Harris Hill Nursing Facility, L L C
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsville, New York.
- Location
- 2699 Wehrle Drive, Williamsville, New York 14221
- CMS Provider Number
- 335757
- Inspections on file
- 15
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Harris Hill Nursing Facility, L L C during CMS and state inspections, most recent first.
Staff failed to maintain a resident’s dignity when two resident assistants were in the resident’s room using personal cell phones while the resident was yelling for assistance. The resident had cognitive impairment, HF, and COPD, and was supposed to receive 1:1 visits and support. Both aides acknowledged they should not have been on their phones in front of the resident, and the LPN, SW, DON, and Administrator all stated staff should have been engaging with the resident instead of using personal devices.
A resident with stroke, hemiplegia, and dementia did not have the wheelchair foot buddy applied as directed in the care plan and Kardex. Staff observed the resident in the wheelchair without the device while the legs moved behind the foot pedals, and a CNA stated they forgot to apply it. An LPN confirmed the device was missing, and the DON and DOR stated the foot buddy remained appropriate and should have been used as planned.
A resident with CHF had ordered daily weights missed on multiple days, including instances where weight gains exceeded ordered parameters without provider notification. Another resident with dementia had a left elbow bruise that was not identified or documented during the weekly skin inspection. A cognitively intact resident had Tylenol left at bedside for self-administration without an active MD order authorizing it, despite staff confirming that such an order was required.
Meal tickets were not followed for several residents. A resident with DM, schizophrenia, and dysphagia did not receive the pancakes or juice listed on the meal ticket during observations, while two other residents with stroke-related deficits and dementia were not served the foods, fluids, or adaptive equipment documented for them. Staff and the RD stated residents should receive or at least be offered the items on their meal tickets, but the observed meals did not match the documented orders and preferences.
Unlabeled, expired, and personal food items were found in Unit A and Unit D servery refrigerators, along with soiled refrigerator surfaces and food debris on the floor. Staff interviews confirmed that opened items should be dated, discarded within the required time frame, and kept separate from personal items, and that the servery areas should be clean and sanitary.
A resident with multiple diagnoses, including glaucoma, was observed self-administering eye drops without an assessment or physician's order, contrary to facility policy. The comprehensive care plan required nursing staff to administer the medication, but the resident stored and used the medications independently. Staff interviews confirmed the lack of an assessment tool, physician's order, and documentation, leading to a deficiency.
A resident with hemiplegia was injured during a transfer when a CNA failed to follow the care plan requiring two-person assistance, resulting in a leg injury. The CNA attempted the transfer alone, leading to a hematoma. Staff interviews confirmed the neglect due to non-adherence to the care plan.
A resident received long-term prophylactic antibiotics without proper monitoring by the facility's Antibiotic Stewardship Program. Despite recommendations for regular lab tests and follow-up appointments, these were not completed or communicated to the infectious disease provider. Interviews revealed a lack of coordination among staff, including the LPN, Unit Manager, and DON/Infection Preventionist, leading to a deficiency in the facility's infection prevention and control program.
Staff Used Personal Cell Phones While Resident Called for Help
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when two resident assistants were in the resident’s room using their personal cell phones while the resident was calling out for assistance. The resident was sitting in a wheelchair in the room yelling for help, while one resident assistant stood about three feet away facing the window and tapping on a phone screen, and the other sat in a recliner behind the resident with a lit phone screen. The resident assistants stated they were assigned to keep the resident company and busy to help lower anxiety, but both were using their phones instead of engaging with the resident. The resident involved had diagnoses including cognitive communication deficit, heart failure, and COPD. The MDS documented moderate cognitive impairment, with the resident able to understand and be understood by others. The care plan identified a potential for alteration in psychosocial well-being and mood related to medical condition, adjustment to subacute rehabilitation, and confusion at times, with interventions to respect and listen to expression of feelings and establish trust. The Kardex indicated the resident required minimal assistance of one staff member for ADLs and was to receive 1:1 visits and transportation to activities as desired. During interviews, one resident assistant stated they were on a personal call from a family member and acknowledged that being on a phone in front of a resident was disrespectful. The other resident assistant stated they were shutting off a phone alarm and also acknowledged that staff should not be on their phones in front of residents because it was disrespectful and distracting. The LPN stated both resident assistants should have been engaging with the resident and neither should have been using personal phones. The SW, DON, and Administrator all stated staff should not use personal cell phones in resident care areas and should have been giving attention to the resident.
