Hudson Hill Center For Rehabilitation & Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Yonkers, New York.
- Location
- 65 Ashburton Avenue, Yonkers, New York 10701
- CMS Provider Number
- 335080
- Inspections on file
- 25
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Hudson Hill Center For Rehabilitation & Nursing during CMS and state inspections, most recent first.
A resident with obesity, paraplegia, generalized weakness, and dependence for bed mobility had a rehab assessment and physician order for a left enabler bar to aid in turning and positioning, but the care plan lacked specific goals and interventions for its use and documentation did not show that the device was in place during care. While a CNA was providing peri care and turning the resident, the resident slipped or rolled off the bed and fell to the floor, later being found to have a right intertrochanteric hip fracture requiring surgical repair. Staff interviews revealed uncertainty or lack of recall about the presence or position of the enabler bar, and the resident reported that they did not have enablers before the fall and that they were pushed over too far during turning.
The facility failed to follow its own food storage and handling policies, resulting in residents receiving expired or improperly held food and beverages. A resident reported curdled, off‑tasting milk that was past its expiration date. Surveyors observed multiple opened, unlabeled, and undated food items in the main kitchen and unit pantries, along with several clearly expired products, including milk and cooked meats. They also found personal and resident food in unit refrigerators and freezers that was not labeled or dated as required. During meal tray assembly, milk portions were left out and measured at temperatures well above the required 40°F or less, and several residents complained that the milk tasted sour even though the cartons were within date. Staff interviews confirmed that policies required labeling, dating, discarding expired items, and maintaining proper temperatures, but staff could not explain why expired and unlabeled foods remained or why milk was allowed to warm during tray preparation.
A resident with overactive bladder, muscle weakness, impaired cognition, and dependence on staff for ADLs had a care plan and Kardex directing staff to check and assist with toileting at least every two hours using a bedpan or bedside commode and to provide peri-care after each incontinent episode. Over multiple days, the resident reported being left in a wet brief for extended periods and not being offered toileting assistance after morning care, despite expecting staff to return. A CNA acknowledged the resident required two-person assistance, should be toileted every two hours, and admitted that toileting was delayed or not repeated due to being busy, while an LPN could not state actual toileting frequency and an RN supervisor, though identifying in-bed toileting every two hours as the safest approach, was unaware of how often staff were actually checking or toileting the resident.
Two residents with cognitive impairment and known elopement risks were able to exit the facility unsupervised due to lapses in required one-to-one supervision and failures in the wander guard alarm system. In both cases, staff left the residents unattended without arranging coverage, and the facility's alarm system did not alert staff to the exits. There was also a lack of documentation showing that ordered safety interventions were implemented.
A resident assessed as an elopement risk with dementia and other conditions had a wander guard applied, but the care plan and CNA monitoring instructions were not updated until two days later. Staff relied on informal knowledge rather than documented procedures, and required documentation was missing until the delay was identified by leadership.
A resident with severe cognitive impairment and a history of wandering eloped from the facility on two occasions. After the first incident, the facility's investigation called for increased monitoring and one-to-one supervision at night, but these interventions were not added to the care plan or implemented. As a result, the resident eloped again and was found by police, requiring emergency evaluation.
A resident with multiple complex medical conditions experienced a delay in receiving antiviral treatment for Influenza A due to nursing staff not promptly notifying the physician after positive lab results. The lack of timely communication led to a delay in starting Tamiflu and implementing droplet precautions, contrary to facility protocol and CDC guidelines.
A resident with multiple complex medical conditions and severe cognitive impairment tested positive for Influenza A, but staff failed to promptly implement droplet precautions and notify the physician as required by facility protocol. Documentation was lacking for both the clinical rationale for testing and the communication of results, resulting in a delay in infection control measures.
A resident with severe cognitive and mobility impairments, who required two-person assistance for bed mobility and was known to be combative, fell from bed and sustained a laceration when a CNA provided care alone and turned away to retrieve equipment, leaving the resident unattended. The resident's care plan specified the need for two staff during such activities, but this was not followed, resulting in an accident despite other fall precautions being in place.
A resident with diabetes and neuropathy accessed an unsupervised hot liquid cart, filled a basin, and soaked their feet, resulting in second- and third-degree burns that required hospitalization and a skin graft. The facility lacked a specific policy and consistent staff monitoring for hot liquid carts, allowing the resident to obtain scalding water without detection.
The facility did not include patient care assistants in its facility-wide assessment, omitting their roles, training, and competencies, despite these assistants being scheduled daily to help with grooming and housekeeping. The assessment also failed to document the training provided to these assistants, and interviews revealed that both the assistants and their training program were not recognized as required elements in the assessment.
A resident with diabetes and peripheral vascular disease sustained severe burns after soaking their feet in hot liquid obtained from a cart, undetected by staff. The facility's investigation was incomplete, as statements from a CNA and another resident who witnessed the event were not obtained, and the investigative summary lacked a documented conclusion date, contrary to facility policy.
A resident sustained second- and third-degree burns from hot water obtained from a hot liquid cart. The administrator did not initiate or document any policy changes, protocol updates, or action plans to prevent recurrence, nor was there evidence of performance improvement plans for deficiencies identified in QAPI meetings. Attendance at QAPI meetings was documented, but no follow-up actions were recorded.
A resident sustained second- and third-degree burns from hot water obtained from a hot liquid cart, and there was no documented evidence that the QAPI committee developed or implemented an action plan to address the deficiency. Review of QAPI meeting minutes and staff interviews confirmed the lack of targeted follow-up or corrective action related to the incident.
The facility failed to ensure residents' mail privacy, as 15 residents reported their mail was opened by staff before delivery. The facility's policy allowed unopened mail unless advised otherwise, but the Admission Agreement permitted opening financial mail for assistance. The Administrator was unaware of this stipulation, leading to a deficiency in maintaining residents' privacy.
The facility failed to implement proper admission policies, requiring residents or their representatives to assume financial liability and waive rights. Two cognitively impaired residents signed agreements without understanding, and another resident denied signing. The facility's electronic signature process lacked transparency and security measures.
The facility failed to ensure accurate MDS 3.0 assessments for residents, leading to documentation errors. One resident's pressure ulcer and deep tissue injury were incorrectly noted as present on admission, another resident's smoking status was omitted, and a third resident's discharge location was inaccurately recorded. These errors were acknowledged by the MDS Director and were unintentional discrepancies from medical records.
Two residents at risk for pressure ulcers did not receive necessary preventive care, leading to the development of avoidable wounds. One resident did not have documented evidence of turning, repositioning, or use of heel booties, resulting in pressure ulcers. Another resident's air mattress was not set according to their weight, with no documentation of air pressure checks. Staff interviews confirmed the lack of adherence to care plans and facility policies.
