Ferncliff Nursing Home Co Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rhinebeck, New York.
- Location
- 21 Ferncliff Drive, Rhinebeck, New York 12572
- CMS Provider Number
- 335405
- Inspections on file
- 25
- Latest survey
- November 14, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ferncliff Nursing Home Co Inc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and behavioral needs was physically abused by an LPN following an altercation over food in the dining room. The resident, after spitting at the LPN, was slapped on the cheek, resulting in redness, swelling, and emotional distress. The incident was witnessed by two CNAs, and the resident required consolation immediately afterward.
The facility did not perform the required generator fuel quality test as per NFPA standards. During a survey, it was found that documentation for the current test was missing, with the last test conducted in 2023. The Corporate Regional acknowledged the oversight and stated that the vendor would be contacted.
The facility failed to provide adequate nursing staff, resulting in delayed resident care and meal services. Staffing shortages were observed on numerous shifts, with staff interviews confirming the negative impact on resident assistance and supervision, particularly on the dementia unit. Lunch services were also delayed due to insufficient staffing.
The facility failed to adhere to food safety and infection control standards, as surveyors observed undated food items in storage and dietary aides not changing gloves between tasks. The Food Service Director was unaware of the undated items, and despite training, dietary staff did not follow the glove use policy.
A resident's representative was not informed of changes in the resident's medication regimen, including the reduction and discontinuation of Seroquel and the initiation and discontinuation of Sertraline. Facility staff interviews revealed a lack of communication and responsibility in notifying the family, with the Assistant Director of Nursing and attending physicians acknowledging the oversight.
The facility did not ensure a safe, clean, and homelike environment. A shower room had mildew and drafts, soiled linens were found on the floor, and a broken handrail posed a risk. Staff were unaware of these issues until observed during the survey.
Two residents in an LTC facility were not adequately supervised, leading to safety risks. One resident with dementia wandered unsupervised, entering other residents' rooms and attempting to open exit doors. Another resident with Huntington's Disease experienced multiple falls due to unclear care plan documentation and lack of assistance during ambulation. Staff interviews revealed challenges in managing these issues due to limited staff availability and communication gaps.
A resident with impairments and dependency on staff for self-care was observed with long, dirty fingernails on multiple occasions, indicating a failure in maintaining personal hygiene. Despite the resident's inability to manage their nails and expressing a desire for assistance, staff were reportedly too busy, leading to inconsistent care. Interviews revealed that while personal hygiene tasks were the responsibility of CNAs, there was no specific documentation for fingernail clipping, contributing to the deficiency.
A resident with intact cognition and frequent bladder incontinence did not receive appropriate treatment to restore continence. The facility failed to implement a voiding diary or toileting program as per policy, despite the resident's ability to use the bathroom prior to admission. Staff interviews revealed a lack of awareness and implementation of an incontinence care plan, with the resident only recently placed on a toileting program.
A resident with limited range of motion was observed with their foot dangling off the wheelchair pedal due to improper positioning and equipment issues. Despite evaluations for mobility, there was no documentation of proper positioning or repairs. The occupational therapist noted a malfunctioning phalange and a misaligned foot box, while a CNA observed but did not report the issue. There was no official schedule for assessing wheelchairs, leading to a deficiency in care.
A resident with severely impaired cognition experienced significant weight loss, which was not properly documented or addressed by the facility. The resident's weight was not recorded for two months, and the registered dietician did not document any interventions. Staff interviews revealed a lack of awareness and communication regarding the resident's nutritional status.
A resident with severely impaired cognition and a history of [REDACTED] was not properly positioned during meals, leading to increased coughing and gagging. Despite being dependent on staff for all activities, the resident was observed sliding down in their chair while being fed, with no interventions documented in the care plan. Staff interviews revealed a lack of evaluation for chair positioning, and only after a family request was a device added to prevent sliding.
The facility did not ensure that the means of egress was clearly marked, as the exit sign between the elevator and the recreation room on the B wing directed travel through an occupied daycare space. This was observed on one of the four resident floors, and the Director of Maintenance acknowledged the issue during an interview.
The facility did not maintain continuous illumination in the means of egress as required by NFPA 101. During a survey, it was found that turning off the wall-mounted light switches in the fifth-floor dining room also turned off all lights, including those needed for an emergency stairwell exit. This issue was identified on one of the three resident floors, and the Director of Maintenance confirmed the lights would be continuous.
Two residents experienced incidents due to inadequate supervision and maintenance in the facility. One resident, with a history of Alzheimer's and hip surgery, was bumped by elevator doors twice, causing hip pain. Another resident with severe dementia and wandering behaviors accessed a housekeeping closet due to a malfunctioning door. The facility failed to ensure proper elevator sensor function and secure the closet, leading to these deficiencies.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia, diabetes mellitus, and major depressive disorder, was subjected to physical abuse by a staff member. The incident took place in the dining room during lunch, when the resident took another resident's cake, leading to an argument with an LPN. During the altercation, the resident spat at the LPN, who then responded by slapping the resident on the right cheek. This act was witnessed by two certified nurse aides, and the resident was observed to have redness and swelling on the right cheek and was crying immediately after the incident. The resident's care plan indicated a need for ongoing redirection, monitoring, and structured activities due to behavioral symptoms and a risk of victimization related to dementia. Despite these documented needs, the staff member engaged in a physical confrontation rather than employing de-escalation or redirection techniques. The incident resulted in observable physical harm and psychosocial distress to the resident, as evidenced by immediate crying and the need for consolation by staff. Interviews with staff confirmed that attempts were made to intervene and de-escalate the situation, but the argument continued, culminating in the physical abuse. The LPN involved acknowledged the incident and expressed regret, while other staff members promptly reported the event to facility leadership. The deficiency centers on the failure to protect the resident from abuse by a staff member, contrary to facility policy and regulatory requirements.