Failure to Apply Wheelchair Foot Buddy as Care Planned
Penalty
Summary
Resident #119 did not receive the foot buddy that was documented in the comprehensive care plan and Kardex for wheelchair positioning. The resident had diagnoses including stroke with hemiplegia and dementia, and the MDS documented moderate cognitive impairment. The care plan dated 01/28/2026 identified self-performance deficits related to activity intolerance, limited mobility, and limited range of motion, and included the intervention to use a foot buddy when out of bed in a wheelchair. The Kardex dated 04/20/2026 also directed staff to apply the foot buddy when the resident was in the wheelchair. Observations showed the resident in the dining room and in front of the community television in the wheelchair without the foot buddy in place, with both legs moving behind the wheelchair foot pedals. A foot buddy was observed on the floor next to the resident's nightstand in the room. CNA #3 stated they were responsible for the resident's care on 04/14/2026 and 04/17/2026 and said they must have forgotten to apply the foot buddy. LPN #4 also observed the resident without the foot buddy in place and confirmed the resident was supposed to use it to keep the legs from falling through the wheelchair pedals. The Director of Therapy stated the foot buddy remained appropriate and expected staff to follow the plan of care, and the DON stated staff should have applied it as recommended by therapy.
Failure to Follow Orders for Weights, Skin Checks, and Bedside Medication Use
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with physician orders and the comprehensive care plan for three residents. One resident with congestive heart failure, COPD, respiratory failure, and a history of pulmonary edema was ordered daily weights because of fluid retention concerns, but weights were not obtained on multiple days in February, March, and April, and there was no documentation that the provider was notified when weight gains exceeded ordered parameters. Staff interviews confirmed that the resident was expected to be weighed daily, that missed weights occurred, and that the provider was not notified as required. A second resident with dementia, protein-calorie malnutrition, and reduced mobility had a weekly skin inspection order tied to shower care. During observation, the resident was found with an approximately three-inch multicolored bruise over the left elbow. The bruise was not documented on the skin inspection record, which had been signed as completed, and staff interviews showed that the bruise was not identified during the shower-day skin check or during routine hands-on care. The resident’s emergency contact was also unaware of any recent injury. A third resident who was cognitively intact and independent for decision-making had a care plan that allowed self-administration of medications as ordered and stored at bedside. Staff found Tylenol at the bedside, but there was no active physician order authorizing self-administration of that medication. Interviews with the DON and Administrator confirmed that a physician order was needed for bedside self-administration and that no such order was in place at the time the medication was left at the bedside.
Meal tickets, fluids, and adaptive equipment not followed
Penalty
Summary
The facility failed to ensure that menus and meal tickets were followed for residents in one dining room, resulting in residents not receiving all foods, fluids, and adaptive equipment listed for them. The report states that dietary personnel were expected to assemble trays according to the menu and special requests, nursing personnel were responsible for providing beverages and reviewing the menu with residents, and designated personnel were to visually check each tray for accuracy. The facility also had policies stating residents should receive sufficient fluids to maintain hydration and that residents requiring adaptive equipment should be issued the appropriate equipment at mealtimes. Resident #17 had diagnoses including type 2 diabetes mellitus, schizophrenia, and dysphagia, and was assessed as severely cognitively impaired and requiring supervision with eating. The resident’s care plan identified risks for altered nutrition and dehydration and included interventions for preferred fluids and meal plan adjustments. During one breakfast observation, the meal ticket listed two pancakes and two sausages, but the resident was served scrambled eggs, sausage, and toast. The resident stated they would have liked pancakes, and after staff were notified, two pancakes were provided and one was eaten. During another breakfast observation, the meal ticket listed coffee, juice, and milk, but the resident was only given milk and stated they would have liked juice, which was not provided. Resident #52 had diagnoses including stroke with hemiplegia, aphasia, and dementia, and was documented as severely cognitively impaired and requiring supervision with eating. The care plan identified a self-performance deficit for eating and documented the need for an inner lip plate, along with interventions for nutrition and hydration. During observations, the resident’s meal tickets listed pastries, banana, and multiple beverages including water, prune juice, house juice, and a mighty shake, but the resident was served different foods and only received chocolate milk or juice, with no other listed beverages provided. On another breakfast observation, the resident’s meal ticket again listed pastries and banana with an inner lip plate, but the resident was served eggs, toast, and oatmeal on a regular plate. Resident #119 had diagnoses including type 2 diabetes mellitus, stroke with hemiplegia, and dementia, and was documented as moderately cognitively impaired and requiring supervision with eating. The care plan identified risks for altered nutrition and dehydration. During lunch and breakfast observations, the meal tickets listed multiple beverages, including prune juice, milk, coffee, and house juice, but the resident received only one cup of juice and no additional fluids. Staff interviews confirmed that residents should be offered the items on their meal tickets and that the meal tickets should be followed unless the resident stated otherwise.