The facility failed to provide necessary respiratory care for three residents. A resident was observed self-suctioning a tracheostomy without a physician's order, another received incorrect oxygen flow rates, and a third had no documented evidence of oxygen tubing changes. These deficiencies highlight lapses in adherence to physician orders and facility protocols.
The facility failed to maintain an effective pest control program, resulting in a roach infestation on multiple floors. Residents reported significant roach activity in their rooms, with one resident resorting to using a glove to kill roaches near their bed. Despite exterminator visits, the infestation persisted, and there was no documented evidence of a valid Pest Management Contract or an action plan to address the issue. Staff confirmed the presence of roaches, and the deficiency was exacerbated by residents keeping food in their rooms and ongoing construction.
The facility did not ensure residents and their representatives were informed of their right not to sign a binding arbitration agreement as a condition of admission. Two residents' admission agreements included language implying consent to arbitration without documented evidence of an option to decline. The administrator was unaware of the agreement's contents and stated it was a template used by other facilities.
The facility failed to provide required annual in-service training, including dementia management and abuse prevention, to CNAs. Documentation was lacking for five CNAs regarding dementia training, and one CNA did not complete the required 12 hours of training. Interviews revealed scheduling issues, particularly for overnight staff, contributing to these deficiencies.
A resident's dignity was compromised when their soiled fitted mattress sheet was not changed for six days, despite being cognitively intact and dependent on staff for daily activities. The resident reported infrequent sheet changes, and staff mentioned a linen shortage. However, a CNA stated that sufficient supplies were available, and the Director of Housekeeping confirmed linens were delivered twice daily. The failure to address the stained sheet in a timely manner led to the deficiency.
A resident-to-resident altercation in an LTC facility was not reported to the State Survey Agency within the required two-hour timeframe. The incident involved a physical confrontation resulting in a cut lip and pain for one resident, while the other was sent for psychiatric evaluation. The Director of Nursing was aware of the reporting requirement but reported the incident late.
A facility failed to notify a resident's representative in writing about a facility-initiated discharge. The resident, with complex medical conditions, received a discharge notice, but there was no evidence it was sent to their representative. The Ombudsman noted issues with the notification process, and the Social Worker confirmed the lack of documentation for mailing the notice to the representative.
A resident with a primary language of Spanish was not provided with necessary interpretive services, as documented in their care plan. The facility's staff were unaware of how to access translation devices, and the need for interpretive services was not documented in the Certified Nurse Aide instructions. Interviews revealed a lack of Spanish-speaking aides and insufficient training on language translation devices.
A resident with a history of dysphagia and pneumonitis was not provided with a plan to address their dietary needs and minimize choking hazards, despite hospital recommendations. The facility failed to monitor the resident's oral intake and difficulty swallowing, and communication breakdowns among staff led to a lack of follow-up on the resident's dietary needs. The resident was found unresponsive after being served a lunch meal tray, and the facility did not thoroughly investigate the incident to rule out choking.
A physician failed to review a resident's total care plan, including dietary needs, leading to the resident not receiving necessary dietary modifications for dysphagia. The physician did not incorporate hospital and dietician recommendations into the care plan, relying instead on nursing staff for information.
A resident's tax refund checks were mishandled by the facility, as they were opened and deposited into the facility's account without the resident's consent. The resident, who was cognitively intact, was not informed of the receipt or deposit of these checks. The facility failed to provide documented evidence of the resident's authorization for financial management or detailed transaction history, violating the resident's right to manage their financial affairs.
A resident's tax refund checks were misappropriated by the facility's Business Office, which deposited them into a facility account without the resident's consent. The resident, who managed their own finances, was not informed of the checks' arrival or the transactions. Facility policies on resident funds were not followed, and the Administrator was unaware of the issue.
A resident with a history of acute stress reaction and substance abuse did not receive a psychology consult as ordered, despite expressing a need for therapy to address past traumas. The facility failed to ensure the consult was conducted, leading to a deficiency in providing necessary behavioral health services.
The facility failed to properly label and store drugs and biologicals, as an expired insulin pen was found in the medication storage room refrigerator, and a controlled medication was improperly stored in a medication cart. Staff interviews revealed non-compliance with medication storage policies, and issues with accessing the controlled medication box were noted.
A resident reported that a dialysis transportation worker withdrew $5,900 from their cash app account under false pretenses. The facility failed to ensure the worker did not have access to non-dialysis residents and did not conduct a thorough investigation, including interviews with other residents or obtaining a statement from the accused worker. The resident had intact cognition and was not protected by an abuse care plan.
A resident alleged that a dialysis transportation worker withdrew $5,900 from their cash app account under the pretense of assisting with finding an apartment. The facility reported the incident to law enforcement but failed to interview other residents transported by the worker or obtain a written statement from the accused. No abuse care plan was initiated to protect the resident, and the facility did not substantiate the allegation due to a lack of evidence.
Two residents in an LTC facility experienced deficiencies in care. One resident with a history of vaginal bleeding did not receive a timely gynecological appointment due to transfer issues, leading to a hospital transfer. Another resident's intravenous antibiotic treatment was delayed by three days due to a failure in medication reconciliation. Staff interviews revealed lapses in communication and procedural adherence.
Failure to Implement Ordered Enabler Bar Resulting in Bed Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible by not implementing a physician-ordered left enabler bar as specified. An assessment completed by rehabilitation on 01/13/2025 documented that an enabling device was indicated to promote independence and recommended a left enabler bar, with nursing notified and a request made to maintenance for installation. A physician order dated 01/14/2025 directed use of a left enabler bar for bed mobility to aid in turning and positioning on every shift, and the care plan dated 01/14/2025 documented that the resident may use enabler bars; however, there was no documented evidence that specific goals and interventions addressing enabler bar use were added to the care plan prior to 05/06/2025. The admission MDS dated 01/17/2025 showed the resident was cognitively intact, had functional impairment of one upper extremity and both lower extremities, was dependent for rolling from back to side, and was documented as not at risk for falls. On 04/05/2025 at approximately 5:30 AM, the resident slipped or rolled off the bed during care provided by a CNA. The Accident and Incident form completed by RN #21 documented that the resident slipped off the bed when the CNA was turning the resident, with no visible injury but complaints of head and lower extremity pain. The CNA’s written statement indicated they turned the resident to the left to clean them, the resident started to shake, the right leg slipped down, and the resident fell out of bed. There was no documentation on the Accident and Incident form or on the CNA Follow Up Question Report for 04/01/2025–04/31/2025 indicating that a left enabler bar was in place or addressed. Subsequent progress notes by RN Supervisor #21 recorded that the resident rolled off the bed during care, was holding their head in pain, and was transferred to the emergency room for evaluation. The Emergency Department Visit Summary documented that the resident sustained a right intertrochanteric fracture, and later progress notes recorded that the resident underwent surgical repair with right gamma nailing. The facility’s Summary of Investigation dated 04/15/2025 stated the resident used a left enabler bar for bed mobility and required substantial/maximal assistance and one-assist for bed mobility, but again contained no documented evidence that a left enabler bar was in place at the time of the fall. In interviews, the DON stated the resident had a left enabler bar since January 2025 but could not say whether it was in the up position at the time of the fall, and RN #9 reported they could not recall the resident having bed enablers. The resident stated they did not have enablers before the fall and that the CNA pushed them over too far, causing them to fall on their right hip. The Administrator stated that enablers on the second floor were fixed and could not be raised or lowered without tools, and suggested the enabler may have been obscured by the mattress, while acknowledging they had reviewed and signed the Accident/Incident report without noting the discrepancy regarding the enabler bar documentation.
