Humboldt House Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Buffalo, New York.
- Location
- 64 Hager Street, Buffalo, New York 14208
- CMS Provider Number
- 335164
- Inspections on file
- 25
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 28 (1 serious)
Citation history
Health deficiencies cited at Humboldt House Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow professional standards and its own policies for food storage and sanitation. In the kitchen, an active ceiling and A/C leak near the walk‑in refrigerator and freezer created standing water on the floor, while tray catties with food covers and a shelving unit with uncovered condiments and peanut butter were stored directly under the leaking area and tarp. Inspectors observed heavy grease and food debris on the commercial oven range and on the wall behind the stove and two‑bay sink, along with broken and missing wall tiles and peeled plaster. Ceiling pipes above food prep and serving stations were covered with thick dust, and a hand wash sink had a leaking drainpipe, a non‑working paper towel dispenser, and a stack of wet paper towels in the basin. The walk‑in freezer had a damaged door gasket, black debris on the window, significant condensation and ice buildup on the door, and a large ice accumulation inside. Interviews with dietary, maintenance, and administrative staff confirmed these problems had been ongoing for months and that staff were aware of the leaks, structural damage, and cleaning deficiencies.
A resident with CVA, schizophrenia, intellectual disability, and severe cognitive impairment, who required total assistance for hygiene and toileting and was incontinent of bowel and bladder, was found lying in bed on heavily urine-soaked linens, wearing only an incontinent brief, with multiple soiled linens, a soiled brief, feces, and dried food debris on the floor nearby. Despite this condition, a CNA delivered and left a lunch tray, which the resident fully consumed while still soiled. The care plan and Kardex lacked specific instructions for managing incontinence, staff acknowledged that incontinence care should occur every 2 hours and before meals, and leadership and a family member confirmed that the resident should not have been left in that undignified state, with the family member reporting ongoing issues of the resident being found soiled during visits.
A resident with a history of CVA, schizophrenia, and intellectual disability, who was severely cognitively impaired and totally dependent for personal hygiene and toileting, was found lying on a urine-soaked sheet with multiple soiled linens, feces, and dried food debris on the floor, and was served and consumed lunch without being cleaned or the room being sanitized. The resident’s care plan and Kardex lacked a bowel and bladder incontinence plan or clear incontinent care instructions, and there was no documentation of care refusal. A CNA reported providing care only once early in the morning despite an expectation for incontinent care every 2–3 hours, and video showed this CNA delivering the lunch tray while the resident remained soiled. The RN unit manager and corporate DON confirmed the resident required total assist for incontinence care and that care should have been provided regularly and before meals, while a family member reported the resident was consistently found soiled during visits.
A resident with quadriplegia, chronic kidney disease, and a history of UTIs had an indwelling Foley catheter and a care plan directing staff to keep the drainage bag below bladder level, provide catheter care each shift, and monitor and document output. Surveyors repeatedly observed the urine drainage bag, containing a large volume of amber urine with white mucus, lying directly on the floor while an LPN entered the room to administer medications and feed the resident without correcting the bag’s position. Later, despite posted enhanced barrier precautions and available supplies, a CNA wearing only gloves placed a urinal directly on the floor, emptied approximately 1,800 mL from the drainage bag while intermittently placing both the bag and urinal on the floor, left the spigot open on the floor during the process, and failed to clean the spigot tip with alcohol, contrary to facility policy and expected infection control practices.
The facility did not maintain an effective pest control program, as evidenced by multiple observations of dead mice, rodent droppings, and food debris in resident rooms and common areas. Staff and residents reported ongoing rodent sightings, and interviews revealed inconsistent awareness and response among staff. The exterior garbage compactor area was found littered with food waste and soiled items, attracting pests and flies, with no clear policy on pest control or garbage disposal in place.
A resident with chronic venous ulcers did not consistently receive wound care treatments as ordered by the physician, with multiple missed treatments and lack of documentation in the medical record. Observations showed wounds were uncovered or not dressed as ordered, and staff interviews confirmed that treatments were not always completed or properly documented, contrary to facility policy.
Two cognitively impaired residents were found engaged in sexual activity without staff knowledge, highlighting a failure in monitoring and protection. Despite policies against abuse, both residents lacked the capacity to consent, and the incident was only discovered when a CNA entered the room. The facility's investigation concluded the encounter was consensual, despite evidence of cognitive impairment.
A resident readmitted with multiple pressure and vascular ulcers did not receive a timely skin assessment, delaying treatment initiation. Facility policy required immediate assessment and treatment, but this was not followed, resulting in a two-day delay in obtaining physician orders and starting treatment.