Missing Generator Fuel Quality Test Documentation
Penalty
Summary
The facility failed to ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110 standards. During a Life Safety recertification survey, it was observed that the documentation for the current fuel quality test of the facility's generator was missing and not provided at the time of the survey. The last recorded fuel quality test was conducted in 2023, indicating a lapse in compliance with the testing schedule. This deficiency was confirmed during an interview with the Corporate Regional, who acknowledged the oversight and mentioned that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 K918 – Essential Electrical Testing and Maintenance I. Immediate Corrections The facility engaged the Emergency Generator service provider to perform fuel quality testing. Testing completed (MONTH) 7, 2025. II. Plan of Correction to Identify Other Areas Potentially Affected It was determined that all residents have the potential to be affected by the facility not ensuring that the required emergency generator fuel quality test is completed. The Director of Plant Operations will review all record and log reports to ensure required systems testing and inspection are completed as per the required code and regulations. Work completed: (MONTH) 12, 2025 III. Systemic Changes The facility maintenance record and log policy were reviewed; it was determined that no changes were needed to the policy. The Director of Plant Operations will review all required records and logs to ensure periodic testing, inspections, and services are completed as per schedule. All maintenance staff will receive in-service education, and all participants will understand the life safety issues identified, with a focus on the annual fuel testing requirements for the Emergency Generators. The Director of Plant Operations has been assigned responsibility for the education of staff. Work completed: (MONTH) 13, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that required generator annual fuel tests are completed in accordance with NFPA 101 and NFPA 110. 1. Audits will be completed by the Director of Plant Operations quarterly x 2 quarters, then complete annually thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to the QA Committee Quarterly x 2 Quarters then annually thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee
Staffing Shortages Lead to Delayed Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by the staffing shortages observed during the recertification and abbreviated surveys. Specifically, the facility did not meet the minimum staffing levels outlined in their Minimum Staffing Standard Matrix on sixty-nine out of ninety-six shifts, and on nine out of thirty-two night shifts, the staffing fell below the general staffing plan documented in the Facility Assessment. Interviews with staff revealed that these shortages led to delays in resident care and meals, with some staff members being mandated to work additional shifts, which affected their ability to perform their duties effectively. Observations on the dementia unit highlighted the impact of staffing shortages, with unsupervised residents appearing confused and unable to find seats in the day room. Staff interviews confirmed that the dementia unit often operated with fewer certified nurse aides than required, which compromised the supervision and care of residents. Additionally, the lunch service on the 3rd floor was delayed, with some residents receiving their meals significantly later than others, further indicating the strain on staff resources. The report includes multiple staff testimonies describing the negative effects of working with insufficient staff, such as residents not receiving timely assistance with toileting and transfers, and meals being delayed. These deficiencies in staffing and care delivery were corroborated by the facility's own staffing records and staff interviews, which consistently pointed to a pattern of inadequate staffing levels that failed to meet the facility's documented standards.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 725 Sufficient Nursing Staff I. The Following Actions were accomplished to ensure minimum staffing levels for certified nurse aides are met on all shifts: A review of the facility-wide assessment was conducted on 3/17/25 based on the revised Medicaid CMI to re-evaluate the allocation of resources needed to care for the residents. The facility-wide assessment will provide information regarding direct care staff needs and capabilities to provide services to the residents. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have the potential to be affected by the deficient practices. The facility-wide assessment conducted will re-evaluate the allocation of resources and staffing on all shifts. Corrective action will include following the minimum determined staffing levels for certified nurse aides on all shifts. III. The following systemic changes will be implemented to ensure minimum staffing levels for certified nurse aides are met on all shifts: The Administrator and Director of Nursing will provide education to the Staffing Coordinators on the importance of meeting minimum staffing requirements for all shifts. The Facility Assessment will be conducted on a routine basis by the Administrator and the Director of Nursing to review the staffing levels based on current Case Mix Index information and ADL and care needs of the residents. Any changes to the staffing levels in all shifts based on the facility assessment will be communicated to the staffing coordinator to ensure that staffing levels are maintained. When staffing levels are not at the designated levels after all resources available to the staffing coordinator will notify the Administrator and the Director of Nursing to determine additional actions needed to meet the needs of the residents’ levels determined by the facility assessment. The Administrator, along with the Director of Nursing, continuously works on hiring more C.N.A. staff for all shifts. The facility staffing levels improved over the last three months by successfully hiring more staff for all shifts. These new staff members assisted our residents needs by picking up shifts each week. Agency staff are also utilized to meet the needs if all employed staff solutions are exhausted. The facility has a plan to meet staffing requirements through an in-house recruiter who was recently hired and has helped tremendously with staff recruitment. Also, the facility has offered referral bonuses, sign-on bonuses and retention bonuses. An in-house childcare center will be opening soon and will be offered to all staff to help with recruitment and retention. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: The daily staffing is reviewed by the facilities Staffing Coordinator, Director of Nursing and Administrator to assure that the staffing levels meet the residents’ needs. These levels are reported weekly for 3 months. A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing. Responsible Person: The Director of Nursing is the person responsible to ensure all of the above actions have been completed.