Unlabeled and Expired Food Stored in Servery Refrigerators
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in two unit serveries, Unit A and Unit D. Surveyors observed that both servery refrigerators contained unlabeled or out-of-date food and drink items, and that personal food was stored with residents’ food. The cited policy required opened items to be labeled and dated and discarded after three days, and non-potentially hazardous or time/temperature control for safety foods to be labeled and dated and discarded after five days once opened. In Unit D, the refrigerator handle was sticky with an unknown substance and the front of the refrigerator had streaks of food debris. Inside the refrigerator were multiple items including sliced cold cut bologna, ham, turkey, and cheese with dates ranging from 04/07/2026 to 04/09/2026, along with undated egg salad, undated sliced tomatoes, and two undated 64-ounce pitchers of juice. In Unit A, the servery floor had food debris, crumbs, dried spills, and a black substance buildup in front of the refrigerator. The refrigerator contained an unopened, unlabeled personal iced tea, opened and undated margarine, opened milk containers without dates, undated cups of juice and chocolate milk, undated bagels, raisin bread, English muffins, and frozen water bottles and an opened, unlabeled ginger-ale can in the freezer. During interviews, dietary staff stated that opened items should be dated and checked for expiration, that personal items should not be stored in the servery refrigerator, and that the floors should be swept and mopped regularly. Dietary staff and supervisory staff acknowledged that items should be dated and discarded within the required time frame, and that the servery areas should be kept clean and sanitary. The FSD, DON, and Administrator also stated that food and drinks should be labeled and dated and that a clean environment was expected.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed by the interdisciplinary team to determine their ability to safely self-administer medications. Resident #12, who has diagnoses including peripheral neuropathy, intraspinal abscess, and glaucoma, was observed with medications in their room and self-administered these medications without an evaluation. The facility's policy requires an assessment and a physician's order for self-administration, which was not completed for Resident #12. The resident's comprehensive care plan indicated that nursing staff should administer ophthalmic medication, yet the resident was storing and self-administering eye drops without documented approval. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that there was no assessment tool completed, no physician's order for self-administration, and no documentation in the comprehensive care plan. The facility's failure to follow its policy and procedure for self-administration of medications led to this deficiency.
Neglect Due to Non-Adherence to Care Plan During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a Certified Nurse Aide (CNA) who did not adhere to the care plan for a resident requiring assistance during transfers. The resident, who had a history of stroke and hemiplegia, was dependent on others for transfers and required the assistance of two staff members using a sit-to-stand lift. Despite this requirement, the CNA attempted to transfer the resident alone, resulting in an injury to the resident's left lower leg. The incident was documented in a nursing progress note and an incident report, which detailed that the resident's leg was injured during the transfer when it hit the bed rail. The resident experienced pain and swelling, leading to a hematoma, as confirmed by a radiology report. Interviews with the resident and staff members, including the CNA involved, confirmed that the care plan was not followed, and the CNA acknowledged the mistake, citing a lack of available assistance at the time. Interviews with other staff members, including a Licensed Practical Nurse (LPN), the Director of Nursing (DON), and the Administrator, reinforced the expectation that care plans should be followed to prevent neglect. The LPN and DON both stated that failing to adhere to the care plan constituted neglect, as it resulted in harm to the resident. The Administrator also emphasized the importance of following care plans to ensure resident safety.
Failure to Monitor Antibiotic Use for Resident
Penalty
Summary
The facility failed to ensure that its infection prevention and control program included antibiotic use protocols and a system to monitor antibiotic use for a resident. Specifically, a resident received prophylactic antibiotics, Rifampin and Bactrim, since October 2022 without ongoing monitoring by the Antibiotic Stewardship Program. The resident's comprehensive care plan did not include infectious disease consults and recommendations, and there was no documented evidence of laboratory tests or follow-up appointments with the Infectious Disease Physician. The resident was admitted with diagnoses including peripheral neuropathy, intraspinal abscess, and glaucoma. The resident was cognitively intact and had a risk for infection related to long-term prophylactic antibiotic use. Despite recommendations from the Infectious Disease Physician for regular blood work and follow-up appointments, these were not completed or communicated to the infectious disease provider. The facility's infection and antibiotic tracking tool lacked documentation of lab monitoring or communication with the infectious disease provider. Interviews with facility staff revealed a lack of communication and responsibility for ensuring the completion of recommended labs and appointments. The Licensed Practical Nurse, Unit Manager, and Director of Nursing/Infection Preventionist were not effectively coordinating to monitor the resident's antibiotic use. The Pharmacy Consultant and Medical Director were also unaware of the specific recommendations for the resident, indicating a breakdown in the facility's antibiotic stewardship program.
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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