Evergreen Commons Rehabilitation And Nursing Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in East Greenbush, New York.
- Location
- 1070 Luther Road, East Greenbush, New York 12061
- CMS Provider Number
- 335110
- Inspections on file
- 19
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Evergreen Commons Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
A resident with dementia, prior femur fracture, and severe cognitive impairment had a care plan identifying fall risk and requiring use of proper footwear/non-skid socks, along with floor mats and bed in low position. The resident was dependent on staff to don and doff footwear. During a night shift, a CNA provided incontinence care and documented that the resident did not have appropriate footwear on, and an LPN also documented that the resident lacked appropriate footwear. Later, the resident was found nude, face down on the floor next to the bed on a floor mat, and subsequently complained of hip pain; imaging confirmed a femoral fracture. There was no documentation that non-skid socks were in place at the time of the fall or that the resident had refused them, indicating the care-planned intervention for non-skid footwear was not implemented.
A resident with chronic kidney disease on dialysis, cellulitis, and metastatic endometrial cancer left for hemodialysis alert and communicative and returned hours later slumped in a wheelchair, unresponsive, and soon pronounced deceased. Facility video, a friend’s written statement, and staff interviews showed that the resident became disoriented and distressed at dialysis, was reportedly unresponsive when brought out by dialysis staff, and arrived back at the facility limp and drooling. The dialysis communication sheets for two treatments had no entries from the dialysis center, and multiple attempts by nursing leadership to reach the dialysis provider were unsuccessful, leaving the events during treatment unexplained. Despite facility policies requiring reporting and investigation of incidents not consistent with routine care and situations where abuse or care plan violations could not be ruled out, no internal investigation was conducted and the incident was not reported to the New York State Department of Health.
A resident with CKD on dialysis, cellulitis, and metastatic endometrial cancer left for hemodialysis alert, upright, and communicating, with oxygen in place. Facility policy required a dialysis communication book with an Interfacility Report completed by facility staff before transport and by the dialysis unit before return, but the dialysis sections for this and a prior treatment were left blank. On return, video and a friend’s statement showed the resident slumped, limp, drooling, and unresponsive, with staff unable to obtain vital signs and an RN confirming no pulse, mottling, and cyanosis before the resident was pronounced dead. Despite policies requiring thorough investigation of all unusual occurrences and potential injuries of unknown source, and despite unsuccessful attempts to reach the dialysis center, facility leadership, including the DON and Administrator, acknowledged that no investigation or incident report was completed into the events at dialysis or during transport that preceded the resident’s death.
A resident with chronic kidney disease on dialysis, cellulitis, and metastatic endometrial cancer received intermittent O2 therapy without a physician’s order or related care plan interventions, contrary to facility policy requiring a specific medical order and respiratory care plan. MAR and vital sign records documented the resident on 2L O2 on multiple occasions, including pre-dialysis, and staff reported the resident returning from dialysis on portable O2, being supplied with O2 tanks for trips, and having O2 in place at the time of death. The Administrator acknowledged that an O2 order should have been in place.
Failure to Implement Care-Planned Non-Skid Footwear Leading to Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from neglect by not implementing a care-planned intervention requiring proper footwear/non-skid socks to prevent falls. The facility’s abuse/neglect policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required investigation of all potential neglect incidents. The resident had a care plan for being at risk for falls that included bilateral floor mats, encouraging the resident to wear proper footwear/non-skid socks, maintaining the bed in the lowest position, providing a call bell and frequently used items within reach, a perimeter mattress, early get up, and PT/OT evaluation as needed. The resident had diagnoses including dementia, a left femur fracture, and an acute gastric ulcer with hemorrhage, and was assessed as having severe cognitive impairment, being able to be understood but rarely/never understanding others. The care plan for ADLs/mobility documented that the resident was dependent on a mechanical lift with two staff for sit-to-chair transfers and required one-person assistance to put on and take off footwear. On the night of the incident, a CNA documented that they had provided incontinence care approximately 30–40 minutes before the fall and indicated on the incident statement that the resident did not have appropriate footwear on at that time. Another staff statement from an LPN also indicated that the resident did not have appropriate footwear on. At approximately 4:10 AM, the resident was found on the floor next to the bed, face down, nude, with a small amount of feces observed, lying on or near a floor mat with the bed in the lowest position. An RN assessment initially documented no apparent injury and neurological checks within normal limits, with the resident denying pain and no pain observed in the extremities. However, a later post-fall RN assessment documented that the resident complained of right hip pain and had facial grimacing with range of motion, and an x-ray subsequently showed a right femoral fracture. There was no documented evidence that the resident was wearing non-skid socks at the time of the fall, and no documentation that the resident had refused to wear them, despite the care plan intervention to encourage proper footwear/non-skid socks.