Food Safety and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain specific food items in accordance with professional standards for food safety and infection control prevention. During the initial tour of the kitchen, surveyors observed an opened and undated container of thickened milk in the refrigerator and an opened, undated bag of powdered sugar wrapped with plastic wrap in dry storage. The Food Service Director, when interviewed, stated they were unaware that these items were not dated after opening, which was contrary to the facility's policy requiring all unused portions and open packages to be covered, labeled, and dated using the Medvantage/Freshdate labeling system. Additionally, the facility did not ensure proper use of disposable gloves by dietary aides during meal service. Three dietary aides were observed failing to change gloves after touching non-meal service objects. Dietary Aide #26 was seen using gloves to handle an ink pen, clipboard, and garbage lid before continuing meal service without changing gloves. Dietary Aide #27 used gloves to touch a door handle and refrigerator door before preparing meal trays. Dietary Aide #28 answered a phone call while wearing gloves and then continued to serve meals without changing them. The Food Service Director confirmed that all dietary staff had been trained on the policy requiring glove changes between tasks, but the aides did not adhere to this policy during the observations.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 812 Food Procurement I: Immediate Corrections - The opened undated container of thickened milk and undated bag of powdered sugar were all discarded on 2/20/25. - The Dining Service staff that were identified during observations were immediately provided with an in-service education on proper disposable glove usage on (MONTH) 14 through (MONTH) 16, 2025. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All freezers, refrigerators, and dry storage areas were inspected for any additional items that may be unlabeled or past their expiration date and holding. - All Dining Service Staff were provided in-service education on (MONTH) 25, 2025, on proper food storage procedures including importance of labelling all opened items and monitoring food expiration dates, including all dates identified as “sell-by,” “best-by,” “enjoy-by,” or “use-by.” - All Dining Service Staff were provided in-service education on (MONTH) 14 – (MONTH) 16, 2025, on proper disposable glove usage. III: The following system changes will be implemented to ensure continuing compliance with regulations: - The Administrator and Director of Food Services reviewed the policy titled, Production, Purchasing, Storage: Food and Supply Storage. There were no revisions necessary. - The Administrator and Director of Food Services reviewed the policy titled, Sanitation and Infection Control: Disposable Glove Use Policy. There were no revisions necessary. - All Dining Services Staff were provided with in-service education on the facility’s policy titled Production, Purchasing, Storage: Food and Supply Storage by the Director of Food Services. - All Dining Services Staff were provided in-service education on the facility’s policy titled, Sanitation and Infection Control: Disposable Glove Use Policy by the Director of Food Services. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: - Director of Food Services will develop an audit tool entitled, “Labeling of Food Products.” This tool will be utilized by the Dining Service Managers and will conduct daily inspection of all refrigerators, freezers, and dry storage areas to ensure all items are properly labelled, dated, and within appropriate date ranges. The audit will be conducted weekly for 3 months. - Director of Food Services will develop an audit tool entitled, “Disposable Glove Use.” This audit tool will be utilized to monitor compliance of five (5) Dining Service Staff members on Sanitation and Infection Control with Disposable Glove Use. The audit will be conducted weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement committee by the Food Service Director. Responsible Person: The Dining Director is the person responsible for ensuring all the above actions are completed.
Failure to Notify Resident's Representative of Medication Changes
Penalty
Summary
The facility failed to notify the representative of a resident about changes in their medication regimen, which is a requirement under the facility's policy. The resident, who had diagnoses including dementia, anxiety, insomnia, and Alzheimer's disease, was undergoing a gradual dose reduction of Seroquel, an antipsychotic medication, and the initiation and subsequent discontinuation of Sertraline, an antidepressant. Despite these significant changes in the resident's plan of care, there was no documentation indicating that the resident's representative was informed of these changes. Interviews with facility staff revealed a lack of communication and responsibility regarding the notification process. The Assistant Director of Nursing acknowledged that the family should have been notified by the physician, but this did not occur, partly due to the attending physician's departure from the facility. Attending Physician #2 and the Psychiatric Nurse Practitioner involved in the resident's care also did not recall notifying the family, highlighting a breakdown in the communication process within the facility's interdisciplinary team.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 580 Notification of Changes I: The Following Actions were accomplished for the residents identified in the Sample: ? Resident #400 expired on (MONTH) 13, 2024. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ? All residents have the potential to be affected by the same practice. ? The Director of Nursing/Designee will complete chart reviews of other residents with psychoactive medication changes from (MONTH) 2024 till present to ensure all resident’s family or representative were notified of any changes on psychoactive medications. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ? The Administrator and Director of Nursing reviewed the policy entitled “Psychoactive Drugs” on (MONTH) 17, 2024, and no revision is needed. ? The Licensed Nurse Educator/Designee will provide education to all licensed nurses on the existing policy for Psychoactive Drugs. ? The Attending Physician #2 was also provided one to one education by the Licensed Nurse Educator/ADON of the responsibility to notify the Resident’s family or representative of any psychoactive medication changes. ? The Medical Director will also complete the educational in-service to all medical providers. ? The Staff Educator/Designee will create a lesson plan regarding Psychoactive Medication changes. The lesson plan will be discussed with all licensed nurses to ensure compliance with the policy for Psychoactive Medication. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ? Director of Nursing/Designee will develop an audit tool entitled “Psychoactive Medication Notification of Changes.” The audit tool will be utilized to monitor compliance with family or representative notification for any psychoactive medication changes. The audits will be conducted weekly for 3 months. ? A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing. Responsible: Director of Nursing is responsible for ensuring all above is completed.