A resident readmitted with multiple pressure and vascular ulcers did not receive a timely skin assessment, delaying treatment initiation. The facility's policy required a comprehensive skin examination upon admission, but this was not completed, leading to a lapse in care. The resident had conditions including peripheral vascular disease and protein calorie malnutrition, with several documented ulcers. A proper assessment and treatment orders were delayed by two days, contrary to the facility's protocol.
The facility failed to protect residents from abuse, including a resident threatened with scissors and two residents engaged in non-consensual sexual activity. Despite staff witnessing these incidents, appropriate actions were not taken to separate the residents or prevent further harm, leading to immediate jeopardy and substandard care.
The facility failed to report abuse and neglect incidents involving three residents in a timely manner. A resident-to-resident altercation involving a threat with scissors was not reported for three days, causing mental anguish. Additionally, two residents engaged in non-consensual sexual activity were not reported immediately, allowing the behavior to continue. Staff interviews confirmed the delay in reporting, contrary to facility policy.
The facility failed to provide a safe, clean, and homelike environment, with issues including inconsistent hot water temperatures, inadequate bathroom access, and poor maintenance. Residents reported difficulties with hygiene due to cold water, and some had to travel long distances to access bathrooms. Observations revealed soiled walls, mold, foul odors, and non-functioning call bells, indicating a failure to uphold residents' rights.
The facility failed to serve food and drinks at safe and appetizing temperatures, affecting residents on multiple floors. Meals were often cold and unpalatable, with residents reporting dissatisfaction and some relying on external food sources. Test trays confirmed that food temperatures were below required standards, posing a risk of foodborne illness.
The facility failed to maintain food safety standards in three nourishment unit refrigerators, with issues such as undated and unlabeled food items, liquid spills, and unsafe temperatures. Observations revealed that the Fourth floor Unit refrigerator lacked a thermometer and was not maintaining a safe temperature, while the Second floor Unit refrigerator also lacked a thermometer. Staff interviews indicated a failure to adhere to policies for food storage and temperature monitoring, leading to unsafe conditions.
A resident was not informed or allowed to participate in their care plan meeting, despite being cognitively intact and eager to attend. The facility's policy required advance notice for such meetings, but the responsible social worker failed to notify the resident, leading to their exclusion. Staff interviews confirmed the oversight, acknowledging the resident's disappointment.
A facility failed to treat residents with respect and dignity, as evidenced by an LPN's unprofessional behavior towards a resident and the lack of privacy in a shared bathroom. A resident was upset after an LPN used inappropriate language and slammed medication on a tray table. Additionally, a shared bathroom on the dementia unit lacked stall doors or privacy curtains, raising privacy concerns. Staff acknowledged these issues, highlighting deficiencies in resident care.
A facility failed to promptly and thoroughly investigate a resident-to-resident altercation involving a threat with scissors. The incident was not reported immediately, leading to a delayed investigation. The investigation lacked interviews with involved residents and potential witnesses, and the responsible party of the affected resident was not notified. The Director of Nursing considered the incident isolated, and the Administrator acknowledged the delay in reporting.
The facility failed to provide adequate hygiene and nail care for residents unable to perform activities of daily living. A resident did not receive timely incontinence care, leading to saturated linens and improper hygiene practices by CNAs. Another resident, dependent on staff for personal hygiene, had long, debris-filled fingernails, posing an infection risk. A third resident expressed a need for nail care, but staff only cleaned under the nails without trimming them, despite the potential harm of long nails.
A facility failed to provide adequate care and treatment for residents, including delays in antibiotic administration for a UTI, improper PICC line maintenance, and failure to administer prescribed supplements for electrolyte imbalances. These deficiencies were due to inaccurately transcribed orders, lack of supplies, and poor communication and documentation.
The facility failed to offer and document pneumococcal and influenza immunizations for several residents, as well as provide education on the benefits and side effects. Despite policies requiring documentation within five days of admission, records for residents with conditions like diabetes and COPD lacked evidence of immunization offers or education. Interviews confirmed the admitting nurse's responsibility for documentation, but the necessary records were not found.