Failure to Report Unexplained Death Following Dialysis to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged incident related to possible abuse, neglect, exploitation, or mistreatment to the New York State Department of Health as required, following the death of a resident who had been transported to and from dialysis. Facility policy required that all occurrences not consistent with routine operations and resident care that had or may have caused physical injury or harm be reported, reviewed, and thoroughly investigated, including completion of an Accident/Incident Report and, when applicable, abuse investigation materials. The policy also specified that injuries of unknown origin and incidents where the facility could not rule out abuse or a care plan violation must be reported to the Department of Health and that the Director of Investigations and Administrator be notified as soon as possible. Despite these requirements, there was no documented evidence that the events surrounding this resident’s death were reported to the state. The resident had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was assessed as minimally cognitively impaired and able to understand and be understood. On the day of the incident, the resident left the facility around late morning for hemodialysis and returned in the early evening. Video footage showed the resident leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A second video showed the resident returning from dialysis slumped to the left, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the driver or the friend who was waiting. The friend later documented that the resident arrived at the dialysis center uncomfortable, crying, and disoriented but still able to state their name, address, and recognize the friend, and that upon pickup after treatment the resident appeared unconscious, was not moving, and did not respond. Upon arrival back at the facility, the friend reported that the resident was limp and drooling and brought them to the nursing station, where staff quickly attended. Nursing staff attempted to obtain vital signs and a fingerstick; the fingerstick was believed to be within normal limits, but the blood pressure machine was not reading, and staff could not recall if an oxygen saturation reading was obtained. Multiple nurses observed that the resident was unresponsive, pulseless, with blue lips and mottling of the hands and fingers, and the resident was pronounced deceased shortly after return. The dialysis communication sheet showed that facility staff had documented pre-dialysis vital signs, but the section to be completed by the dialysis center was blank for this and the prior treatment, and attempts by the ADON and other staff to reach the dialysis center by phone were unsuccessful. The DON acknowledged there was no facility investigation into what happened at dialysis, stated that because the resident arrived with no pulse or respirations and had a DNR there was nothing to investigate, and reported that it did not occur to them that the incident should have been reported to the Department of Health. The Administrator similarly stated that no investigation was done because it was believed the resident had died at dialysis, and only in hindsight acknowledged they should have looked into it further. There was no documentation of a report to the state despite the unexplained circumstances and lack of information from the dialysis provider. The facility’s own policies on reporting and investigating incidents and on renal dialysis required thorough documentation, communication with the dialysis center, and reporting of incidents where the facility could not rule out abuse or a care plan violation. Staff interviews revealed that CNAs did not document in the dialysis communication book, that the dialysis center had not been completing its portion of the communication sheets for this resident’s treatments, and that there was no checklist or documentation of what items were sent with the resident to dialysis. The Director of Transportation confirmed that transport drivers were not medically trained and might not recognize subtle changes in condition. Despite these gaps and the unexplained change in the resident’s condition between departure and return, the facility did not initiate an internal investigation or report the incident to the New York State Department of Health as required by policy and regulation.