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as observed during the recertification and abbreviated surveys. In the shower room on the 3A unit, there were black stains on the shower curtain, brown discoloration on the tiles at the base of the toilet, and black and orange stains on the tile grout in the shower stall. Additionally, a window air conditioner caused a cold draft in the room. Resident #18 reported the shower room was cold and had mildew. The Director of Housekeeping acknowledged that the shower curtain should have been replaced and the tiles needed cleaning, but they had not received any reports about these conditions. The Director of Maintenance was unaware of the issues but acknowledged the need for addressing the grout discoloration and the draft caused by the air conditioner. In another incident, soiled linens were found on the floor next to Resident #27's bed. A Certified Nurse Aide confirmed that soiled linens should be bagged and placed in a linen hamper, not on the floor. Additionally, a broken handrail with a sharp edge was observed at the entrance to the 3A dining room. The Maintenance Worker and the Director of Maintenance were not aware of the broken handrail, but the Director of Maintenance stated that handrails would be added to the list of items to check during rounds.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 584 Safe/ Clean/ Comfortable Homelike Environment I. Immediate Corrections: - The Housekeeping staff cleaned the Shower room on unit 3A. The black and orange dis-coloration along the base of the shower stall was removed. Completed 2/26/2025. - The Housekeeping staff cleaned shower curtains. Black stains on the bottom of curtain were removed. Completed 2/25/2025. - The Housekeeping staff cleaned the toilet. Discolored brown stains on tiles around the base of toilet were removed. Completed 2/26/2025. - The window air conditioner unit that was allowing cold draft to enter the shower stall was removed by the maintenance staff. Completed 2/26/2025. - The Certified Nursing Assistant picked up the soiled linen with feces that was next to the bed in Resident # 27 room. The Linen was bagged and placed in hamper. Completed 2/20/2025. - The broken handrail on the right side of the dining room entrance was repaired by the maintenance staff. Completed 2/26/2025. II. Plan of Correction to identify other areas potentially affected - The facility acknowledges that all residents have the potential to be affected by this practice. - The Director of Plant Operations will inspect all areas throughout the facility for same deficiencies. Any deficiencies found will be scheduled for correction. Completed 2/28/2025. III. Systemic Changes - All maintenance staff, housekeeping and nursing will receive additional education, and all participants will understand the requirements of providing a Safe, Clean, Comfortable, and Homelike Environment for residents in compliance with 483.10. The Director of Plant Operations and Staff Development has been assigned responsibility for the education of staff. - The Policy & Procedures were reviewed, and it was determined that no changes to the policy were necessary. IV. Quality Assurance Monitoring - The Director of Plant Operations/Housekeeping will conduct audits on all rooms to ensure a homelike environment is maintained weekly x 4 weeks and then monthly for 3 months unless any significant trends are identified. Any concerns during audits will be addressed immediately to ensure compliance with standards of care or practice. - The Director of Plant Operations or Designee will review monthly audits for any cases of non-compliance. The Director of Plant Operations or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. Responsibility: Director of Plant Operations
Inadequate Supervision and Accident Prevention for Two Residents
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, leading to deficiencies in accident prevention. Resident #183, diagnosed with non-Alzheimer's dementia and other conditions, was observed wandering unsupervised into other residents' rooms and attempting to open exit doors. Despite having a care plan that included visual checks and engagement in activities, Resident #183 was frequently unsupervised, leading to potential safety risks. Staff interviews revealed challenges in managing the resident's wandering behavior due to their advanced dementia and limited staff availability. Resident #242, diagnosed with Huntington's Disease, experienced multiple falls over a period of time. The care plan initially required staff assistance for ambulation due to gait and balance issues. However, observations showed the resident ambulating unassisted, and there was no documentation indicating the discontinuation of the assistance requirement. Interviews with staff revealed a lack of clarity and communication regarding the resident's need for assistance, contributing to the resident's falls. The deficiencies highlight the facility's failure to provide adequate supervision and maintain a safe environment for residents at risk of accidents. The lack of consistent staff intervention and documentation regarding care plan changes contributed to the residents' exposure to potential hazards and accidents.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 689 Free of Accident Hazards/Supervision/Devices I: The Following Actions were accomplished for the residents identified in the Sample: - Resident #27 and Resident #151 were provided with a mesh stop sign on the door to prevent Resident #183 from wandering in the rooms on (MONTH) 18, 2025. - Resident #183 background interest and past occupation were reviewed by IDT and revised care plan intervention to simulate her past profession as a housekeeper. - Resident #242 was re-evaluated on (MONTH) 18, 2025, by rehab and continues to demonstrate the ability to safely perform independent bed mobility, functional transfers, and ambulation to desired locations within the unit with chorea movements. This gait pattern is consistent with long-term effects of [MEDICAL CONDITION]’s disease. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - All Unit Managers/Designee will review facility’s wanderguard list to identify residents who exhibit intrusive wandering behavior in their assigned unit(s) and will update resident’s care plan for appropriate interventions. - All residents diagnosed with [REDACTED]. This assessment will focus on any fluctuations in their gait beyond their baseline chorea movements. Based on the findings, their care plans will be updated to implement appropriate interventions. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - All licensed nurses in the facility will be re-inserviced on the facility’s Elopement Risk Assessment and Procedure Policy as it relates to the assessment of Elopement risk and initiation of Resident specific interventions such as monitoring of residents for their safety. - The Staff Development Nurse will be responsible for re-inservicing all other Licensed Nurses on the facility’s Elopement Risk Assessment and Procedure Policy. - The Staff Development Nurse will provide an inservice education to all licensed nurses, highlighting the importance of promptly notifying the rehabilitation department about any residents diagnosed with [REDACTED]. This in-service education aims to ensure early identification of ambulation fluctuation and prompt implementation of intervention. - The Director of Nursing and Administrator reviewed the facility’s Elopement Risk Assessment and Procedure Policy and the Wander Alert System Operation. No revision is necessary. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: - The Director of Nursing/Designee will develop an audit tool entitled, “Identification of Intrusive Wandering Behavior.” The audit tool will be utilized to identify residents exhibiting intrusive wandering behavior. It will also assess the immediate interventions implemented by staff and ensure that the plan of care is updated accordingly to address these behaviors effectively. The audits will be conducted weekly for 3 months. - The Director of Rehab/Designee will develop an audit tool entitled “[MEDICAL CONDITION]’s Disease – Ambulation Fluctuations.” This audit tool will be utilized to identify residents who experience falls during ambulation in the HD unit, specifically focusing on fluctuations in their gait that are not attributable to their baseline chorea movements. This approach will effectively recognize and implement appropriate interventions tailored to enhance safety and mobility. The audits will be done weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing and Director of Rehab. Responsible Person: The Administrator is responsible for ensuring all the above is completed.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene. Specifically, a resident with intact cognition and impairments in both upper and lower extremities was dependent on staff for self-care abilities, including personal hygiene. Despite this dependency, the resident was observed on three occasions with long and dirty fingernails, indicating a lack of proper hygiene care. The resident expressed a desire to manage their fingernails but was unable to do so due to their condition and reported that staff were too busy to assist. Interviews with facility staff revealed that personal hygiene care, including fingernail clipping, was the responsibility of certified nurse aides. However, there was no specific documentation task for fingernail clipping, leading to inconsistencies in care. A certified nurse aide admitted to not remembering the condition of the resident's nails during hygiene assistance, while an LPN stated they clipped the resident's nails when the aides were busy. This lack of consistent attention to the resident's personal hygiene needs resulted in the observed deficiency.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 677 ADL Care Provided for Dependent Residents I. The Following Actions were accomplished for the residents identified in the Sample: - Resident #27 was assessed by Licensed Unit Manager on 2/25/2025 and the designated C.N.A provided nail care, including trimming, and documented accordingly. - The C.N.A assigned to Resident #27 and the Licensed Practical Nurse #18 received in-service education on the importance of providing nail care for all residents. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have been identified as potentially affected by the same practices. - All Unit Managers will conduct direct care observations of all residents in their assigned units to ensure that fingernails are properly trimmed, cleaned and filed. - Any identified residents will be provided with nail care and will be documented accordingly. III. The following systemic changes will be implemented to ensure the deficient practice will not recur: - The Policy and Procedure titled Clinical, Activities of Daily Living Protocol and Policy was reviewed by the Administrator and Director of Nursing. No further revisions were necessary. - Nursing staff will be provided with in-service education by the Licensed Staff Educator or ADON on providing nail care and documented accordingly. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur utilizing the following Quality Assurance practice: - The Director of Nursing/designee will develop an audit tool entitled “Nail Care – Personal Hygiene.” The Audit tool will be utilized to monitor ten (10) residents per week for each unit and all new admissions to ensure that nail care is provided and documented accordingly. - The audits will be conducted weekly for 3 months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Committee by the Director of Nursing/Designee. Responsible: Director of Nursing is responsible for ensuring all above is completed.
Failure to Implement Bladder Management Program
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. Resident #112, who had intact cognition and required substantial assistance with activities of daily living, was frequently documented as incontinent of bladder. Despite this, the resident's care plan did not include a voiding diary or a toileting program, which are essential components of a bladder management strategy. The facility's policy required assessments and individualized re-training programs for bladder function, but these were not implemented for Resident #112. Interviews with the resident and staff revealed that the resident was not placed on a toileting schedule and was not encouraged to use the bathroom regularly, despite expressing a desire to do so. The resident reported being able to use the bathroom without accidents before entering the facility and expressed dissatisfaction with wearing pullups. Staff interviews indicated a lack of awareness and implementation of an incontinence care plan for the resident, with the Assistant Director of Nursing and a Registered Nurse both unsure why such a plan was not created. A Certified Nurse Aide mentioned that the resident was only put on a toileting program the day before the interview, indicating a delay in addressing the resident's needs.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 690 Bowel/Bladder Incontinence, Catheter, UTI I: The Following Actions were accomplished for the residents identified in the Sample: ? Resident # 112 is now on a toileting program. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: ? All residents have the potential to be affected by this deficient practice. ? All new admissions will be reviewed for the past three months to ensure appropriate interventions are in place. ? Any identified resident who has a decline in continence of bladder will be placed on toileting program. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: ? The Administrator and Director of Nursing reviewed the facility policy titled Clinical Bladder Management. ? There were no revisions necessary. ? All nursing staff will receive an in-service education focused on identifying residents who have recently become incontinent with bladder, as well as newly admitted residents who are incontinent with bladder. This in-service education will emphasize the importance of initiating a toileting program aimed at restoring continence to the extent possible. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: ? The Director of Nursing/Designee will develop an audit tool entitled “Incontinent of Bladder – Toileting Program.” This tool will identify residents who are admitted as being incontinent with bladder, as well as residents who have recently become incontinent with bladder. It will assess whether they were promptly placed in a toileting program immediately, with the aim of restoring the resident’s continence to the extent possible. ? This audit will be conducted weekly for three (3) months. ? A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Director of Nursing/Designee. Responsible Person: The Director of Nursing is responsible for ensuring all above is completed.
