Highland Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, New York.
- Location
- 120 Highland Avenue, Middletown, New York 10940
- CMS Provider Number
- 335526
- Inspections on file
- 19
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Highland Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, cerebral infarction, and heart failure experienced multiple significant changes in condition and pain management, including transitions from tramadol and oxycodone to morphine for end-of-life hospice care, increased morphine dosing, initiation of oxygen for low O2 levels, and treatment for fever. Facility policy required notifying the responsible party of significant changes in status and treatment, yet there was no documentation that the family representative was informed of the resident’s increased pain, initiation and escalation of morphine, or other treatment changes. The family only learned of the resident’s decline and morphine use when they called the facility, and interviews with the NP, LPN unit manager, and DON confirmed that such changes should have been communicated and documented but were not.
A resident with hemiplegia, major depressive disorder, and type 2 DM did not receive a timely admission Comprehensive MDS assessment within the required 14-day timeframe. The MDS coordinator allowed the ARD from a prior admission to remain active because the earlier assessment cycle and comprehensive care plan had not been fully closed by all disciplines, and the new stay was incorrectly treated as a readmission without verifying admission status. As a result, the current admission’s comprehensive MDS was not initiated and completed as required and remained overdue, while the administrator reported being unaware of any MDS tracking or ARD issues and had not been informed of the delay.
The facility failed to maintain an effective resident identification system, resulting in one cognitively impaired new admission having no identification band or other identifier and another cognitively intact resident wearing a wristband belonging to a different resident with a similar last name. Staff, including CNAs and the DON, reported that they rely primarily on identification wristbands to identify residents, especially when residents cannot state their names or when staff float to unfamiliar units, and acknowledged that bands may not be promptly applied or replaced and that no alternate identification process was in place when bands were missing or incorrect.
Surveyors found that the facility did not maintain a clean and safe environment, with observations of dirty floors, soiled equipment, and unclean radiators. Staff were unclear about cleaning responsibilities for items like floor mats and wheelchairs. Additionally, a resident's personal food was taken and eaten by a staff member, and subsequent checks revealed ongoing issues with improper food storage and labeling in the resident refrigerator, despite facility policies and staff reminders.
Surveyors found that three residents with severe cognitive impairment and dependence on staff did not receive necessary assistance with ADLs, including mobility and personal hygiene. One resident was not routinely transferred out of bed as required by their care plan, while two others were observed with long, dirty, or stained fingernails due to inconsistent nail care and unclear staff responsibilities.
A resident with severe cognitive impairment and multiple medical conditions was not allowed to receive visits from a friend, despite expressing a desire to do so. Facility staff and the Administrator restricted the friend's visitation based on concerns from a family member and financial safety, even though the family member had no legal authority. The resident was aware of and upset by the restriction, and staff confirmed the resident's wishes to see the friend were not honored.
A resident's belongings or money were wrongfully used due to the facility's failure to safeguard personal property and funds, resulting in a violation of resident rights.
Comprehensive care plans were not reviewed or revised for two residents after significant incidents, including a fall and repeated episodes of aggression. One resident with hemiplegia and pain was not provided updated interventions after a bathroom fall, and another resident with cognitive impairment had no care plan changes following multiple aggressive outbursts. Staff interviews and documentation confirmed the care plans were not updated as required.
A deficiency was cited for not ensuring an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and staff did not provide the necessary supervision.
Failure to Notify Family of Significant End-of-Life Condition and Medication Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family representative of significant changes in the resident’s condition, treatment, and medication regimen, as required by facility policy and 10NYCRR 415.3. The facility’s written policy on Change in Resident Status Notification required that the attending physician and responsible party be notified when there is a significant change in the resident’s physical, mental, or psychosocial status, or when there is any situation requiring a change in the plan of care, medications, or treatment regimen. Surveyors reviewed the medical record of a resident with dementia, cerebral infarction, and heart failure, whose MDS documented severely impaired cognition, and found no documented evidence that the family representative was notified of multiple significant changes in condition and pain management. From the dates reviewed, the resident’s pain management regimen changed several times. Initially, the resident was prescribed tramadol 50 mg by mouth every morning and at bedtime for pain, and oxycodone 5 mg by mouth every six hours as needed for pain. Subsequently, the resident was prescribed morphine sulfate 5 mg every six hours as needed for pain, shortness of breath, and restlessness related to end-of-life hospice care, and later morphine sulfate 10 mg buccally every three hours as needed for the same indications. Additional orders included initiation of 2 liters of oxygen via nasal cannula for low oxygen levels and an acetaminophen 650 mg suppository for fever. A nursing progress note documented a call from a hospice nurse reporting increased pain and discussing the resident’s pain regimen, with a plan to follow up with the nurse practitioner, but there was no documentation that the family representative was notified of the increased pain or the potential changes in pain management at that time. The record further showed that the resident’s family representative only received information about the increased morphine dosage after they themselves contacted the facility for an update, at which time they were informed of the dosage increase to address increased pain. The resident later expired, with the time of death documented in the nursing notes. In interviews, the complainant stated they were not notified when morphine was started and were unaware of its use until they called the facility, at which point they were told the resident had been declining for about a week and that medication changes had been made. The nurse practitioner stated that changes such as increasing morphine from 5 mg to 10 mg represent a significant change requiring family notification. The LPN Unit Manager and the Director of Nursing both acknowledged that staff are expected to notify family representatives of significant changes and to document such notifications, and upon review of the progress notes, they were unable to find documentation that the family representative had been notified of the medication and condition changes.