Improper Food Storage, Labeling, and Milk Temperature Control
Penalty
Summary
The deficiency involves the facility’s failure to store and prepare food in accordance with its own policies and professional food safety standards. One resident reported receiving milk for cereal that tasted off and was curdled; the resident then noted the milk carton was past its expiration date. Surveyors reviewing the kitchen on multiple dates observed numerous food items that were opened, unlabeled, and undated, including cooked vegan chicken cutlets, veggie burgers, an opened brick of cheese, shredded mozzarella, thawing peppers, waffles, muffins, and frozen chicken necks. In the unit pantries, surveyors found multiple bags and containers of food that were unlabeled and undated, including an unwrapped brick of cheese, butter in a plastic bag, pickle slices in a specimen cup, a cut lemon in a cup, and fast-food drinks with uncovered straws. Expired items were also found in the main kitchen and unit pantries, including multiple cartons of milk and a pan of cooked turkey breasts in the kitchen refrigerator, and containers and bags of food in a unit pantry that were dated well past their labeled dates. The facility also failed to maintain milk at safe temperatures as required by policy. During tray assembly, a diet aide prepared racks of individual juice cups and 4‑oz milk portions; the milk did not feel cold, and the Food Service Director measured the milk temperature at 69°F. Later, three residents complained that the milk tasted sour; the cartons were within date, but the milk temperature was measured at 58°F. A RN unit manager suggested the milk might have warmed because lunch trays were delivered late. On another observation of lunch tray assembly, the Food Service Director measured milk at 47°F and stated the milk had not been in the refrigerator long before tray line started. Interviews with the Food Service Director and a RN unit manager confirmed that staff had been educated on labeling and dating, that anyone could discard expired food, and that nursing staff were responsible for logging refrigerator temperatures and discarding expired or unlabeled items, but they were unable to explain why expired, unlabeled, and undated foods remained in the kitchen and unit pantries or why milk was left out during tray preparation.
Failure to Provide Scheduled Toileting Assistance per Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide toileting assistance every two hours as specified in the comprehensive care plan for a resident who was dependent on staff for activities of daily living. The resident had diagnoses including overactive bladder, muscle weakness, and localized swelling of the lower limb, with the MDS documenting moderately impaired cognition, dependence on staff for chair-to-bed transfers, and a need for substantial assistance with toileting and personal hygiene. The resident’s bowel incontinence care plan and Kardex directed staff to check the resident every two hours, assist with toileting as needed, provide a bedpan or bedside commode, and provide perineal care after each incontinent episode. The facility’s ADL policy required staff to ensure residents’ basic needs were met, including toileting, and supervisors/managers were to oversee implementation of care plans. Surveyor observations and resident interviews over several days showed that staff did not follow the two-hour toileting schedule. The resident reported that on one morning the night shift changed their brief at approximately 6:30 a.m., and no staff offered toileting assistance again until early afternoon, leaving the resident in a wet brief for about two hours and without any toileting offers since morning care. On subsequent days, the resident stated they were assisted with toileting around 9:00 a.m. but were not offered further toileting assistance later in the morning or early afternoon, despite having been incontinent and expecting staff to return. A CNA confirmed the resident required two-person assistance and was toileted in bed, acknowledged toileting should occur every two hours, and admitted that on one date they did not toilet the resident until about 1:00 p.m. due to being busy with documentation, and that on another date the last toileting was around 9:00 a.m. with no additional checks. An LPN stated the resident should be toileted approximately every two hours but could not state the actual frequency, and the RN supervisor stated the safest intervention was frequent in-bed toileting at least every two hours but was unaware of how often staff were actually checking or toileting the resident.
Failure to Prevent Elopement and Inadequate Supervision of At-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at risk for elopement received adequate supervision and that the environment was free from accident hazards, as evidenced by two separate incidents involving residents with documented elopement risks. In the first case, a resident with diagnoses including anxiety disorder, cerebral infarction, and schizoaffective disorder, and with a history of wandering and elopement attempts, was placed on one-to-one supervision. Despite this, the assigned Patient Care Assistant left the resident unattended to take a dinner break without arranging for coverage, and the resident was able to exit the facility undetected. The facility's wander guard system did not alarm, and the resident was later found at a nearby bus station. Staff interviews confirmed that the resident was known to be at high risk for elopement and that one-to-one supervision required the staff member to remain within arm's reach at all times, which was not followed in this instance. In the second case, another resident with diagnoses including dementia with mood disturbance, agitation, and Parkinson's disease, and with severely impaired cognition and wandering behaviors, also eloped from the facility on two separate occasions. The resident was assessed as an elopement risk and had a wander guard in place. After the first elopement, interventions such as 30-minute visual checks and one-to-one supervision at night were ordered, but there was no documented evidence that these interventions were implemented. The resident subsequently eloped again, exiting through the front entrance without staff detection, and was found by police walking on a nearby street. Staff interviews revealed that the wander guard system did not alarm or secure the elevators or exit doors at the time, and there was a lack of internal cameras to monitor resident movement. Throughout both incidents, facility staff, including the DON and Administrator, acknowledged that the required supervision protocols were not followed and that the wander guard system was not fully integrated with all exits and elevators. Staff responsible for one-to-one supervision left residents unattended without arranging for relief, and there was a lack of documentation to show that required safety interventions were consistently implemented. The facility's policies on elopement prevention and one-to-one supervision were not adhered to, directly contributing to the residents' ability to leave the premises unsupervised.