Deficiency in Wheelchair Positioning and Maintenance
Penalty
Summary
During a recertification survey, it was found that the facility failed to ensure proper positioning and equipment for a resident with limited range of motion in their lower extremities. The resident, who was independent in cognition and had a diagnosis that included decreased muscle strength, was observed multiple times with their foot dangling off the foot pedal of their wheelchair. Despite being evaluated for wheelchair mobility to increase strength for self-propelling, there was no documentation of an assessment for proper positioning or necessary repairs to the wheelchair. The occupational therapist noted that the wheelchair's phalange was not functioning correctly, causing the foot pedal to swing out and making it difficult for the resident to keep their foot in place. Additionally, the left foot box was out of position and required fixing. A certified nurse aide observed the issue but did not report it, and the occupational therapist confirmed that there was no official schedule for assessing wheelchairs or documented audits. This lack of communication and documentation contributed to the deficiency in providing necessary care and equipment for the resident.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F 688 Increase/Prevent Decrease in ROM/Mobility I. The Following Actions were accomplished for the residents identified in the Sample: - The wheelchair for Resident #36 was repaired first thing in the morning on (MONTH) 27, 2025. - Certified Nurse Aide #14 received an education on the importance of promptly reporting broken wheelchair to their immediate supervisor to ensure that repairs are initiated without delay. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - The Director of Rehab/Designee will identify all residents utilizing bariatric wheelchairs. This will specifically focus on foot pedals that show signs of increased wear and tear resulting from the weight of the foot pedal support. - Any identified deviations will be promptly reported to the Support Services for immediate repair and provide appropriate intervention or change existing intervention. III. The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - All Nursing Staff will be provided with an in-service education for promptly reporting any broken wheelchair to their immediate supervisor. This ensures that necessary repairs are initiated without delay, thereby maintaining resident’s functional status. - The Occupational Therapist will continue to monitor the foot pedals of residents using bariatric wheelchairs, as these experience increased wear and tear due to the extent of weight put on them. During quarterly screenings, the Occupational therapist will document assessment findings to ensure proper positioning in wheelchair and address necessary adjustments or interventions. IV. The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following Quality Assurance practices: - The Director of Rehab/Designee will develop an audit tool entitled “Bariatric Resident - Wheelchair Positioning.” This audit tool will be utilized to monitor residents who use bariatric wheelchairs focusing on foot pedals that exhibit wear and tear. It will help identify those requiring repairs or additional devices to maintain their functional mobility. Additionally, the tool will ensure that all necessary documentation regarding resident’s wheelchair positioning is reflected in the resident’s chair. The audit will be conducted weekly for three (3) months. - The Support Services Director/Designee will develop an audit tool entitled “Wheelchair Reporting and Repair.” This tool will be utilized to assess whether the staff have properly followed the facility’s procedure for reporting broken wheelchairs and to verify that repairs were completed in a timely manner. Responsible Person: The Administrator is responsible for ensuring all above is completed.
Failure to Monitor and Address Resident's Nutritional Status
Penalty
Summary
The facility failed to monitor and address the nutritional status of a resident, leading to a significant weight loss that was not properly documented or managed. The resident, who had severely impaired cognition and was dependent on assistance for activities of daily living, experienced a 7.5% weight loss over three months and a 13% weight loss over four months. Despite these changes, the resident's weight was not recorded for the last two months, and there was no evidence that the weight loss was addressed by the registered dietician or other staff members. The resident's comprehensive care plan aimed to maintain a weight of 135 pounds +/- 3%, but the resident's weight dropped from 134.4 pounds to 116.8 pounds over a four-month period. The registered dietician had not documented any nutritional notes or interventions since August 2024, and the nursing staff failed to obtain and record the resident's weight in the subsequent months. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's weight loss and the absence of recorded weights, indicating a breakdown in the facility's monitoring and documentation processes.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 692 Nutrition/Hydration Status Maintenance I: The Following Actions were accomplished for the residents identified in the Sample: - Resident #93 had their most current weight obtained on 2/27/25. This was reported to the Registered Dietitian and recommendations were made and carried out. - An IDCP team meeting was held on 3/21/25 with Resident #93 family to discuss the anticipated progression of the resident’s [MEDICAL CONDITION]’s Disease, which is impacting the resident’s appetite and contributing to ongoing weight loss. Resident’s family has decided to place her on Palliative Care due to progression of [MEDICAL CONDITION]’s Disease. II: The following corrective actions will be implemented to identify other residents who may be affected by the same practice: - All residents have the potential to be affected by this deficient practice. - All residents’ weight from (MONTH) 2024 to present will be reviewed to ensure that the most recent and accurate weights will be obtained and will be reported to the Dietician. Any recommendations will be implemented promptly. - All residents identified as experiencing weight loss over the past four months will be reviewed to ensure that appropriate documentation and care plan interventions are in place to address their weight loss. Concurrently, the medical provider will be notified to incorporate any recommendations into the resident’s care plan, ensuring that proper documentation and interventions are implemented effectively. - All residents identified as experiencing weight loss will also be reviewed weekly by the IDCP team during weekly weight management meetings to ensure ongoing monitoring and support for residents’ nutritional needs are maintained. III: The following systemic changes will be implemented to ensure new interventions are added to the interdisciplinary care plans for continued compliance with regulations: - The Director of Nursing and Dietitian will conduct a review of the facility’s current process for obtaining and recording residents’ weights and re-weights. This review will be communicated to all Nursing Staff as an education in-service to ensure that weight is recorded or reported promptly and accurately. - The Administrator will provide in-service education to the Dietitian to ensure that weight loss is addressed promptly and effectively. This includes ensuring all relevant documentation is accurately recorded in the residents’ charts and that interventions to manage weight loss are implemented without delay. IV: The facility’s corrective action will be monitored to ensure the deficient practice does not recur by utilizing the following quality assurance practices: - The Dietician or Designee will develop an audit tool entitled, “Timely Recording of Weights/Re-Weights.” This audit tool will be used to monitor the weight of twenty (20) residents on a weekly basis for a duration of three (3) months. This process aims to ensure that weights and re-weights are recorded and reported in a timely manner. - The Director of Nursing or Designee will develop an audit tool entitled “Addressing Weight Loss Timely.” This audit tool will be utilized to review the weights of five (5) residents identified as experiencing weight loss during the weekly IDCP team weight management meetings. The audit tool will monitor whether dietary notes or medical provider recommendations regarding weight loss have been properly documented and addressed. This audit will be conducted weekly for three (3) months. - A quantitative summary of findings and corrective actions will be reported monthly to the Quality Assurance Performance Improvement Committee by the Registered Dietitian. Responsible Person: The Administrator is the person responsible for ensuring all the above actions have been completed.