Ongoing Kitchen Sanitation, Structural Damage, and Improper Food Storage Under Active Leaks
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own sanitation and food storage policies. Intermittent observations of the kitchen revealed an active ceiling leak near the walk‑in refrigerator and freezer, with a large opening in the plaster ceiling and a tarp suspended to divert water into a floor drain. An adjacent air conditioning ventilation unit was actively leaking, resulting in standing water pooled on the floor in front of the walk‑in units. Under this leaking area, staff had stationed tray catties holding numerous food covers and plate warmers, and a metal shelving unit extended under the tarp holding multiple uncovered condiments and food items such as salt, pepper, sugar, creamer packets, and containers of peanut butter. Additional observations showed widespread sanitation and maintenance problems in the kitchen. There was a significant accumulation of gray, dusty debris on ceiling pipes throughout the kitchen, including above food preparation and serving stations. The hand wash sink near the kitchen entry had an active drainpipe leak when in use, with a stack of partially wet paper towels in the basin and a non‑working paper towel dispenser above it. The wall behind the stove, oven, and two‑bay sink was heavily soiled with thick black grease and food debris and had broken and missing wall tiles, with peeled plaster in areas behind the stove, oven, and above the two‑bay sink. The commercial oven range’s exterior surfaces were heavily coated with grease and food debris, and staff acknowledged the stove should be cleaned after each meal but that it was not being cleaned properly. The walk‑in freezer also exhibited multiple structural and cleanliness issues. The freezer door gasket was not securely attached and protruded between the door and unit, and there was black debris on the freezer window, condensation and ice buildup on the interior and exterior lower sides of the door, and a large accumulation of ice on the floor and ceiling inside the unit. Interviews with the Food Service Director, Administrator, and Maintenance Supervisor confirmed that the kitchen ceiling leak and roof issues had been ongoing for months, that the freezer had required repeated service for condensation and ice buildup, and that broken and missing wall tiles had been a known issue since the prior year. Staff also acknowledged that condiments and tray catties should not be stored under the leaking ceiling, that the gasket needed replacement, that the pipes over prep areas should be cleaned, and that the wet paper towels at the hand sink should not be used, confirming ongoing noncompliance with the facility’s sanitation and food storage policies.
Failure to Provide Dignified Incontinence Care and Clean Environment During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect and dignity, including maintaining cleanliness and appropriate incontinence care. The resident had diagnoses of CVA, schizophrenia, and intellectual disability, was severely cognitively impaired, and required total assistance for personal hygiene and toileting, with documented bowel and bladder incontinence. The resident’s care plan and Kardex specified total assistance for hygiene and toileting but did not include specific interventions or instructions for managing bowel and bladder incontinence. On the survey date, the resident was observed in bed wearing only an incontinent brief, a small blanket, and a flat sheet that was visibly soaked and soiled with urine from shoulders to the foot of the bed. Between the bed and the wall, there were multiple soiled flat sheets, a soiled brief, a large amount of feces, and dried food debris on the floor. Later the same day, the resident remained in bed on the heavily soiled sheet while their lunch tray, which had been fully consumed, sat on the overbed table, and the soiled linens, brief, feces, and food debris remained on the floor. CNA staff reported that the resident had been washed and provided incontinence care earlier in the morning and acknowledged that incontinence care should be provided every two hours, that they had not returned to the room since the morning, and that the resident should have been cleaned before receiving lunch. Video surveillance showed that the same CNA delivered the lunch tray shortly before the resident was observed eating while still soiled. Although the bed linens were later changed, the dried food debris and large amount of feces remained on the floor behind the bed. The unit manager, corporate DON, and a family member all stated that the resident should have been provided care and that the situation was undignified, with the family member reporting that the resident was always soiled with urine and feces during visits and that prior complaints to staff had not resulted in changes.
Failure to Provide Timely Incontinent Care and Hygiene for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically grooming and personal hygiene, to a resident who was incontinent of bowel and bladder. The resident had diagnoses including cerebral vascular accident, schizophrenia, and intellectual disability, and the MDS documented severe cognitive impairment, total assistance needs for personal hygiene, and total assistance of two staff for toileting. Despite these needs, the resident’s care plan and Kardex did not include a bowel and bladder incontinence care plan or specific instructions for incontinent care, and there was no documentation that the resident refused care. On the survey date, observations showed the resident in bed wearing only an incontinent brief, with a small blanket and a flat sheet that was visibly soaked with urine from the shoulders to the foot of the bed. Multiple soiled flat sheets and a soiled brief were found on the floor between the bed and the wall, along with a large amount of feces and dried food debris. The resident remained on the heavily soiled sheet for at least 40 minutes, during which time the lunch tray was delivered and fully consumed while the room and the resident’s bedding remained soiled. Later observation showed that although the bed linens had been changed, the dried food debris and large amount of feces remained on the floor behind the bed. Interviews confirmed that incontinent care was expected every two to three hours and that the resident should have been cleaned before receiving lunch. The CNA assigned to the resident stated they had provided incontinent care around 7:30 a.m., had not returned since, and acknowledged the resident should have been cleaned before lunch. Video surveillance showed that this CNA delivered the lunch tray shortly before 1:00 p.m., contradicting their initial statement that they had not provided the lunch tray. The RN Unit Manager stated the resident was incontinent and required total assistance, was unsure if the resident was care planned for incontinence, and confirmed that incontinent care should occur every two to three hours and before meals. A family member reported the resident was always soiled with feces and urine during visits, and the Corporate DON stated incontinent care should be completed every two to three hours and that the resident and room should have been cleaned before lunch, noting that the facility does not document ADL completion.