Failure to Complete Admission MDS Assessment Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely completion of a federally required admission Comprehensive Minimum Data Set (MDS) assessment for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, major depressive disorder, and type 2 diabetes mellitus. Facility policy required a systematic MDS scheduling process, including establishment of an Assessment Reference Date (ARD) within the allowable window and maintenance of an MDS scheduling calendar and tracking log. Record review showed that a comprehensive MDS assessment was required within 14 days of admission, but the assessment associated with an ARD of 12/23/2025 was not completed by that timeframe and was already 10 days overdue at the time of the initial record review on 01/02/2026. Interviews and further record review revealed that the MDS coordinator had the resident’s ARD tracking under a prior admission that ended in discharge in August 2025, and the comprehensive care plan from that prior admission had not been completed and closed by all disciplines. This prevented closure of the previous admission assessment cycle and left the prior ARD active, which interfered with the MDS process for the current admission. The MDS coordinator stated that the resident’s new admission had been treated as a readmission and the admission status was not verified, contributing to the failure to complete the new comprehensive assessment within the required 14-day timeframe. The administrator reported being unaware of any MDS or ARD tracking issues and had not been notified of delays. On revisit, the comprehensive assessment for the current admission remained incomplete, with required sections from other disciplines still outstanding and the ARD 35 days overdue.
Failure to Maintain Accurate Resident Identification Wristbands
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective resident identification system, resulting in residents either wearing incorrect identification wristbands or having no identification at all. During an abbreviated survey, observations on the dementia unit showed multiple residents, including Residents #2 and #5, without identification wristbands despite a facility policy requiring a resident identification system to support the provision of medical and nursing care. Staff interviews confirmed that identification wristbands are the primary method used by CNAs and other personnel, especially when residents cannot state their names or when staff float to unfamiliar units. Resident #5, a newly admitted resident with diagnoses including dementia, myocardial infarction, and peripheral vascular disease, had a recent Comprehensive MDS documenting severely impaired cognition. On observation, this resident had no identification wristband, name tag, or any other identifier in place. When the surveyor asked CNA #1, who was assigned to this resident, to identify them, CNA #1 was unable to do so and stated that residents are supposed to wear identification wristbands and that they could not identify the resident because the resident was new and had no band. The RN Unit Manager acknowledged that identification wristbands are expected to be applied upon admission and that they did not complete this admission and could not explain why the band was not applied. Resident #2, admitted with anxiety disorder, intracardiac thrombosis, and major depressive disorder, had an MDS indicating intact cognition. This resident reported an incident in which they were issued and wore another resident’s identification wristband belonging to a resident with a similar last name. The resident stated that when the podiatrist came to provide routine podiatry services, the podiatrist addressed them by the incorrect name shown on the wristband. The RN Unit Manager and the DON both confirmed that Resident #2 had been found wearing an incorrect identification wristband, but they could not identify which staff member applied it or how long it had been in place. Leadership interviews further revealed that identification wristbands may fall off or break and are not always promptly replaced, and no alternate process was described to ensure resident identification when wristbands are missing or incorrect.
Failure to Maintain Clean Environment and Protect Resident Property
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, as evidenced by multiple observations of uncleanliness and lack of maintenance on Unit 2. Surveyors observed peeling wallpaper, dirty and debris-covered floors, a floor mat with a strong urine odor, a soiled wheelchair, and radiators with air vent grates and metal fins heavily soiled with dirt, dust, dried food, and liquids. Glass balcony doors and windows in the dining room were also found to be dirty and covered with fingerprints and grease. Staff interviews revealed a lack of clarity regarding cleaning responsibilities for floor mats and wheelchairs, with some staff unaware of cleaning schedules or which department was responsible for certain tasks. There was no documentation of regular cleaning for wheelchairs, and spot cleaning was only performed when visible soiling was noticed. Additionally, the facility did not ensure reasonable care for the protection of resident property from loss or theft. One resident, who was cognitively intact and had diabetes and anxiety, reported that their personal food stored in the dining room refrigerator was taken and partially eaten by a staff member. The incident was confirmed through surveillance footage, and the facility acknowledged the misappropriation of the resident's property. Despite reminders and inservice training for staff that only resident food should be stored in the dining room refrigerator, subsequent observations found unlabeled, undated, and spoiled food items, as well as staff food, in the refrigerator. Staff interviews confirmed ongoing issues with labeling and storage of food items, and that dietary staff were responsible for checking and maintaining the refrigerator. Facility policies reviewed by surveyors outlined daily and monthly cleaning procedures for floors and common areas, but did not specify cleaning processes for radiators or floor mats. Policies also required that resident food be labeled and stored separately from staff food, and that perishable items be discarded after 72 hours. However, observations and staff interviews indicated that these policies were not consistently followed, resulting in an environment that did not meet standards for cleanliness, safety, or protection of resident property.
