Martine Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in White Plains, New York.
- Location
- 12 Tibbits Avenue, White Plains, New York 10606
- CMS Provider Number
- 335424
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Martine Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with COPD, vasculitis, and cellulitis had a sacral pressure injury that was initially documented by an admission nurse as a stage 2 ulcer, while a wound care provider shortly thereafter assessed it as unstageable with necrosis and the care plan identified it as stage 4. Because the wound care provider’s assessments were uploaded into the record after the MDS ARD 7‑day look‑back period, the staff member completing the MDS only saw the earlier stage 2 assessment and coded the wound accordingly, resulting in inaccurate MDS coding of the resident’s pressure injury status.
A resident with COPD, vasculitis, cellulitis, and multiple wounds was admitted with a sacral pressure injury initially documented by an admission nurse as stage 2, but a wound care provider assessed it as unstageable with necrosis and it was later care-planned as stage 4. Wound care assessments by the specialist were uploaded late, so the MDS was completed using only the initial stage 2 documentation. There were no EMR treatment orders for the sacral wound for several days after admission, and although an RN obtained a Santyl dressing order from an on-call PA and performed a dressing change, this treatment was not documented in a nursing note, resulting in incomplete and delayed documentation and orders for wound care.
Surveyors identified widespread environmental deficiencies, including chipped paint, dirt, scuff marks, foul odors, missing fixtures, and evidence of pests throughout the facility. Interviews confirmed that while cleaning and maintenance routines exist, the facility did not maintain a consistently clean, functional, and comfortable environment for residents, staff, and the public.
Three residents did not have their care plans updated or implemented as required: one experienced a fall without a documented fall risk or post-fall care plan, another developed a pressure injury that was not reflected in the care plan, and a third had a change to two-person assist for all cares that was not documented. Nursing staff and the DON confirmed that care plans were not updated as per facility policy.
A resident with cognitive impairment and limited mobility told a CNA they would jump out of bed if left alone. The CNA left the resident unattended, and upon return, found the resident on the floor with skin tears. The resident's care plan required supervision and assistance, but these were not provided at the time, leading to a fall and injury.
A resident with impaired cognition due to dementia and schizophrenia, identified as at risk for elopement, left the facility undetected during a busy holiday week day. The facility staff did not notice the resident's absence until dinner time, and the incident was reported to the state agency the following day, beyond the required two-hour window. The investigation found reasonable cause for potential abuse, neglect, or mistreatment, but the delay in reporting constituted a deficiency.
A resident with schizophrenia and dementia, identified as high risk for elopement, exited the facility undetected due to inadequate supervision. The resident was last seen in the lobby and was not accounted for until hours later. The facility's cameras were non-functional, and there was no documentation of the required frequent monitoring. The resident was later found by police in Los Angeles.
The facility did not complete annual performance evaluations for two CNAs, as required by their policy. One CNA had no evaluation since their hire date, and another had not been evaluated since 2018. The Director of Nursing and the Director of Human Resources confirmed the oversight, acknowledging that evaluations were not conducted according to policy.
A resident with Parkinson's, Schizophrenia, and Dementia had inconsistent MDS assessments regarding the level of assistance needed for daily activities. CNAs reported varying levels of assistance required, and the MDS Coordinator admitted to offsite assessments, leading to inaccuracies. This resulted in a deficiency due to the facility's failure to ensure accurate assessments.
A resident with severe cognitive impairment and dependency for all activities of daily living did not have a comprehensive care plan accurately reflecting their needs, leading to a fall and injuries. Staff provided conflicting accounts of the required assistance level, and assessments were sometimes conducted offsite, causing discrepancies. Facility leadership maintained that the care plan was appropriate, but the incident revealed communication and assessment gaps.
A resident with severe cognitive impairment and mobility dependence experienced a fall, but the facility failed to update the resident's care plan to reflect this incident. Despite documentation of the fall and subsequent actions, the care plan was not revised as required by facility policy. The RN Unit Manager acknowledged responsibility for updating the care plan but did not document the fall, leading to a deficiency.