Failure to Ensure Proper Positioning During Meals
Penalty
Summary
The facility failed to ensure that a resident with severely impaired cognition and a history of [REDACTED] received appropriate positioning during meals, as per professional standards of practice. The resident, who was dependent on staff for all activities of daily living, including eating, was observed multiple times sliding down in their chair while being assisted with feeding. Despite the resident's diet being downgraded to pureed consistency with honey thickened liquids due to increased coughing and gagging, there were no interventions documented in the care plan regarding proper positioning during meals. Interviews with staff revealed that the resident had not been evaluated by occupational or physical therapy for chair positioning during feeding, and no devices were initially used to prevent the resident from sliding down. The Registered Nurse Unit Manager acknowledged the difficulty in feeding the resident and the lack of an upright position during meals. An Occupational Therapist confirmed that a screen for positioning had not been requested, although devices were available to assist with proper positioning. It was only after a family request and subsequent evaluation that a device was added to help prevent the resident from sliding down in the chair.
Plan Of Correction
Plan of Correction: Approved March 21, 2025 F684 Quality of Care I. Immediate Corrections - The Director of Rehab conducted a complete and thorough investigation into the resident’s plan of care regarding their positioning in the wheelchair during mealtimes. The Occupational Therapist assessed the resident during lunch on 2/27/2025 and added a positioning wedge under the front end of the cushion to help prevent them from sliding down in the wheelchair. - The CNA was educated regarding the positioning wedge and how to ensure the resident was properly positioned in the wheelchair. The nurse and RN supervisor were also provided with an in-service on the use of the device. II. Plan of Correction to identify other areas potentially affected - The Director of Rehab reviewed all residents in the facility positioning during mealtimes to ensure all were safely and appropriately positioned and all positioning devices (have orders and) were included in the comprehensive care plans. - In-service was also provided to all CNAs assigned to each resident. Respectfully, no other residents were identified to have been affected at this time. III. Systemic Changes - The policy for positioning was reviewed and found to be compliant with the regulations. The licensed nurses, CNAs, and licensed therapists were educated on the updated policy and the need to ensure all devices are in place in the care plans to reflect the condition of the residents. A copy of the lesson plan and attendance sheets will be kept on file for validation. IV. Quality Assurance Monitoring - The Director of Rehab/designee will perform monthly audits for the positioning of residents during mealtimes on all units x 3 months, then quarterly thereafter to ensure residents are properly positioned, any positioning devices are in place, and care plans are accurate and reflect the services required by the residents. Any outstanding issues will be corrected on site by the auditor. - All audit findings will be reported to the Administrator and QA committee. Responsible Party: Director of Rehab/Designee
Incorrect Exit Signage in Egress Path
Penalty
Summary
The facility failed to ensure that the means of egress was clearly marked to indicate the direction of travel to the nearest exit. Specifically, the exit sign with directional arrows between the elevator and the recreation room on the B wing indicated a path of travel through a separate occupied space, the daycare. This issue was observed on one of the four resident floors during a survey conducted on February 25, 2025, at 1:55 PM. The Director of Maintenance acknowledged the incorrect signage during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved March 17, 2025 K293 – Exit Signage I. Immediate Corrections The facility removed the directional arrow on the exit sign installed between the elevator and recreation room on the B wing indicating the path of travel through the Daycare Center. Work completed (MONTH) 12, 2025 II. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for the same deficiency. None were identified. Work completed: (MONTH) 14, 2025 III. Systematic Changes The facility maintenance and repairs were reviewed; it was determined that no changes were needed to the policy. The Director of Plant Operations will provide in-service education to all maintenance staff. All participants will understand the safety issues with NFPA Life Safety Code 2012 7.10.2, with a focus on exit signs, maintenance, and inspections. Work completed: (MONTH) 14, 2025 IV. QA Monitoring The Director of Plant Operations or Designee will develop an audit tool to verify that exit and directional signs are displayed in accordance with NFPA Life Safety Code 2012 7.10.2. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee
Failure to Ensure Continuous Illumination in Egress Pathway
Penalty
Summary
The facility failed to ensure continuous illumination in the means of egress as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the wall-mounted light switches in the fifth-floor dining room, when turned off, extinguished all lights in the room. This room contained an emergency stairwell exit, which should have been continuously illuminated. This deficiency was noted on one of the three resident floors. During an interview, the Director of Maintenance acknowledged the issue and stated that the lights in the rooms would be continuous.