Improper Foley Catheter Management and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services for a resident with an indwelling Foley catheter, in accordance with its own urinary catheter care and enhanced barrier precautions policies. The resident had diagnoses including quadriplegia, chronic kidney disease, and depression, was cognitively intact, and had a documented history of urinary tract infections. The care plan and Kardex directed staff to monitor for signs and symptoms of urinary tract infection, position the drainage bag and tubing below the level of the bladder, provide Foley catheter care every shift, and monitor and document Foley output every shift. On multiple observations during one morning, the resident’s urinary drainage bag, containing approximately 1,000 milliliters of amber urine with a large amount of white mucus in the tubing, was seen lying directly on the floor under the bed. An LPN entered the room to administer medications and later to feed the resident breakfast, but did not correct the position of the drainage bag, which remained on the floor at 8:55 AM, 9:10 AM, 10:16 AM, and 11:26 AM. Staff interviewed acknowledged that the drainage bag should not have been on the floor and that it should have been emptied because it was full, particularly given the resident’s propensity for urinary tract infections. Later that morning, despite a sign on the resident’s door indicating the need for enhanced barrier precautions and the availability of supplies, a CNA entered the room wearing only gloves and no gown to empty the urinary drainage bag. The CNA picked the drainage bag up from the floor, placed a clean urinal directly on the floor without a barrier, opened the drainage spigot, and filled the urinal to the top. The CNA then placed the drainage bag with the spigot open back on the floor, emptied the urinal into the toilet, returned the urinal to the floor, and finished emptying the bag into the urinal. The CNA replaced the spigot into the bag holder without cleaning the spigot tip with alcohol and confirmed that 1,800 milliliters had been emptied. Facility nursing leadership and the infection preventionist stated that drainage bags should never be on the floor and that staff were expected to follow enhanced barrier precautions, including gown and glove use, when providing care to residents with Foley catheters.
Failure to Maintain Effective Pest Control and Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents and evidence of rodent activity on three of four resident-use floors. Multiple observations revealed dead mice in traps, rodent droppings in resident rooms, and physical damage to room structures such as crumbled walls and exposed insulation. Food debris, such as cookie wrappers and crumbs, was found in resident drawers and on floors, often mixed with rodent droppings. Staff and residents reported recent and ongoing sightings of live mice in resident rooms, with some residents stating that rodents had been an issue for several months. Interviews with staff, including CNAs, the Housekeeping Supervisor, LPNs, and the DON, indicated inconsistent awareness and response to the rodent problem. Some staff were unaware of the extent of the droppings and dead rodents, while others acknowledged the need for immediate cleaning and pest control. The Housekeeping Supervisor was newly promoted and unfamiliar with the deep cleaning schedule, and the DON had not personally observed rodents but recognized the health concerns associated with their presence. Maintenance staff reported that rodent traps were checked and changed, and a licensed exterminator serviced the building every two weeks, but evidence of rodent activity persisted. The exterior of the facility, particularly the garbage compactor area, was found to be littered with food waste, soiled items, and garbage, attracting flies and creating conditions conducive to pest infestation. Interviews with the Food Service Director, Regional Maintenance Director, and Administrator revealed shared responsibility for maintaining the garbage area, but also a lack of clear policies on pest control and garbage disposal. Internal records and exterminator reports documented ongoing issues with food spillage, accessible garbage, and rodent activity, with some improvement noted after changing exterminators, but continued deficiencies in maintaining a pest-free environment.
Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency was identified when a resident with chronic venous hypertension, lymphedema, and chronic kidney disease did not receive wound care treatments to bilateral lower extremity ulcers as ordered by the physician. The resident's care plan required treatments to be administered as ordered and for refusals to be documented and addressed, but there was no evidence in the care plan or medical record that the resident refused care. Physician orders specified cleansing the wounds with normal saline and applying Medi honey gel every evening shift, but multiple dates were identified where the treatment was not documented as completed. Observations revealed the resident's wounds were uncovered or not dressed as ordered, with visible open ulcers and dried drainage present. The resident reported that wound care was not consistently performed and that dressings were not applied on certain days. Review of treatment administration records and nursing notes confirmed that wound care was not documented as completed on several dates, and there was no documentation of resident refusal or alternative interventions. Skin and wound assessments indicated deterioration of the wounds during the period when treatments were missed. Interviews with nursing staff and facility leadership confirmed that treatments were not completed or documented as required. Staff acknowledged that the physician's orders were not always followed, and that documentation was incomplete when treatments were missed or not performed. Facility policy required all treatments to be administered as ordered and refusals to be documented, but these procedures were not consistently followed for this resident.