Failure to Investigate Resident Death Following Dialysis and Missing Interfacility Documentation
Penalty
Summary
The deficiency involves the facility’s failure to investigate an alleged incident related to a resident’s death following a dialysis treatment, despite policies requiring thorough investigation of all occurrences not consistent with routine operations and care. Facility policy on Reporting and Investigating Resident Accident/Incidents required that all such occurrences, including those that may have caused physical injury or harm, be reported, reviewed, and thoroughly investigated, with completion of an Accident/Incident Report, review of the care plan and CNA profile, and appropriate notifications. The policy also referenced federal regulation 42 CFR 483.13 regarding injuries of unknown source and outlined that incidents with injury without known incident and where abuse or care plan violation could not be ruled out must be reported to the New York State Department of Health and to the Director of Investigations and Administrator. Despite these requirements, there was no documented evidence that the facility conducted any investigation into the circumstances surrounding the resident’s condition upon return from dialysis and subsequent death. The resident involved had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was minimally cognitively impaired but able to understand and be understood. On the day in question, the resident left the facility around 11:00 AM for hemodialysis and was observed on video at noon leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A facility policy on Renal Dialysis required that residents be sent with a communication book containing an Interfacility Report completed prior to transport, and that the dialysis unit complete its section and a Dialysis Information Sheet before the resident’s return. However, the Dialysis Communication Sheet for that day, and for the prior dialysis visit, showed that the dialysis center’s section was left blank. Later that day, video showed the resident returning around 6:00 PM slumped to the left in the wheelchair, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the transport driver or the friend who met them. The friend’s written statement documented that the resident arrived at the dialysis center uncomfortable, crying, and disoriented but still able to state their name, address, and recognize the friend. The friend further documented that when they returned to pick the resident up, the resident appeared unconscious, was not moving, and did not respond, and that dialysis staff reported the resident had been crying and yelling and then fell asleep during treatment. Upon arrival back at the facility, the friend noted the resident was limp and drooling and brought them to the nursing station, where staff quickly attended to the resident. Multiple staff interviews confirmed that upon return from dialysis, the resident was unresponsive, with staff unable to obtain vital signs and a nurse confirming the resident was pulseless with blue lips and mottling of the hands and fingers. The resident was pronounced deceased shortly after arrival. Staff, including the ADON and an RN, attempted to call the dialysis center but were unable to reach anyone, and there was no other resident using that dialysis facility for comparison. The DON and Administrator both acknowledged that no facility investigation was conducted into what happened to the resident at dialysis or during transport, and there was no documentation of what items were sent with the resident or any checklist used. The DON stated that because the resident arrived with no pulse or respirations and had a Do Not Resuscitate order, there was nothing to investigate, and the Administrator stated that no investigation was done because it was believed the resident had died at dialysis. This lack of investigation into an unusual occurrence involving a resident’s death, in the context of missing dialysis documentation and unanswered calls to the dialysis center, constituted the cited deficiency under 10 NYCRR 415.4(b)(3).
Oxygen Therapy Provided Without Physician Order or Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving oxygen therapy had a corresponding physician’s order and care plan interventions, as required by facility policy and professional standards. The facility’s oxygen therapy policy dated 3/2012 required a medical order specifying liter flow, route, and frequency, initiation of an “At Risk for Compromised Respiratory Care” care plan with appropriate interventions, and allowed nurses to initiate oxygen only in an emergency with an order obtained within 24 hours. Resident #1, admitted with chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium with metastasis, was documented as minimally cognitively impaired and able to understand and be understood. Record review showed no documented physician’s order for oxygen administration and no documented interventions or goals related to oxygen use in the care plan. Despite the absence of an order, multiple records and staff interviews confirmed that the resident was on oxygen intermittently during the admission. Medication Administration Records documented that on at least two pre-dialysis occasions at 11:00 AM, the resident was using 2 liters of oxygen, and vital sign records showed the resident on 2 liters of oxygen on multiple additional dates. Staff interviews corroborated that the resident routinely used oxygen: the Assistant DON reported seeing the resident returning from dialysis wearing oxygen from a portable tank; an RN stated they removed oxygen from the resident’s face when pronouncing the resident deceased; an LPN reported the resident was wearing oxygen upon arrival to the unit from dialysis; and another RN stated they typically send two oxygen tanks with residents for dialysis or longer trips. The Administrator acknowledged there should have been an order for oxygen, confirming that the resident received oxygen therapy without the required medical order and associated care planning.
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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