to intervene or assist. Interviews revealed a lack of staff training in behavioral health management, contributing to the deficiency.
A resident with dementia was not engaged in meaningful activities as per their care plan, with observations showing scheduled activities were not conducted. Staff interviews revealed a lack of training in dementia care, and the Director of Recreation cited scheduling conflicts as a reason for activity cancellations, which were not reported to the Administrator.
A resident with a fractured front tooth experienced a delay in receiving emergency dental services due to the facility's failure to schedule an oral surgeon appointment in a timely manner. Despite the resident's ongoing pain and the dentist's referral for extraction, the appointment was not scheduled until months later, highlighting a lack of documentation and follow-up by the staff.
The facility failed to adhere to food safety and hand hygiene standards, as observed during a survey. Food items in refrigerators were not labeled or dated, and raw meats were improperly stored. Staff members were seen touching unsanitary surfaces with gloved hands and preparing food without changing gloves. Additionally, the food thermometer was not properly sanitized, and sandwiches and juices were not labeled. The Director of Food Services was responsible for overseeing these operations, but deficiencies were noted.
The facility failed to maintain sanitary conditions for waste disposal, as observed during a survey. A mouse was seen in the kitchen, and the dumpster was uncovered with a missing lid. Staff interviews revealed lapses in oversight and adherence to the waste management policy, which was undated and unsigned.
Failure to Implement Gastroenterology Consultation Recommendations for Chronic Constipation
Penalty
Summary
A deficiency occurred when a resident with a history of chronic constipation and multiple comorbidities, including dementia and schizoaffective disorder, did not receive care in accordance with professional standards following a gastroenterology consultation. The resident was recommended to start Linzess, a medication for chronic constipation, after a consult, but there was no documented evidence that this medication was ever ordered or administered. The facility's policy required that consultation recommendations be reviewed by the nurse manager or supervisor within 24 to 72 hours and that the attending physician or nurse practitioner be notified within 24 hours for review and potential orders. Upon the resident's return from the gastroenterology appointment, the LPN who received the resident documented that there were no recommendations from the consult. The LPN stated during interviews that they did not recall seeing any new orders on the consultation document and would have acted if there were any. The LPN also indicated that if there were no new orders, the consultation sheet would be filed in the resident's chart. However, the consult documentation recommending Linzess was not found in the resident's chart, and the medication was never ordered. Interviews with the DON, nurse practitioner, and assistant director of nursing revealed that the consultation documentation was either not received, misfiled, or not reviewed as required. The nurse practitioner stated that if they had seen the consult documentation, the order for Linzess would have been entered. The DON confirmed that the process involves reviewing the consult and informing medical staff of recommendations, but in this case, the consult form could not be located, and the recommended medication was not initiated.
Physician Review and Documentation Lapse for Medication Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician reviewed a resident's total program of care, including medications and treatments, at each required visit. Specifically, a resident with a history of chronic constipation was seen by a gastroenterologist, who recommended starting the medication Linzess. However, there was no documented evidence that this medication was ever ordered for the resident, nor was the consultation documentation available in the resident's record for review. The resident in question had multiple diagnoses, including dementia, schizoaffective disorder, and chronic constipation, and was dependent on staff for most activities of daily living. The care plan for constipation included several medications and interventions, and the gastrointestinal consult recommended adding Linzess to the regimen. Despite this, the medication was not ordered, and the consult documentation was missing from the resident's chart. Interviews with facility staff revealed that the process for reviewing and filing consultation documentation was not consistently followed. The DON confirmed the consult was not in the chart and had to be obtained by phone. The LPN described the usual process for handling consults, and the nurse practitioner stated they did not recall seeing the consult or the recommendation for Linzess, despite documenting that the consultation services were reviewed. This lapse resulted in the resident not receiving the recommended medication and incomplete documentation in the medical record.