Failure to Timely Develop and Document Elopement Risk Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to timely develop and implement a comprehensive care plan addressing elopement risk for a resident with dementia, cerebral infarction, and cervical spondylosis. The resident was assessed as an elopement risk and had a wander guard device applied, but the elopement care plan was not initiated until two days later. Additionally, the Certified Nurse Aide Assignment/Accountability Record and related monitoring instructions were not updated at the time the wander guard was placed, contrary to facility policy. Interviews revealed that staff relied on informal knowledge rather than documented instructions to monitor the resident's wander guard, and the required documentation in the care plan and CNA records was missing until after the delay was identified. The Director of Nursing confirmed that the care plan should have been updated immediately upon assessment and intervention, and that the omission was not in line with facility expectations or policy.
Failure to Revise Care Plan After Elopement Incident
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to include measurable interventions addressing an identified elopement risk. After an initial elopement incident, the facility's investigation summary specified that the resident should be monitored every 30 minutes for three days and placed on one-to-one supervision at night. However, these interventions were not incorporated into the resident's care plan, nor were they implemented. The care plan remained unchanged despite the resident's ongoing risk factors, including severely impaired cognition, wandering behaviors, and diagnoses such as adjustment disorder, dementia with mood disturbance and agitation, and Parkinson's disease. As a result of the care plan not being updated, the staff did not receive directives to implement the required interventions. Subsequently, the resident eloped again and was found by local police wandering on a nearby street, after which the resident was brought to the emergency room for evaluation. Interviews with nursing staff and the Director of Nursing confirmed that the care plan should have been revised to reflect the new interventions following the initial elopement, and that the failure to do so led to the deficiency.
Delay in Notification and Treatment for Positive Influenza A Result
Penalty
Summary
A deficiency occurred when the facility failed to provide timely medical evaluation and treatment for a resident who tested positive for Influenza A. The laboratory report indicated a positive result for Influenza A, but there was no documented evidence that nursing staff reviewed or addressed these results on the day they were received or the following day. Additionally, there was no documentation that the physician was notified of the positive test result during this period. As a result, antiviral treatment with Tamiflu was not initiated until two days after the positive result was available. The resident involved had significant medical conditions, including malignant neoplasm of the cerebellum, diabetes mellitus, multiple sclerosis, thrombocytopenia, and severely impaired cognition. Interviews with facility staff confirmed that the delay in treatment was due to a lack of timely communication from nursing staff to the physician. Staff also acknowledged that droplet precautions could have been implemented sooner, as a physician's order is not required to begin such precautions when Influenza is suspected or confirmed. The delay in starting Tamiflu and implementing appropriate precautions represented a failure to provide necessary care and services according to the facility's own Influenza protocol and CDC guidelines.
Delay in Initiating Droplet Precautions for Influenza A Positive Resident
Penalty
Summary
The facility failed to implement timely infection prevention and control measures for a resident who tested positive for Influenza A. After a respiratory panel plus COVID test was completed, the positive result for Influenza A was obtained, but droplet precautions were not initiated until two days later. There was no documented evidence that droplet precautions were started immediately after the positive result, as required by the facility's Influenza Protocol. The medical record also lacked documentation of the clinical rationale for ordering the test, and there was no record of timely physician notification regarding the positive result. Interviews with facility staff revealed that nurses are responsible for notifying physicians of abnormal test results and can initiate droplet precautions without a physician's order. However, in this case, there was a delay in both notifying the physician and implementing necessary precautions. The Director of Nursing and the Medical Director both confirmed that the delay represented a lapse in communication and infection control practices. The resident involved had significant medical conditions, including severe cognitive impairment, and was at increased risk due to the delay in implementing appropriate infection control measures.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Parkinson's disease, impaired mobility, and a history of being combative with care, fell from their bed and sustained a laceration to the left eyebrow. The resident was completely dependent on staff for all activities of daily living, including bed mobility and transfers, and required the assistance of two staff members for these tasks. On the day of the incident, a certified nurse aide was providing care alone and turned away from the resident to retrieve a mechanical lift pad, during which time the resident fell from the bed to the floor. The resident's care plan and assessment documentation indicated a need for two-person assistance for bed mobility and transfers due to the resident's inability to move independently and their tendency to be combative, including kicking, hitting, and reaching for objects. Despite these documented needs, the aide performed care and repositioning without a second staff member present. The resident was positioned in bed with their body against the wall, and the bed was in a low position, but the aide left the resident unattended while turning to get equipment, resulting in the fall. Interviews with staff confirmed that the resident was known to be completely dependent and often combative, requiring two-person assistance for safe care. The environment at the time of the incident was otherwise free of hazards, with appropriate fall precautions in place, but the lack of adequate supervision and failure to follow the resident's care requirements directly led to the accident and injury.
Failure to Prevent Resident Access to Hot Liquid Cart Resulting in Severe Burns
Penalty
Summary
A deficiency occurred when a resident with diabetes, peripheral vascular disease, and polyneuropathy, who was cognitively intact but required supervision for activities of daily living, was able to access hot water from an unattended hot liquid cart. The resident filled a basin with hot water and soaked their feet in another resident's room without staff knowledge or detection. The resident, who had neuropathy and could not feel pain in their feet, sustained second- and third-degree burns, resulting in blisters and subsequent hospitalization for burn evaluation and treatment, including a skin graft. The facility's hot liquids safety policy required that hot liquids be served at safe temperatures and that precautions be taken to regulate the temperature of liquids accessible to residents. However, there was no specific policy addressing the monitoring of hot water carts on resident units, and staff monitoring of the carts was inconsistent and informal, relying on word of mouth. The hot liquid cart was left accessible to residents, and staff were unaware that the resident had obtained hot water until after the injury occurred. Interviews revealed that the hot liquid cart was typically left outside the dining room and was accessible for extended periods, especially when logistical issues such as elevator availability delayed its removal. Documentation and interviews confirmed that staff did not observe the resident obtaining the hot water or soaking their feet, and the incident was only discovered after the resident reported blisters. The lack of consistent monitoring and absence of a clear policy for supervising hot liquid carts directly contributed to the resident's ability to access scalding water, resulting in actual harm. The event was classified as Immediate Jeopardy due to the actual harm and the risk posed to other residents.