Failure to Protect Cognitively Impaired Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents who were found engaged in sexual activity without staff knowledge. Both residents were cognitively impaired and lacked the ability to consent. The facility's policy on abuse prevention and capacity to consent clearly states that residents have the right to be free from abuse, including sexual abuse, and that consent is not valid if a resident lacks the capacity to consent. Despite this, the incident occurred, indicating a failure in monitoring and protecting the residents. Resident #1, diagnosed with dementia, depression, and altered mental status, was documented as severely cognitively impaired. Their care plan noted a risk for mood and behavior problems, and they had a history of wandering and making inappropriate sexual comments. On the day of the incident, Resident #1 was found in Resident #2's room, engaged in a sexual encounter. Staff intervention was delayed as the incident was only discovered when a Certified Nurse Aide entered the room. The resident's cognitive impairment and history of disrobing and confusion about other residents being their spouse were known to the staff, yet adequate supervision was not provided. Resident #2, with diagnoses including Wernicke's encephalopathy and vascular dementia, was also severely cognitively impaired. Their care plan noted behavior problems, including disrobing and being not always redirectable. The incident was reported to law enforcement, but the facility did not receive any feedback. Interviews with staff and family members revealed that both residents lacked the capacity to consent, yet the facility's investigation concluded the encounter was consensual. This discrepancy highlights a significant oversight in assessing and ensuring the residents' safety and protection from abuse.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #1 was discharged on [DATE] and has since passed away. a. Resident #2 had a room/floor change after the incident occurred. Resident #2's care plan has been reviewed and found to be appropriate. A psychosocial evaluation has been completed by social work and resident does not even recall the incident. b. No further incidents have occurred. II. All wandering residents who lack capacity have the potential to be affected by this deficiency. a. A 100% audit of current residents who lack capacity, that may be displaying behaviors (handholding, arms around each other, seating preferences, etc.) will be conducted. Any concerns will be brought to the IDT and the behaviors and potential relationship will be reviewed and interventions will be care planned as appropriate. III. Facility policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021 and Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022 have been reviewed and found to be appropriate. a. A monthly “relationship meeting” will be held to include Administrator, DON, Social Work, and the Dementia Unit Manager/Designee to discuss/identify any residents that may be displaying behaviors that could suggest a developing relationship between residents. The Unit Manager/Designee will be the chairperson/spokesperson for all nursing employees assigned to the unit. Care plans and further interventions updated as indicated. b. All nursing staff will be educated on the establishment of the 4th floor “relationship meeting.” c. All nursing staff will be educated on identification and reporting any residents who are displaying behaviors such as (hand holding, arms around each other, seating preference, etc.). d. Any staff reports related to the identification of the potential for resident relationship development will be reported immediately to their immediate supervisor. Nursing Supervisory staff will be educated to begin the process of convening the IDT to audit the circumstance of this relationship to include resident capacity, family and MD notification, and care plan review. IV. Any changes in behavior or adverse interactions will be reported immediately to DON/Administrator or designee and brought to morning report daily for review and QAPI monthly. a. Administrator will audit the monthly relationship meetings to ensure completion and follow through monthly x 3 months, then quarterly thereafter. b. At monthly QAPI, the Administrator will review the results of the monthly relationship meeting and any other reported occurrences of potential relationships developing. V. The administrator is responsible for this plan.
Delayed Skin Assessment and Treatment for Resident with Ulcers
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Upon readmission, the resident, who had multiple pressure and vascular ulcers, did not receive a timely skin assessment that included measurements, descriptions, and staging of the ulcers. This delay resulted in a postponement in obtaining physician orders and initiating treatment. The facility's policy required a full assessment of pressure sores upon admission, but this was not completed for the resident, leading to a lack of documented treatment orders for the ulcers until two days after readmission. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that skin integrity assessments should be conducted by a Registered Nurse within 24 hours of admission or readmission. These assessments should include detailed documentation of the type, location, and measurements of wounds, with treatments initiated immediately upon identification of skin integrity alterations. However, in this case, the necessary assessments and treatments were delayed, as confirmed by the facility's records and staff interviews.