Medication Errors Affect Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #202 was administered Lasix and Losartan without a physician's order, which led to the need for frequent blood pressure monitoring and intravenous fluids. The error occurred because the nurse administered the medication intended for the resident's roommate. The nurse admitted to being distracted and failing to verify the resident's identity before administering the medication. This resulted in Resident #202 experiencing hypotension, requiring medical intervention. Resident #96 was nearly given an incorrect dose of Tizanidine, a muscle relaxant, during a medication administration observation. The LPN involved took a 4 mg tablet instead of the prescribed 2 mg dose. The error was caught by a surveyor before the medication was administered. The LPN acknowledged overlooking the physician's order and admitted to making a mistake by not checking the order prior to administration. This incident highlights a lapse in following the facility's medication administration policy, which requires verification of the correct medication and dosage.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with the manufacturer's specifications and professional standards of practice. Specifically, two residents were found with medications at their bedside without proper authorization or care plans to self-administer these medications. Resident #12 had an ipratropium nasal spray and an albuterol sulfate inhaler on their bedside table, and they were not following the physician's instructions to rinse their mouth after using the inhaler. There was no documented care plan for Resident #12 to self-administer their medications. Similarly, Resident #96 was found with multiple medications, including Trelegy inhalers, a Flonase nasal spray, an ipratropium nasal spray, an albuterol sulfate inhaler, and a triamcinolone acetonide ointment at their bedside. Although there was a physician's order for Resident #96 to self-administer the albuterol inhaler, there was no assessment or care plan in place for self-administration of any medications. Resident #96 expressed confusion and distress when their inhaler was removed by staff, indicating a lack of communication and proper procedure. Additionally, the facility failed to secure medication and treatment carts properly. The 5th Floor Medication Cart and Treatment Cart were observed unlocked and unattended, making them accessible to residents, visitors, and unlicensed staff. This oversight was acknowledged by the staff, including a Registered Nurse and an LPN, who admitted that the carts should always be kept locked. These lapses in medication storage and security represent a significant deficiency in the facility's adherence to safety protocols.
Inadequate Staff Competency and Training in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to provide adequate care and maintain resident safety and well-being. This deficiency was observed on two resident units, where personnel files for six Certified Nursing Assistants (CNAs) lacked evidence of competency in basic nursing skills and activities of daily living. Additionally, four licensed nursing personnel files did not contain competency assessments for medication management. The facility's assessment indicated that staff should have competencies in various areas, including abuse prevention, resident rights, and dementia care, but these were not documented in the personnel records. The Human Resources Director acknowledged communication issues between the HR and Nursing departments, particularly regarding disciplinary actions and performance concerns. The facility had removed the Inservice Educator position, which was responsible for staff training, and the duties were absorbed by the Director of Nursing (DON). The Assistant Director of Nursing (ADON) stated that competency evaluations were only conducted in response to specific incidents or complaints, rather than consistently. The facility lacked computer terminals for staff to complete online training, and behavior management and dementia care were not included in the annual inservice training. Interviews with the DON and ADON revealed that the system for evaluating nursing staff competencies was inadequate, with evaluations not being consistently performed. The DON, who assumed the role in June 2024, was now responsible for inservice training and competency evaluations, but acknowledged that these were not consistently conducted. The facility's Administrator was unsure if competencies and performance evaluations were being performed as required, indicating a lack of oversight and accountability in ensuring staff competency.
Deficiency in Nurse Aide Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to ensure that each nurse aide received a performance review at least once every 12 months and regular in-service education based on the outcomes of these reviews. This deficiency was observed on the 5th Floor of the facility, where 6 out of 6 Certified Nursing Assistant (CNA) personnel files lacked evidence of performance evaluations and in-service training based on evaluation results. The facility's assessment documented that staff were expected to have competencies in various areas, including abuse, resident rights, and dementia care, but there was no documented evidence that these competencies were part of the orientation or annual in-service package. The facility's survey report indicated that each nurse aide was required to receive 6 hours of paid in-service training every 6 months, but the review of personnel records showed no evidence of the required 12-hour annual in-service training. Additionally, the facility did not include behavioral health care and management in the list of in-service topics provided to staff. The Human Resources Director acknowledged communication issues between Human Resources and the Nursing Department, which affected the handling of disciplinary actions and performance evaluations. The facility also lacked an Inservice Educator, as the position was absorbed into the Director of Nursing's responsibilities. Interviews with the Director of Nursing and the Assistant Director of Nursing revealed inconsistencies in conducting competency evaluations and in-service training for nursing staff. The Director of Nursing admitted that the system for ensuring competency evaluations was inadequate, and the Assistant Director of Nursing stated that they only conducted evaluations related to specific incidents or complaints. The Administrator was unsure if competencies and performance evaluations were being performed as required, indicating a lack of oversight and accountability in the facility's processes for maintaining staff competencies.