Omission of Patient Care Assistants from Facility Assessment
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all personnel, specifically omitting patient care assistants from the documentation. Although patient care assistants were scheduled daily on each unit to assist residents with grooming and housekeeping tasks, their roles, education, training, and competencies were not documented in the facility assessment. The assessment also did not reflect the training provided to these assistants, despite the facility operating a patient care assistant school on the premises and utilizing these individuals in resident care support roles. Interviews with the Staffing Coordinator confirmed that patient care assistants, who are students trained by the facility, were not included in staffing numbers but appeared on daily schedules. The Administrator acknowledged being unaware that both the patient care assistants and the training program needed to be included in the facility assessment. The deficiency was identified during a partial extended survey, with documentation and interviews supporting that the facility assessment did not meet regulatory requirements for comprehensively listing all direct care staff and their competencies.
Failure to Thoroughly Investigate Resident Burn Incident
Penalty
Summary
A deficiency was identified when the facility failed to thoroughly investigate an alleged violation involving a resident who sustained second and third-degree burns to both feet after immersing them in hot liquid obtained from a hot liquid cart. The incident occurred when the resident, who had diagnoses including diabetes mellitus, peripheral vascular disease, and polyneuropathy, accessed hot liquid from a cart on the unit and carried it to another resident's room without staff detection. The resident, who was cognitively intact and required some assistance with activities of daily living, soaked their feet in the hot liquid for 25 to 30 minutes, resulting in significant burns. The facility's accident/incident report was found to be inconsistent with the accounts provided by the resident and witnesses. Specifically, there was no documented evidence that statements were obtained from the certified nurse aide and another resident who witnessed the incident, as required by the facility's policy. Interviews confirmed that the certified nurse aide observed the resident with their feet in the basin and reported the incident to nursing staff, but was not asked to provide a written statement. Similarly, the other resident present during the incident was not interviewed for a statement at the time of the investigation. Further, the investigation summary lacked a documented date of conclusion, and the process for collecting and reviewing witness statements was not consistently followed. Nursing management acknowledged that statements from all relevant witnesses were not obtained and that investigative summaries were not dated, which was contrary to facility policy. These lapses resulted in an incomplete investigation of the incident involving the resident's injury.
Failure to Implement and Document Quality Improvement Actions After Resident Burn Incident
Penalty
Summary
The facility administrator failed to ensure effective and efficient use of resources to maintain the highest practicable well-being of each resident. Specifically, a resident sustained second- and third-degree burns after obtaining hot water from a hot liquid cart. Following this incident, there was no evidence that the administrator initiated any policy changes or protocol updates to prevent recurrence, nor was there documentation of a review of the incident details. Additionally, the administrator did not provide documented evidence of action plans or performance improvement plans for deficiencies identified during Quality Assurance and Performance Improvement (QAPI) meetings. The facility's QAPI policy requires the establishment of an interdisciplinary Quality Assessment and Assurance committee, including the administrator, to meet regularly and address quality deficiencies. However, while attendance sheets for several QAPI meetings were provided, there was no documentation of implemented action plans or performance improvement plans for identified deficiencies. Interviews with the administrator and DON revealed uncertainty regarding policy updates and a lack of immediate changes following the incident, as well as inconsistent participation in QAPI meetings by the administrator.
Failure to Develop and Implement QAPI Action Plan After Resident Burn Incident
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee developed and implemented appropriate plans of action to address identified quality deficiencies. Specifically, after a resident sustained second- and third-degree burns from hot water obtained from a hot liquid cart, there was no documented evidence that the QAPI committee took steps to identify or correct the deficiencies related to this incident. Review of QAPI meeting minutes following the incident did not reveal any action plans or performance improvement plans addressing the event. Interviews with the Administrator and Director of Nursing confirmed that while QAPI meetings are held and issues are discussed, there was no documentation or evidence of targeted actions taken in response to the burn incident. The facility's policy requires the QAPI committee to develop plans of action for identified deficiencies, but this process was not followed in this case, as shown by the lack of documentation and follow-up specific to the incident.
Violation of Residents' Mail Privacy
Penalty
Summary
The facility failed to ensure residents' right to privacy when sending and receiving mail, as evidenced by the experiences of 15 residents who reported that their mail was opened by facility staff before being delivered to them. The facility's policy on mail, dated May 2024, stated that residents were allowed to send and receive personal mail unopened unless otherwise advised by the attending physician and documented in the residents' medical records. However, during a Resident Council meeting, all attendees reported receiving mail that had been opened by facility staff prior to delivery. Interviews with the Activities Director and Security Director revealed that the Security Director received and sorted the mail, and the Business Office Coordinator and Manager were involved in handling residents' financial mail, which was opened and managed by the Business Office. The facility's Admission Agreement included provisions that allowed the facility to open residents' financial mail for assistance and payment purposes, which was not aligned with the facility's policy on mail privacy. The Administrator, during an interview, stated that they were unaware of the Admission Agreement's stipulation allowing the facility to open mail addressed to residents. This discrepancy between the facility's policy and practice, as well as the lack of awareness by the Administrator, contributed to the deficiency in maintaining residents' right to privacy in their correspondence.