Plan Of Correction
Plan of Correction: Approved March 14, 2025 K281 – NFPA 101 Illumination of Means of Egress I. Immediate Corrections: The manual operated wall mounted light switches in fifth floor dining room were removed, allowing all lights in the room to be on continuously. Work completed (MONTH) 4, 2025. II. Plan of Correction to identify other areas potentially affected The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Plant Operations inspected all areas throughout the facility for the same deficiencies. No additional instances of non-compliant were found. Work completed (MONTH) 6, 2025. III. Systemic Changes The Policy relating to Illumination of Means of Egress was reviewed and it was determined that no changes were needed to the policy. All maintenance staff will be provided with in-service education by the Director of Plant Operations on the policy relating to Illumination of Means of Egress with a focus on the importance of ensuring that Illumination of the Means of Egress were installed and maintained in accordance with 7.8. Work completed: (MONTH) 6, 2025. IV. QA Monitoring The Director of Plant Operations will develop an audit tool to verify that Means of Egress were installed and maintained in accordance with 7.8. 1. Audits will be completed by the Director of Plant Operations monthly x 3 months, then complete quarterly thereafter. 2. Any discrepancies noted will be addressed immediately, reported to the Administrator, and to the QA Committee for tracking and trending. 3. Audit of findings will be presented to QA Committee monthly x 3 months then quarterly thereafter for evaluation and follow-up as indicated. Responsibility: Director of Plant Operations/Designee
Inadequate Supervision and Maintenance Lead to Resident Incidents
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent accidents for two residents, leading to incidents involving elevator doors and access to a housekeeping closet. One resident, with a history of Alzheimer's Disease and right hip surgery, experienced two separate incidents where they were bumped by elevator doors, causing pain and discomfort to their right hip. Despite the resident's severe cognitive impairment and history of hip replacement, the facility did not ensure that the elevator sensors were functioning properly or that the incidents were promptly reported to the Director of Support Services for maintenance intervention. Another resident, with severe dementia and a history of wandering behaviors, was found inside a housekeeping closet due to a malfunctioning door striker plate. The resident, who was at high risk for elopement, was able to access the closet because the door could not close and lock properly. This incident occurred despite the resident's known wandering behaviors and the facility's policy to maintain a safe environment free from accident hazards. The facility's failure to maintain a safe environment and provide adequate supervision resulted in these incidents. The lack of communication and timely reporting of the elevator incidents to the appropriate maintenance personnel further contributed to the deficiency. Additionally, the unsecured housekeeping closet posed a significant risk to the resident with wandering behaviors, highlighting the need for proper maintenance and monitoring of facility areas to prevent similar occurrences.
Plan Of Correction
Plan of Correction: Approved February 11, 2025 F689: Free of Accidents, Hazards, Supervision, Devices I. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 had a pain assessment completed on 1/31/25 which indicated he did not have any pain. Resident #1 receives a pain screen completed every shift and has PRN APAP ordered that can be administered if needed. Resident #3 is non-ambulatory, requires extensive assistance from staff for ADL care/mobility (since last readmission on 12/17/24), and is no longer an elopement risk. His elopement assessment was updated on 1/31/25, along with his comprehensive care plan to reflect the changes in his medical status and low elopement risk. II. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice. Specific to resident #1, a work call was placed to Otis to have the elevator sensors inspected and cleaned, which was completed on 1/15/2025. House-wide education is in progress for all staff on reporting accidents and incidents through the appropriate chain of command, ensuring notification is made to the highest-level supervisor in the facility. Nursing Supervisors have been re-educated to immediately notify the Director of Support Services, or designee, via phone and email if an accident/incident occurs involving equipment that is not maintained by nursing. Specific to resident #3, all locked housekeeping closet doors have been checked, with no other striker plates found to be loose or otherwise malfunctioning, which could lead to recurrence. III. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? Routine maintenance/cleaning of the elevator sensors have been added to the Otis monthly preventative maintenance schedule. Incident and Accident Reports (I&As) are discussed the business day following the occurrence during the Interdisciplinary Team (IDT) morning meeting/clinical meeting. This ensures that follow-up has been communicated and completed. The Director of Nursing Services will complete an audit weekly for 12 weeks of all I&As to ensure no follow-up is omitted or missed during the IDT's review. Results will be presented to the QAPI committee monthly. The Director of Support Services, or designee will conduct audits twice daily to ensure locked housekeeping closets are secure and no other striker plates were loose, malfunctioning, or presented danger to residents. These audits will be completed for a period of at least 90 days post incident, seven days a week. Results will be presented to the QAPI committee monthly. Education is in progress with all nursing staff on Incident & Accident notification process for significant occurrences. This training will also be included in new care member orientation for all new staff. IV. How will corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of the locked housekeeping door audit and the I&A audit are given to the Director of Support Services and Director of Nursing Services, respectively, for review, and are also presented to the QAPI committee monthly. The QAPI committee will determine when substantial compliance has been achieved, and when the audits can be discontinued, frequency changed, or if they should continue as currently scheduled. V. The date for correction and the title of the person responsible for correction of each deficiency? Date Certain - 3/17/2025 Person Responsible - Director of Support Services
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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