Delayed Skin Assessment and Treatment for Resident with Ulcers
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Upon readmission, the resident, who had multiple pressure and vascular ulcers, did not receive a timely skin assessment that included measurements, descriptions, and staging of the ulcers. This oversight resulted in a delay in obtaining physician orders and initiating treatment. The facility's policy required a comprehensive skin examination upon admission, but this was not completed for the resident, leading to a lapse in care. The resident, who was cognitively intact, was readmitted with diagnoses including peripheral vascular disease, congestive heart failure, and protein calorie malnutrition. The resident had one Stage 3 pressure ulcer and several unstageable pressure and vascular ulcers. Despite the hospital discharge summary documenting these conditions, the initial clinical admission assessment was incomplete and unsigned, lacking necessary details about the ulcers. It was not until two days later that a Registered Nurse Assistant Director of Nursing conducted a proper skin assessment and obtained physician orders for treatment, which were initiated the following day. Interviews with facility staff confirmed that skin assessments should be conducted within 24 hours of admission, but this protocol was not followed in this case.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically in cases involving resident-to-resident altercations and non-consensual sexual activity. Resident #129 was verbally and physically threatened by Resident #74, who was cognitively intact, with a pair of scissors. Despite the altercation being witnessed by a Certified Nurse Aide and reported to a Registered Nurse, the facility did not take immediate action to separate the residents or remove the potential weapon, allowing Resident #74 ongoing access to Resident #129. This inaction resulted in mental anguish for Resident #129, who expressed fear for their life. In another incident, Residents #104 and #122, both severely cognitively impaired and unable to consent, were observed engaging in non-consensual sexual activity. Staff witnessed the inappropriate contact but failed to separate the residents or implement protective measures. The facility's care plans for these residents did not include strategies to prevent sexual abuse, and there was no evidence of psychological evaluations or interventions following the incident. The lack of immediate action and supervision allowed the abuse to continue, highlighting a significant oversight in resident protection. The facility's policies on abuse prevention and capacity to consent were not followed, as evidenced by the staff's failure to recognize and address the abuse situations appropriately. Interviews with staff and administrators revealed a lack of understanding and adherence to procedures designed to protect residents from harm. The incidents involving Residents #129, #104, and #122 demonstrate a systemic failure to ensure resident safety and uphold their rights to be free from abuse, resulting in immediate jeopardy and substandard quality of care.
Failure to Report Abuse and Neglect in a Timely Manner
Penalty
Summary
The facility failed to report alleged violations of abuse immediately, as required by policy, for three residents during an Extended Recertification and Complaint survey. Registered Nurse #1 did not report an alleged resident-to-resident abuse incident involving Resident #74 and Resident #129 to the Administrator. This incident, which involved a verbal argument escalating to a threat with scissors, was witnessed by Certified Nurse Aide #1 but was not reported until three days later. This delay resulted in continued access between the residents and mental anguish for Resident #129. Additionally, the facility failed to report non-consensual sexual activity between Residents #104 and #122, both of whom lacked the capacity to consent. Certified Nurse Aide #2 observed inappropriate sexual touching between the two residents but did not report it immediately, considering it a common occurrence. This inaction allowed the behavior to continue, resulting in potential psychosocial harm to the residents involved. The facility's policy required immediate reporting of abuse allegations to the Administrator and appropriate officials, but staff failed to adhere to this policy. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that the incidents were not reported in a timely manner, which hindered the initiation of investigations and appropriate interventions.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during a complaint investigation. The investigation revealed significant issues with the facility's hot water system, with temperatures in resident rooms fluctuating well below the required range, making it unsuitable for resident hygiene. Despite daily temperature checks by maintenance staff, the water temperatures were inconsistent, and residents reported difficulties in accessing warm water for personal care. The maintenance director acknowledged the need for adjustments but failed to maintain consistent water temperatures across the facility. Additionally, the facility did not provide adequate access to bathroom facilities for residents, particularly on the Fourth Floor, where several bathrooms were out of service due to drainage issues. Residents without in-room bathrooms had to travel long distances to access the only available bathroom, leading to inconvenience and potential incontinence. The maintenance director admitted that the drainage problem was a large-scale issue that had not been addressed, affecting multiple floors and requiring external contractors for repairs. The facility also exhibited poor housekeeping and maintenance practices, with observations of soiled walls, mold in shower rooms, foul odors, and windows and ceilings in disrepair. Call bells in shared bathrooms were not functioning properly, posing a safety risk for residents. The maintenance director and housekeeping staff acknowledged these issues, but there was no documentation of plans to address them. These deficiencies highlight a failure to uphold the residents' right to a safe and homelike environment, as mandated by facility policies and regulations.