Deficient Admission Policies and Consent Procedures
Penalty
Summary
The facility failed to establish and implement an admission policy that did not require residents or their representatives to incur personal financial liability or waive their rights. This was evident for all 11 residents reviewed for admission. The admission agreements required resident representatives to assume responsibility for the resident, hold the facility harmless for injury, death, and loss of property, and be personally liable for payment of charges. Additionally, the agreements allowed the facility to open residents' financial mail and manage their income without proper consent. Two residents, who were moderately cognitively impaired, signed admission agreements without documented evidence of their understanding due to their cognitive status. One resident, diagnosed with dementia, signed electronically without evidence of comprehension, while another resident with complex medical conditions and communication difficulties also signed without understanding. These agreements were signed despite the residents' cognitive impairments, raising concerns about their ability to consent. Another resident, who was cognitively intact, denied signing an admission agreement and was unaware of how their electronic signature appeared on the document. This resident had been managing their own finances and did not consent to the facility managing their Supplemental Security Income. The facility's process for obtaining electronic signatures and the lack of individual signatures for supplemental attachments further complicated the situation, as the administrator was unaware of the details and security measures involved in the electronic signature process.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessments accurately reflected the residents' status, leading to deficiencies in the documentation of residents' conditions. Specifically, for one resident with a history of dysarthria, dementia, and stroke, the MDS inaccurately documented the presence of a pressure ulcer and deep tissue injury as being present upon admission, despite these conditions not being present at that time. Another resident, who was a known smoker with diagnoses of diabetes mellitus and chronic obstructive pulmonary disease, was not identified as an active smoker in the MDS assessment, despite documentation in the care plan and nursing notes indicating their smoking status. Additionally, a third resident with diagnoses including diabetes mellitus and cervical disc disorder was inaccurately documented in the MDS as being discharged to a hospital, when in fact, they were discharged to the community with transportation provided to an airport. The inaccuracies in the MDS assessments were acknowledged by the MDS Director, who stated that the errors were unintentional and resulted from discrepancies in the information obtained from the residents' medical records. The facility's administrator was unaware of these inaccuracies prior to the survey findings.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services to promote wound healing and prevent new ulcers from developing. Specifically, for Resident #276, who was at risk for skin breakdown, there was no documented evidence that preventative measures, such as turning and repositioning or the use of heel booties as per the physician's order, were implemented prior to the development of a left heel pressure ulcer and a left dorsal foot deep tissue injury. The resident's care plan included interventions for potential impaired skin integrity, but these were not documented in the Certified Nurse Aide tasks or the Treatment Administration Record. Interviews with facility staff, including the Registered Nurse Supervisor and the Wound Nurse, confirmed the lack of documented interventions and the avoidable nature of the wounds. Resident #115, who had a diagnosis of chronic obstructive pulmonary disease, unspecified dementia, and Alzheimer's disease, was also at risk for skin breakdown. The resident had a Stage 3 pressure ulcer on the left heel and was prescribed an air mattress to aid in pressure relief. However, observations revealed that the air mattress was not inflated according to the resident's weight, as it was set at 350 pounds while the resident weighed 181 pounds. There was no documented evidence that the air pressure inflation monitoring was checked and documented by nurses each shift, as required by the facility's policy. Interviews with staff, including a Certified Nursing Assistant and a Registered Nurse, indicated a lack of awareness and responsibility for checking the air mattress settings. The deficiencies in care for both residents highlight a failure in the facility's implementation of pressure ulcer prevention measures. The lack of documentation and adherence to care plans and physician orders contributed to the development and progression of pressure ulcers in these residents. The facility's policies on pressure injury prevention and air mattress support surface were not effectively followed, leading to avoidable harm to the residents.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards for three residents. Resident #168, who was cognitively intact and had a tracheostomy, was observed performing self-suctioning without a physician's order. Despite the resident's claim that a respiratory therapist had approved their self-suctioning, there was no documented evidence of such an evaluation. Additionally, a registered nurse had previously observed the resident self-suctioning and reported it to respiratory therapy, but no documentation was found to support this claim. Resident #194, who had severe cognitive impairment and a tracheostomy, was observed receiving oxygen at incorrect flow rates of 7 and 8 liters per minute, despite physician orders for 3 and 5 liters. The Medical Administration Record inaccurately documented the administration of oxygen at the prescribed rate. The registered nurse unit manager acknowledged the incorrect oxygen flow but could not explain the discrepancy. Resident #69, with severe cognitive impairment and on continuous oxygen therapy, had no documented evidence of oxygen tubing changes as per physician orders. Observations revealed that the nasal cannula tubing was not dated, and a registered nurse confirmed the lack of documentation regarding the last tubing change. The facility's protocol required checking the order every shift and changing the cannula every three days, but this was not adhered to.
Pest Control Deficiency Due to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a roach infestation on multiple floors. Observations and interviews revealed that residents on the 2nd, 4th, and 6th floors experienced significant roach activity in their rooms. One resident on the 2nd floor reported seeing roaches in their room and bathroom, while another resident on the 6th floor described a pervasive infestation, with roaches visible at all times and worsening at night. The resident had to resort to using a glove to kill roaches near their bed. Despite previous exterminator visits, the roach activity did not decrease. The facility's pest control policy, dated June 2024, required a written agreement with a qualified pest service, but there was no documented evidence of a valid Pest Management Contract. The Facility Survey Report and Facility Assessment did not identify a third-party contractual agreement with a pest control company, nor did they document pest control as a necessary service. Interviews with staff, including certified nurse aides and housekeepers, confirmed the presence of roaches and indicated that exterminators had visited the facility, but the infestation persisted. The Pest Logbook documented roach sightings on the 4th floor but not on the 2nd or 6th floors. The Director of Housekeeping stated that the facility worked with a Pest Management Company, and exterminators visited weekly. However, there was no documented evidence of exterminator meetings, recommendations, or actions taken to address the infestation. The Administrator confirmed that pest control services were provided, but there was no documentation of recommendations or an action plan to address the roach infestation. The deficiency was further compounded by residents keeping food in their rooms and ongoing construction in the facility, which made controlling the infestation challenging.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents and their representatives were explicitly informed of their right not to sign a binding arbitration agreement as a condition of admission. This deficiency was identified during a recertification survey, where it was found that the admission agreements for two residents included language that implied their signatures were applicable to a binding arbitration agreement. The facility's admission packet contained an admission agreement and a list of attachments, including a binding arbitration agreement, but there was no documented evidence that residents were given the option to sign the admission agreement without consenting to the arbitration agreement. During interviews, the facility's administrator stated that they were not aware of the contents of the admission agreement and did not know that binding arbitration agreements were offered to residents. The administrator also mentioned that the admission agreement was a template likely used by other facilities under the same corporate entity. Despite the administrator's claim that the facility did not require residents to sign the arbitration agreement, there was no explanation provided on how residents could differentiate their admission agreement signature from consent to the arbitration agreement.
Deficiency in CNA Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service training, including specific training in dementia management and resident abuse prevention. During a recertification survey, it was found that five CNAs did not have documented evidence of receiving dementia management training. Additionally, one CNA did not complete the required 12 hours of in-service training or the abuse prevention training. The facility's policy mandates regular in-service training for all personnel, and the facility assessment specifies that training must include dementia management and abuse prevention. Interviews with the Nurse Educator and the Director of Nursing revealed gaps in the training schedule, particularly for overnight staff. The Nurse Educator, who was responsible for staff training, had stopped working night shifts in October 2024, which contributed to the missed training sessions. The Director of Nursing was aware of the general lack of training for overnight staff but was not specifically aware of the missed training for the CNA in question. This lack of training documentation and scheduling oversight led to the identified deficiencies.
Resident Dignity Compromised Due to Unchanged Soiled Linens
Penalty
Summary
The facility failed to ensure a dignified experience for a resident, identified as Resident #90, during a recertification and abbreviated survey. The deficiency was observed when the fitted mattress sheet on Resident #90's bed was stained and not changed for six days. Resident #90, who was cognitively intact and dependent on staff for daily activities, reported that their sheets were changed infrequently, and staff mentioned a linen shortage. However, Certified Nurse Aide #29, who was familiar with the resident, stated that they had sufficient supplies and had changed the sheets on 12/14/24. Despite this, the stained sheet was observed on multiple occasions, indicating a lapse in maintaining the resident's dignity. Interviews with staff, including a Registered Nurse and the Director of Housekeeping, revealed that while there could be occasional shortages of linens, procedures were in place to address these shortages by contacting the laundry department. The Director of Housekeeping confirmed that linens were delivered twice daily and additional supplies could be provided if needed. Despite these procedures, the stained sheet on Resident #90's bed was not addressed in a timely manner, leading to the deficiency in maintaining the resident's right to a dignified existence.