Infection Control Deficiencies During Medication Administration
Penalty
Summary
During a recertification survey, the facility was found to have deficiencies in infection control practices by three nurses during medication administration. Registered Nurse #3 failed to practice hand hygiene or sanitize vital signs equipment between residents. This nurse also touched a resident's eyelid with an eye dropper during administration, which is against infection control protocols. Additionally, the nurse placed a thermometer on a resident's breakfast tray without sanitizing it and did not clean the blood pressure cuff between uses. The nurse acknowledged the importance of hand hygiene and equipment sanitization but did not adhere to these practices. Licensed Practical Nurse #2 also neglected to sanitize their hands or wipe down the blood pressure cuff before and after taking a resident's blood pressure. Licensed Practical Nurse #1 was observed with long hair that came into contact with medication cups and a nebulizer treatment box, which they admitted was a poor infection control practice. The Assistant Director of Nursing confirmed that nurses were trained on the importance of hand hygiene and equipment sanitization, but these practices were not consistently followed during the survey observations.
Failure to Ensure Staff Identification and Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by several nursing staff on the Dementia unit not wearing identification badges. This was observed during the recertification survey, where Certified Nursing Assistants (CNAs) were seen without identification badges, which is against the facility's policy. The absence of identification badges was noted to cause confusion among residents, particularly those with cognitive impairments, and concern among visitors and families regarding staff accountability and the dignity and respect afforded to residents. The issue was compounded by the facility's inconsistent staff education and a non-functional identification badge machine during a period when the Human Resources Director was on leave. Despite efforts by the Director of Nursing and the Administrator to ensure compliance through regular rounds, the problem persisted. The lack of identification badges was identified as a persistent concern, and new employees were reportedly provided with badges before working on resident units, yet compliance remained an issue.
Failure to Review Resident Rights During Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their rights and the rules and regulations governing resident conduct and responsibilities during their stay. Specifically, the facility did not provide or review resident rights during monthly Resident Council meetings. The policy and procedure for Resident Council did not include documentation of a review of residents' rights, and meeting minutes from April 2024 to August 2024 lacked evidence of such reviews. During a Resident Council meeting on October 4, 2024, residents confirmed that their rights were not discussed in these meetings, although they received information about their rights upon admission. The Director of Social Services/Grievance Official acknowledged awareness of the Resident Council meetings and reviewed the minutes post-meeting with the Director of Activities. They stated that resident rights information was included in admission packets and posted in day rooms, but after admission, this information was only available upon request. There was no routine or annual discussion of resident rights, and the facility could not provide documentation that these rights were reviewed annually or during the last five Resident Council meetings or care plan meetings.
Failure to Develop Comprehensive Care Plan for Self-Administering Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was self-administering medication. The resident, who had chronic obstructive pulmonary disease, chronic atrial fibrillation, chronic rhinitis, and shortness of breath, was observed with an albuterol sulfate inhaler in their room. The resident stated they could use the inhaler whenever needed for chest tightness, and it was always at their bedside. However, there was no documented evidence in the electronic medical record that a Self-Administration of Medication Care Plan was initiated prior to a specific date. The facility's policy requires the Interdisciplinary Team, in conjunction with the resident and their family or legal representative, to develop and implement a comprehensive, person-centered care plan for each resident. This care plan should describe the services necessary to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Director of Nursing acknowledged that registered nurses are responsible for initiating care plans and that all residents should have care plans reflecting their plan of care. The deficiency was identified during a recertification survey, highlighting the lack of a timely care plan for the resident's self-administration of medication.
Failure to Provide Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses of cerebral infarction, anxiety disorder, and unspecified dementia, exhibited behaviors such as screaming, yelling, and flailing arms without any non-pharmacological interventions or staff interaction to address these behaviors. Despite having a comprehensive care plan that included interventions for cognition, mood, and behavior, there was no documented evidence that these plans were reviewed or revised to include non-pharmacological interventions. Observations during the survey revealed that the resident was often left alone in the dayroom without staff interaction or assistance, even when they were visibly distressed or in need of help. The resident was observed in a wheelchair with their head in their hands, hair unkempt, and clothing stained, without any staff acknowledging or interacting with them. On multiple occasions, the resident was heard screaming and expressing hunger and confusion, yet staff did not intervene or provide the requested assistance. The lack of staff response and interaction was consistent, even when the resident was tearful and expressed feelings of loneliness. Interviews with staff indicated a lack of training and awareness regarding behavioral health management. Certified Nursing Assistants reported that some resident behaviors were ignored, and there was no evidence of behavioral health and management training being part of the facility's annual inservice requirements. The Director of Recreation acknowledged scheduling conflicts that led to the cancellation of activities, which further limited the resident's engagement and social interaction. The facility's failure to implement and document appropriate behavioral interventions and staff training contributed to the deficiency in providing necessary care and services to the resident.