Failure to Provide Assistance with Activities of Daily Living and Personal Hygiene
Penalty
Summary
Surveyors identified that the facility failed to provide necessary care and assistance with activities of daily living (ADLs) for residents who were unable to perform these tasks independently. Specifically, three residents were observed to have unmet needs in the areas of personal hygiene, grooming, and mobility. One resident with severe cognitive impairment and a history of deep vein thrombosis was observed lying in bed on multiple occasions, with no evidence of being assisted out of bed to their wheelchair, despite care plans and medical recommendations indicating the need for regular out-of-bed time and participation in meals and activities outside the resident's room. Interviews with staff revealed that changes to the get-up schedule and staff assignments resulted in this resident no longer being routinely transferred out of bed, contrary to their care plan and physician recommendations. Another resident, also severely cognitively impaired and dependent on staff for personal hygiene and grooming, was observed with long, jagged, yellow and brown stained fingernails. The care plan for this resident required regular nail care due to fragile skin and risk of self-injury. However, the assigned Certified Nurse Aide stated that nail care was only performed on Fridays as part of their personal routine, and if the aide was not assigned to the resident on that day, the nail care was missed. The aide was unaware of the facility's policy regarding nail care frequency, and the resident's nails were not addressed even when observed by nursing staff during medication administration. A third resident, with severe cognitive impairment and dependent on staff for ADLs, was repeatedly observed with dirty, brown-stained fingernails, including while eating meals. Staff interviews revealed that nail cleaning was inconsistently performed, often only during scheduled showers or when activities staff were available. Some staff acknowledged seeing the dirty nails but did not attempt to clean them, and there was a lack of clarity among staff regarding responsibility for ensuring nail hygiene. Nursing staff stated that nail checks were supposed to be part of skin assessments on shower days, but this was not consistently done, resulting in prolonged periods where the resident's nails remained unclean.
Failure to Honor Resident's Right to Visitation
Penalty
Summary
The facility failed to ensure a resident's right to receive visitors of their choosing at the time of their choosing, as required by facility policy and regulation. The deficiency involved a resident with diagnoses including adult failure to thrive, hypertension, and interstitial lung disease, who was noted to have severely impaired cognition. Despite the resident expressing a desire to see their friend, the facility restricted the friend's visitation based on concerns raised by a family member and the Administrator regarding the resident's finances. The family member did not hold legal authority such as health care proxy, guardianship, or power of attorney. The facility communicated visitation limitations to the friend, who did not express concerns at that time. Staff interviews and documentation revealed that the resident consistently expressed a wish to see their friend and was upset about the visitation restrictions. The Administrator acknowledged restricting the friend's visits, citing concerns about the resident's cognitive status and potential financial exploitation, and offered supervised visits, which were declined by the friend. Despite a temporary guardian being appointed by court order to safeguard the resident's assets and determine care providers, the facility continued to restrict visitation, resulting in the resident being unable to see their friend as desired.
Failure to Protect Resident Property and Funds
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report documents that the facility failed to ensure that residents' personal property and funds were safeguarded against misuse or unauthorized access. Specific actions or omissions by facility staff led to the wrongful use of a resident's belongings or money, violating the resident's rights and facility policy. No additional details about the residents' medical history or condition at the time of the deficiency are provided in the report.
Failure to Update Care Plans After Falls and Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and/or revised for two residents following significant incidents. For one resident with end stage renal disease, hemiplegia, and pain, there was no documented evidence that the care plan was updated after a fall in the bathroom. The resident, who required assistance with mobility and transfers, was found on the floor after attempting to transfer to the toilet, resulting in complaints of pain and an X-ray being ordered. Despite the incident, the care plan was not revised to reflect the fall or to include new interventions, and staff interviews confirmed that the care plan update was not completed as required. Another resident with a history of cerebral infarction and moderate cognitive impairment exhibited multiple episodes of physical and verbal aggression, including throwing objects and attempting to hit staff. Progress notes documented these behaviors on several occasions, but there was no evidence that the care plan was reviewed or revised to address the ongoing aggressive behaviors. The lack of care plan updates following these incidents was confirmed through record review and staff interviews.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that staff did not provide the necessary level of supervision to mitigate these risks. No additional details about specific residents, their medical history, or the exact nature of the hazards or supervision lapses are provided in the report.
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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