Delayed Reporting of Resident Altercation
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe, as mandated by the Elder Justice Act. On September 12, 2024, a resident-to-resident altercation occurred between Resident #42 and Resident #273 at 2:50 PM in the facility's elevator. The altercation escalated from a verbal exchange to a physical confrontation, resulting in Resident #273 sustaining a cut lip and pain in the right scapula. Despite the incident being reported to the Director of Nursing at the time it occurred, the facility did not notify the State Survey Agency until 6:17 PM, exceeding the two-hour reporting requirement for incidents involving bodily injury. Resident #42, who was involved in the altercation, was later transferred to the hospital for evaluation and has a medical history including schizophrenia, depression, and dementia. Resident #273, who was injured, has diagnoses including end-stage renal disease requiring hemodialysis, chronic obstructive pulmonary disease, and an anxiety disorder. The Director of Nursing acknowledged the delay in reporting the incident and was aware of the requirement to report within two hours.
Failure to Notify Resident's Representative of Discharge
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing of a facility-initiated discharge for Resident #255. The resident, who had medically complex conditions and depression, was cognitively intact and had a discharge plan in place to return to the community. On December 16, 2024, Resident #255 received a Notice of Discharge, but there was no documented evidence that a copy of this notice was sent to the resident's representative. The facility's policy required written notification to the resident and/or representative, but this was not adhered to in this case. The Ombudsman reported concerns about the facility's discharge notification process, noting that their office did not receive a copy of the discharge notice simultaneously with the resident. The Social Worker issued a revised Notice of Discharge to the resident on December 16, 2024, and emailed a copy to the Ombudsman. However, there was no documented evidence that the notice was mailed to the resident's representative, and the Social Worker was unable to contact the representative to discuss the discharge plans. The Administrator confirmed the lack of documented evidence of mailing the notices to resident representatives.
Failure to Provide Language Interpretation Services
Penalty
Summary
The facility failed to ensure that a resident who primarily spoke Spanish was provided with the necessary interpretive services to communicate effectively with staff. This deficiency was identified during a recertification and abbreviated survey. The resident, who had a history of cerebral infarct, diabetes mellitus, and muscle weakness, was documented in their care plan as needing an interpreter for communication with healthcare staff. Despite this, the facility did not provide a Spanish translator, and staff were unaware of how to access translation devices or services. Interviews with the Director of Nursing and Certified Nurse Aides revealed that the resident's need for interpretive services was not documented in the Certified Nurse Aide instructions. Additionally, there were not enough Spanish-speaking aides to meet the needs of all Spanish-speaking residents, and staff had not been trained on using language translation devices. The facility's policy on communication and language access was not effectively implemented, leading to a failure in providing the necessary care and services for the resident's communication needs.
Failure to Address Resident's Dietary Needs and Aspiration Risk
Penalty
Summary
The facility failed to provide person-centered care and services necessary to maintain the highest practicable well-being for a resident with a history of pneumonitis due to inhalation of food/vomit and dysphagia. The resident was not provided with a plan to address their individual needs and minimize choking hazards, despite hospital recommendations for a soft, bite-sized diet texture, mildly thick liquids with no straw, and intermittent supervision. The facility did not adjust the resident's diet according to their verbalized request for chopped texture proteins due to difficulty with chewing chicken and beef. The facility's policies on accidents and incidents, as well as aspiration precautions, were not adequately followed. Nursing staff were responsible for monitoring residents for signs of aspiration risk and implementing precautions, but there was no documented evidence that the resident's oral intake and difficulty swallowing were monitored. The Speech Language Pathologist did not evaluate the resident after a certain date, and the dietary technician did not follow up to ensure a change in diet consistency was ordered. The resident was found unresponsive in their room after being served a lunch meal tray, and the facility did not thoroughly investigate the incident to rule out choking. Interviews with facility staff revealed communication breakdowns and a lack of follow-up on the resident's dietary needs. The dietary technician communicated the resident's request for a downgraded diet to the registered nurse and director of rehabilitation but did not ensure a speech therapy evaluation was ordered. The speech therapist missed the hospital's diet order for soft foods and thickened liquids and did not receive any referrals for the resident after discontinuing services. The director of nursing was unaware of the resident's dysphagia diagnosis and the hospital's dietary recommendations, and the investigative report did not include information on whether the resident aspirated during the lunch meal.
Physician's Failure to Review Resident's Total Care Plan
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and documented the resident's total program of care, including medications and treatments, at each required visit. This deficiency was identified for a resident with a history of cerebral infarction, dysphagia, and other complex medical conditions. The resident had been discharged from the hospital with specific dietary recommendations due to a swallowing disorder, which were not incorporated into the care plan by the attending physician. The physician did not review the hospital's speech pathology evaluation or the dietician's notes, which documented the resident's difficulty with a regular texture diet and the need for a modified diet. The attending physician admitted to only reviewing hospital discharge paperwork related to medication orders and not paying attention to nutrition or diet orders. The physician relied on nursing staff to provide necessary information for treatment plans, which led to the oversight of the resident's dietary needs. The medical director confirmed that the physician should have reviewed the resident's medical record, including nutrition and dietician notes, when assessing the resident and determining the plan of care. This lack of comprehensive review and documentation resulted in the resident not receiving the appropriate dietary modifications necessary for their condition.
Failure to Manage Resident's Financial Affairs and Inform of Tax Refund Checks
Penalty
Summary
The facility failed to ensure the resident's right to manage their financial affairs, as evidenced by the mishandling of a resident's tax refund checks. The resident, who was cognitively intact and had been living at the facility for approximately four years, reported during a Resident Council Meeting that the facility did not inform them upon receipt of their tax refund checks. The checks were opened and deposited into the facility's operating account without the resident's written authorization. The facility's policies on privacy, confidentiality, and resident rights were not adhered to, as there was no documented evidence of the resident's consent to manage their finances or open their mail. The Business Office Manager confirmed that the tax refund checks were deposited into the resident's account without informing the resident. The facility was unable to provide documented evidence of the resident's written authorization for the facility to manage their finances or a detailed accounting of the transactions related to the tax refund checks. Additionally, the facility failed to provide the resident with quarterly statements or detailed transaction history, which are required to ensure transparency and accountability in managing resident funds. Interviews with the Business Office Manager and the Administrator revealed a lack of communication and oversight regarding the handling of resident mail and financial management. The Administrator, who was not involved in the Business Office operations, was unaware of the practices related to opening resident mail and depositing checks. The facility's failure to inform the resident and obtain proper authorization for managing their finances resulted in a deficiency in maintaining a system that assures a full and complete accounting of the resident's personal funds.