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures for residents on the Second, Third, and Fourth floor Units during the Extended Recertification and Complaint survey. The policy required potentially hazardous foods to be kept at 41 degrees Fahrenheit or below when cold, or 135 degrees Fahrenheit or above when hot. However, observations and interviews revealed that meals were served at suboptimal temperatures, making them unpalatable. Residents reported issues such as cold meals, hard biscuits, and unidentifiable food, leading some to avoid eating or rely on external food sources. During the survey, test trays were used to assess the temperature and palatability of meals. On the Second floor Unit, the baked ziti was 119 degrees Fahrenheit, zucchini was 110 degrees Fahrenheit, and coffee was 124.5 degrees Fahrenheit, all below the required temperature. Similar issues were observed on the Third and Fourth floor Units, with food items like baked ziti, zucchini, milk, mandarin oranges, and coffee served at temperatures below the facility's standards. The Dietary Director acknowledged that some food temperatures were below the acceptable range, which could pose a risk of foodborne illness. Interviews with residents and family members highlighted dissatisfaction with the food quality and temperature. Residents described the food as cold, bland, and sometimes inedible, with some relying on care packages or family-provided meals. The facility's failure to maintain proper food temperatures during storage, preparation, transport, and service contributed to the deficiency, as evidenced by the observations and resident feedback.
Food Safety Deficiencies in Facility Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety across three nourishment unit refrigerators. Observations revealed that the refrigerators contained undated, unlabeled, and expired food and drink items. Additionally, there were liquid spills and dried substances on surfaces, and the Fourth floor Unit refrigerator was not maintaining a safe food storage temperature and lacked a thermometer. The Second floor Unit refrigerator also lacked a thermometer, which is against the facility's policy that requires temperature monitoring twice a day. During the survey, it was observed that the Third floor Unit nourishment kitchen had unidentified and undated items in the freezer and fridge, including latex gloves filled with frozen liquid. The Fourth floor Unit refrigerator was found to have a thermometer displaying unsafe temperatures, and it contained unlabeled and undated items, including a bologna sandwich and nourishment bags with items that should have been distributed to residents earlier. The refrigerator was also wet with brown liquid stains, and the temperature was consistently above the safe range, reaching up to 62 Fahrenheit. Interviews with staff, including registered nurses, dietary supervisors, and technicians, revealed a lack of adherence to the facility's policies regarding food storage and temperature monitoring. The dietary staff were responsible for checking temperatures, but the records were inconsistent, and the equipment was faulty. The Interim Maintenance Director acknowledged the need for new seals for the fridge and freezer, and the Administrator confirmed that the refrigerator should be replaced due to the unsafe conditions observed.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident was informed and allowed to participate in the development and implementation of their person-centered care plan. Specifically, a resident with diagnoses including benign intracranial hypertension, chronic pain syndrome, and migraine headache, who was cognitively intact, was not informed in advance about a scheduled care plan meeting. The facility's policy required that residents be given sufficient notice to participate in care planning meetings, but this was not adhered to in this case. The resident expressed disappointment at not being able to attend the meeting, which was important to them as they wanted to share their progress with their family. Interviews with facility staff, including a social worker and a nurse practitioner, confirmed that the resident was not informed of the meeting, and it was acknowledged that the resident should have been present. The social worker responsible for notifying the resident failed to provide evidence of communication or records of notification, leading to the resident's exclusion from the care planning process.
Deficiency in Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the behavior of a staff member towards a resident and the lack of privacy in a shared bathroom. Resident #134, who was cognitively intact and had a care plan requiring calm and reassuring care, was subjected to unprofessional behavior by Licensed Practical Nurse #6. The nurse allegedly used inappropriate language, slammed medication on the tray table, and left the room in a disrespectful manner, causing the resident to become upset and cry. This incident was corroborated by other staff members who witnessed the behavior. Additionally, the facility did not provide adequate privacy for residents using a shared bathroom on the dementia unit. The bathroom, used by both male and female residents, had three toilet stalls separated by partitions but lacked stall doors or privacy curtains. Observations confirmed that residents used this bathroom independently, raising concerns about privacy and dignity. Staff interviews revealed that the lack of privacy was a known issue, with several staff members acknowledging the problem and expressing concerns about its impact on residents. The facility's failure to address these issues violated the residents' rights to be treated with respect and dignity. The lack of privacy in the shared bathroom and the unprofessional conduct of a staff member towards a resident were significant deficiencies identified during the survey. These findings highlight the need for the facility to ensure that all residents are treated with dignity and that their privacy is respected in all aspects of their care.