Deficiency in Dementia Care and Activity Engagement
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, as evidenced by the lack of engagement in meaningful activities. Resident #24, who was moderately cognitively impaired and diagnosed with dementia and anxiety disorder, was observed multiple times sitting alone in the dayroom without participating in any activities. The resident's care plan included interventions such as encouraging socialization and engagement, but there was no documented evidence that the care plan was reviewed or revised following the Minimum Data Set 3.0 assessment. Observations revealed that scheduled activities were not conducted as planned. On several occasions, the activity calendar listed specific activities, but these were not observed to be taking place. For instance, on one occasion, the Recreation Leader was seen watching two residents color, while other residents, including Resident #24, were left unengaged. Interviews with staff indicated a lack of awareness and training related to dementia care, with some staff unaware of the unit's designation as a Dementia Unit. The Director of Recreation acknowledged issues with the activity schedule, citing conflicts with kitchen timing as a reason for delays and cancellations. Despite these challenges, the Director did not escalate the issue to the Administrator or include it in a Quality Assurance Performance Improvement Project. The Administrator was unaware of the activity cancellations and could not specify how the facility measured its performance in providing dementia care. Additionally, the Human Resources Director confirmed that dementia care was not part of the facility's annual inservice requirements for staff.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide or obtain emergency dental services for Resident #56, who was evaluated by a dentist for a fractured front tooth on July 25, 2024, and was given a referral for extraction. Despite the resident experiencing discomfort while eating and requesting the extraction, the facility delayed scheduling the appointment with an oral surgeon until October 10, 2024. This delay occurred despite the resident's ongoing complaints of pain and the dentist's follow-up to ensure the referral was processed. The deficiency was further compounded by a lack of documentation and follow-up by the facility staff. Staff #22, responsible for scheduling the appointment, failed to document attempts to make the appointment before going on vacation, and no other staff followed up on the matter. The Director of Nursing confirmed that there was no note indicating attempts to schedule the appointment, and the resident continued to experience discomfort due to the delay in receiving necessary dental care.
Food Safety and Hand Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure food was stored and handled in accordance with professional standards for food safety practice during a recertification survey. Observations revealed that food items in the nutrition and storage refrigerators were not labeled and dated, including apple sauce, sliced meats, yellow cheese, frozen meat, and coleslaw. Additionally, raw meats were improperly stored with other items, such as Jello and ice cream, on the same shelf. These practices were contrary to the facility's undated policy and procedure titled Food Inventory, Receiving and Storage, which required each food item to be labeled and dated, and raw meats to be stored below all other items in the refrigerator. Further observations during a second tour of the kitchen revealed that staff members were not adhering to proper hand hygiene practices. Food Service Workers were seen touching unsanitary surfaces and equipment with gloved hands and then preparing food without changing their gloves. Additionally, the food thermometer was not sanitized with alcohol wipes after each use, and sandwiches and juices on the tray line were not labeled and dated. Interviews with the Director of Food Services and the Dietitian confirmed that the Director was responsible for overseeing kitchen operations and staff training on hand hygiene, but these practices were not being followed, leading to the deficiencies noted.
Improper Waste Disposal and Pest Attraction
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, leading to unsanitary conditions that could attract pests. During the recertification survey, it was observed that the dumpsters and compactors on the exterior of the building were not maintained in a sanitary condition. Specifically, a mouse was seen in the kitchen, and the dumpster was found uncovered with a missing lid. Additionally, a garbage bag was found on the ground between the dumpsters. These observations indicate a failure to adhere to the facility's Waste Management Policy and Procedure, which requires waste to be in leak-proof and secured containers. Interviews with facility staff revealed lapses in responsibility and oversight. The Food Service Director acknowledged the dumpster should have been covered but was unsure how long it had been uncovered. The Director of Housekeeping/Laundry admitted to not checking the dumpsters on the scheduled day, which was part of their responsibility to ensure cleanliness. The Administrator, who was responsible for approving the waste management policy, was unaware of the dumpster's condition and had not conducted environmental checks that would have identified the issue. The policy itself was undated and unsigned, indicating a lack of formal documentation and accountability.
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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