Misappropriation of Resident's Tax Refund Checks
Penalty
Summary
The facility failed to protect a resident's right to manage their own finances, resulting in the misappropriation of the resident's tax return checks. Resident #162, who was cognitively intact and had been managing their own finances since admission in 2020, reported that their tax return checks were taken by the facility's Business Office without their knowledge or consent. The checks, issued in 2023 and 2024, were deposited into a facility account, and the resident was not informed of their arrival or the transactions. The facility's policies on misappropriation and personal needs accounts were not followed, as the resident did not consent to the facility managing their funds. Interviews with the Business Office Manager and the Long-Term Care and Business Office Coordinator revealed that the facility's mail handling procedures involved opening residents' mail and depositing checks into facility-managed accounts without resident consent. The Business Office Manager was unable to provide documentation or explain how the checks were deposited without the resident's endorsement. The Administrator, who was new to the facility, was unaware of the issue and stated that residents' mail should not be opened without consent. The facility was unable to provide bank statements or transaction details related to the resident's funds, indicating a lack of proper documentation and oversight in managing resident finances. This deficiency highlights a significant breach of the resident's rights and the facility's responsibility to safeguard personal property.
Failure to Conduct Psychology Consult for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary behavioral health care and services to maintain their mental and psychosocial well-being. Specifically, a psychology consult for the resident, who had a history of acute stress reaction, alcohol dependence, and cocaine abuse, was not conducted as per the physician's order. The resident had expressed a need to talk to a psychology therapist about past traumas, including the loss of parents, homelessness, and a train accident resulting in limb loss. Despite the psychiatrist's recommendation for a psychology consult and the resident's request, the consult was not completed. Interviews with the Director of Nursing and the Registered Nurse/Unit Manager revealed that there was no documentation of a completed psychology consult for the resident. The consultant psychologist confirmed that they did not receive a referral for the resident and did not recall consulting with them. The failure to conduct the psychology consult as ordered and recommended by the psychiatrist led to the deficiency, as the resident did not receive the necessary behavioral health services to address their mental health needs.
Improper Drug Labeling and Storage in Medication Room and Cart
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards, as observed during a recertification survey. An insulin pen for a resident, which had an open date of September 10, 2024, and a use-by date of November 6, 2024, was found in the medication storage room refrigerator on unit 4, despite being past its use-by date. The Registered Nurse Unit Manager acknowledged that expired insulin pens should be removed, but the pen remained in the refrigerator. Additionally, a controlled medication, Phenobarbital, was found in the locked drawer of a medication cart on unit 4, contrary to the facility's policy that required controlled medications to be returned to a double-locked cabinet after medication passes. Interviews with nursing staff revealed a lack of adherence to the facility's medication storage policies. Registered Nurse #21 admitted to keeping the Phenobarbital in the cart, and the Director of Nursing confirmed that controlled medications should be returned to the medication room after each shift. The Pharmacy Consultant Supervisor noted that during a recent audit, expired medications were identified, but it was the responsibility of the nurses to discard them. The inability of staff to access the controlled medication box in the medication room further highlighted issues with medication management and storage practices within the facility.
Misappropriation of Resident's Funds by Dialysis Transportation Worker
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving a transportation worker associated with a dialysis center. The resident, who was not on dialysis, reported that the transportation worker withdrew a total of $5,900 from their cash app account under the pretense of assisting them in finding an apartment. The incident was reported to law enforcement, but the facility did not ensure that the transportation worker did not have access to residents who were not on dialysis. The facility's investigation did not include interviews with other residents transported by the worker or a written statement from the accused worker. The resident involved had a diagnosis of Congestive Heart Failure, Cerebral Infarction, and Ataxia following other Cerebrovascular Disease, with intact cognition as per their MDS assessment. Despite the resident's report of the incident, there was no documented evidence of an abuse care plan being initiated to protect the resident from further abuse. The Director of Nursing acknowledged that the transportation worker was not an employee of the facility but worked for the dialysis center, and the facility could not conclude misappropriation due to a lack of evidence regarding the conversations between the resident and the worker.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
The facility failed to ensure the rights of a resident to be free from abuse and misappropriation of property. During a discharge planning meeting, a resident alleged that a dialysis transportation worker withdrew a total of $5,900 from their cash app account. The incident was reported to law enforcement, but there was no documented evidence that other residents transported by the same worker were interviewed. Additionally, there was no written statement from the accused transportation worker, and no abuse care plan was initiated to protect the resident from further abuse. The resident involved had a diagnosis of congestive heart failure, cerebral infarction, and ataxia following other cerebrovascular disease, with an intact cognition score. The facility's investigation summary documented that the resident reported the transportation worker had been taking their money under the pretense of assisting with finding an apartment. The resident showed an application on their phone revealing the transactions. Despite the facility's acknowledgment of the theft, the allegation was neither substantiated nor unsubstantiated, and the facility did not conclude misappropriation due to a lack of evidence regarding the conversation between the resident and the transportation worker.
Deficiencies in Timely Medical Care and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate medical care for two residents, leading to deficiencies in quality of care. Resident #1, who had a history of Parkinson's Disease, Essential Hypertension, and Type 2 Diabetes, experienced episodes of vaginal bleeding. Despite a pelvic ultrasound revealing an enlarged uterus with fibroids, the facility did not secure a timely gynecological appointment. The resident's condition was monitored, but appointments were repeatedly canceled due to the resident's transfer status, ultimately resulting in the resident being transferred to the hospital after significant delays and family intervention. Resident #4, admitted with conditions including Acute Chronic Respiratory Failure and Stage 4 kidney disease, was prescribed an intravenous antibiotic for an infection. However, the antibiotic treatment was not initiated until three days after admission, following notification by the resident's family representative. The delay in starting the prescribed medication was due to a failure in the medication reconciliation process upon the resident's admission to the facility. Interviews with facility staff, including the Director of Nursing, Registered Nurse, and Primary Physician, revealed lapses in communication and procedural adherence. The Director of Nursing acknowledged the expectation for accurate medication reconciliation, while the Primary Physician could not explain the delay in starting the antibiotic. These deficiencies highlight the facility's failure to provide care in accordance with professional standards and the residents' medical needs.
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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