A resident with severe cognitive impairment and total dependence on staff fell off the bed during care, resulting in serious injuries. The care plan required a one-person assist, but staff interviews indicated a need for more assistance. The facility's policies on side rails and supervision were questioned, revealing a lack of preventive measures and communication among staff.
Inaccurate MDS Coding of Sacral Pressure Injury Due to Late Wound Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Minimum Data Set (MDS) accurately reflected a resident’s pressure injury status. During an abbreviated survey, record review showed that the admission MDS, with an Assessment Reference Date (ARD) of 12/15/2025, coded the resident’s sacral wound as a stage 2 pressure ulcer in Section M, based on an admission nurse’s assessment from 12/08/2025. However, wound documentation showed that the wound care provider assessed the same sacral wound as unstageable due to necrosis on 12/09/2025, and a wound evaluation management summary dated 12/15/2025 also identified the sacral wound as unstageable. Additionally, the resident’s care plan for alteration in skin integrity documented an actual pressure injury identified as a sacral stage 4 with necrotic tissue, initiated on 12/09/2025. The resident had diagnoses including COPD, vasculitis limited to the skin, and cellulitis of an unspecified limb. During interview, the MDS Coordinator stated they did not complete the assessment for this resident and primarily performed administrative tasks. The MDS Coordinator acknowledged that the 12/08/2025 admission nurse assessment documenting a stage 2 sacral wound was significantly different from the 12/09/2025 wound care provider assessment documenting an unstageable sacral wound. The MDS Coordinator further explained that the 12/09/2025 and 12/15/2025 wound care provider assessments were not uploaded into the system until 12/21/2025 and 12/22/2025, after the ARD 7‑day look‑back period, so the person completing the MDS only had access to the earlier stage 2 assessment. As a result, the MDS did not accurately capture the resident’s true wound status during the assessment period, contrary to facility policy and RAI manual guidelines.
Failure to Ensure Timely Orders and Accurate Documentation for Sacral Pressure Injury Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for a resident admitted with multiple wounds, including a sacral pressure injury. On admission, the nurse assessed the sacral wound as a stage 2 pressure ulcer, and there were no corresponding treatment orders entered into the EMR for this wound until several days later. The resident’s diagnoses included COPD, vasculitis limited to the skin, and cellulitis of an unspecified limb. The facility’s skin and pressure injury prevention policy required Braden risk assessments on admission and at specified intervals, and the admission MDS documented a stage 2 pressure ulcer under Section M. However, a wound care provider’s assessment on the day after admission identified the sacral wound as unstageable due to necrosis, and a subsequent wound evaluation documented the sacral wound as unstageable, later reflected in the care plan as a sacral stage 4 pressure injury with necrotic tissue. The wound care provider’s assessments dated shortly after admission were not uploaded into the record until well after the MDS assessment reference date look-back period, so the MDS assessor only had access to the initial admission nurse’s stage 2 documentation when completing the MDS. A medication order for Santyl ointment and associated dressing care to the sacrum was obtained by a supervising RN from an on-call PA and entered into the EMR to start the following day, but the RN reported performing a dressing change on the date the order was obtained without documenting this treatment in a nursing note. These documentation gaps and delays in entering wound assessments and treatment orders resulted in the resident not having timely, clearly ordered, and consistently documented wound care in accordance with professional standards and the facility’s own skin integrity procedures.
Environmental Deficiencies and Sanitation Issues Identified Facility-Wide
Penalty
Summary
Surveyors found that the facility failed to maintain a functional, sanitary, and comfortable environment for residents, staff, and the public. Observations during environmental rounds revealed multiple deficiencies across all units, including chipped paint, scuff marks, visible dirt and stains on walls and floors, peeling baseboards, bubbling wallpaper, and foul odors. Specific rooms were noted to have clutter, crumbs on the floor, missing shower heads, and missing radiator covers. Mouse traps were observed in some rooms, and the presence of mice was acknowledged by staff, particularly on the second and third floors. Additionally, sticky floors, likely due to the wax product used, and a hole in a bathroom wall were documented. A metal panel in a hallway was missing screws, and some areas had not yet been renovated. Interviews with the Administrator and the Director of Environmental/Housekeeping confirmed that environmental rounds are conducted daily, and staff are expected to report maintenance issues through a logbook or direct communication. The Director of Environmental/Housekeeping oversees 15 housekeeping and 2 maintenance staff, with a daily cleaning schedule that includes deep cleaning and waxing of rooms. Pest control services are provided twice weekly, and sightings are logged and addressed. Despite these processes, the observed conditions indicated that the facility did not ensure a consistently clean, safe, and comfortable environment as required by regulations.