Delayed and Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that all alleged allegations of abuse were thoroughly investigated for two residents. Specifically, there was a delay in the initiation of an investigation for a reported allegation of resident-to-resident abuse. The incident involved a verbal argument between two residents, which escalated when one resident threatened the other with a pair of scissors. The altercation was witnessed by a Certified Nurse Aide and reported to a Registered Nurse, who did not consider it a resident-to-resident altercation and thus did not report it to the Director of Nursing or Administrator. This resulted in a delay in the investigation, which was not initiated until three days after the incident. The investigation was incomplete as it did not include interviews with the involved residents or other potential witnesses. The Director of Nursing did not obtain a statement from the resident who was sent to the hospital and returned to a different room. Additionally, there was no documented evidence that the responsible party of the affected resident was notified of the altercation. The Director of Nursing considered the incident isolated and did not interview other residents. The Administrator acknowledged that the staff should have reported the incident immediately to allow for a thorough investigation.
Deficiencies in Resident Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate care for residents who were unable to perform activities of daily living, specifically in maintaining grooming and personal hygiene. Resident #27, who was admitted with diagnoses including diabetes mellitus, anxiety, and depression, did not receive timely incontinence care. The resident's brief and bed linens were saturated with urine, and the Certified Nurse Aide (CNA) performed incomplete incontinence care without proper hand hygiene or glove changes. The CNA also touched items in the resident's room with soiled gloves, leading to potential cross-contamination and infection control issues. Resident #102, who had a history of cerebral infarction and was legally blind, was dependent on staff for personal hygiene. The resident's fingernails were observed to be long, jagged, and filled with dark debris, which posed an infection control risk, especially since the resident ate with their hands. Despite the resident's preference for short nails, there was no documented evidence of nail care being provided, and the regular CNA stated that the resident did not refuse care. The resident's contracted hand had nails pressing into the palm, causing red indentations and discomfort. Resident #105, with diagnoses including diabetes mellitus and peripheral vascular disease, also had long, jagged fingernails with dark debris. The resident expressed a desire for nail care, but staff reportedly only cleaned under the nails without trimming them. The resident's nails were noted to be long and potentially harmful, yet there was no evidence of appropriate nail care being provided. The Director of Nursing acknowledged that long nails could be an infection control issue and expected staff to consult a provider for nail care in residents with certain medical conditions.
Deficiencies in Medication Administration and Care Planning
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. For Resident #16, there was a significant delay in the administration of antibiotics for a urinary tract infection due to inaccurately transcribed physician's orders. The resident, who had an indwelling Foley catheter, experienced a nine-day delay in receiving the correct dosage of Ciprofloxacin, which was not therapeutic for the infection. Additionally, there was no comprehensive care plan developed for the resident's Foley catheter care and urinary tract infection. Resident #305 experienced issues with the maintenance of a peripherally inserted central catheter (PICC) line. The dressing for the PICC line was not changed as ordered due to a lack of available supplies, and the dressing was observed to be peeling and loose. The facility's failure to maintain the PICC line dressing as per the physician's orders posed a risk of infection, and the Director of Nursing was not informed of the inability to complete the dressing changes as required. Resident #154 did not receive prescribed supplements for electrolyte imbalances due to a lack of communication and documentation. The resident, who had a history of hypokalemia, hypomagnesemia, and hypophosphatemia, received only a fraction of the scheduled doses of supplements. The pharmacy did not dispense the required supplements, and there was no evidence that the medical providers were notified of the unavailability of these medications. This lack of communication and documentation resulted in the resident not receiving the necessary treatment for their condition.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal and influenza immunizations, as well as documented education regarding the benefits and potential side effects of these vaccines. This deficiency was identified during an Extended Survey, which revealed that four out of five residents reviewed did not have documented evidence of being offered or declining the immunizations, nor receiving education about them. The facility's policies required that assessments of pneumococcal vaccination status be conducted within five business days of admission and that education and declination be documented in the resident's medical record. However, this was not adhered to for residents with various medical conditions, including diabetes, chronic obstructive pulmonary disease, and dementia. Interviews with facility staff, including the Infection Preventionist/Assistant Director of Nursing and the Director of Nursing, confirmed that the responsibility for obtaining and documenting immunization statuses fell on the admitting nurse, with oversight by the infection preventionist. Despite this, the Regional Director of Nursing was unable to locate the necessary immunization documents for the affected residents. This lack of documentation and adherence to policy resulted in a deficiency under 10 NYCRR 415.19 (a) (1).
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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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