Failure to Update and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three out of five residents reviewed during an abbreviated survey. For one resident with multiple diagnoses and moderate cognitive impairment, there was no documented fall risk or actual fall care plan in place before or after the resident experienced an unwitnessed fall that resulted in skin tears. The incident report noted the bed was in the lowest position and the call bell was within reach, but there was no evidence of a care plan addressing fall risk or interventions to prevent future falls. Interviews with nursing staff and the DON confirmed that care plans should have been updated to reflect the fall and any resulting injuries, but this was not done. Another resident, admitted with a history of impaired mobility and at risk for pressure injuries, developed an eschar on the left heel. Although the presence of the eschar was documented in a nurse's progress note, the resident's care plan was not updated to reflect the new pressure injury, its measurements, or tracking. The responsible RN acknowledged that the care plan should have been updated with this information but confirmed it was not completed. The facility's policy requires that care plans be updated with measurable objectives and interventions when new issues arise, but this was not followed in this case. A third resident, who required assistance due to lower extremity impairment, had a care plan that was not updated to reflect a change to two-person assistance for all cares after a meeting with the resident's representatives. The DON and Administrator both confirmed that the care plan did not include this updated intervention, despite the change being made to ensure the resident's safety. The lack of timely updates to care plans for these residents demonstrates a failure to ensure that services were provided to maintain each resident's highest practicable physical, mental, and psychosocial well-being, as required by facility policy and regulation.
Resident Left Unattended After Expressing Intent to Exit Bed, Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, limited mobility, and a history of depression expressed to a Certified Nurse Aide (CNA) an intent to jump out of bed if left alone. Despite this clear verbalization of risk, the CNA left the resident unattended in their room to respond to another situation elsewhere in the facility. Upon returning, the CNA found the resident on the floor, having sustained skin tears to both upper extremities. The resident's care plan indicated a need for assistance with self-care and mobility, as well as monitoring for cognitive changes, but these interventions were not adequately followed at the time of the incident. The facility's policy required a systems approach to safety, considering both environmental hazards and individual resident risk factors. The resident's care plans documented the need for supervision and assistance due to their cognitive and physical limitations. However, the CNA did not use the call bell or seek immediate help before leaving the resident, despite the resident's explicit statement of intent to get out of bed. This failure to provide adequate supervision and to follow established safety protocols resulted in the resident's fall and subsequent injuries.
Failure to Timely Report Resident Elopement
Penalty
Summary
The facility failed to report an incident involving a resident's elopement in a timely manner to the New York State Department of Health. The resident, who had impaired cognition due to dementia and schizophrenia, was identified as being at risk for elopement. Despite this, the resident left the facility undetected on a busy holiday week day. The facility staff did not realize the resident was missing until dinner time, several hours after the resident had left. The incident was not reported to the state agency until the following day, which was beyond the required two-hour reporting window. The facility's policy requires that all occurrences of accidents or incidents be evaluated and investigated, with the Director of Nursing and Administration responsible for determining if an incident requires reporting to outside agencies. In this case, the investigation revealed that the resident exited through the front door during a high traffic period while the reception staff was occupied. The facility determined that there was reasonable cause to believe that abuse, neglect, exploitation, or mistreatment may have occurred, making the incident reportable. However, the delay in reporting the incident constituted a deficiency in the facility's compliance with state regulations.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 The elopement incident for resident # 1 was reported on 11/27/24. All facility DOH reportable events have the potential to be affected by this deficient practice. All DOH reported incidents were reviewed for the past 30 days. Facility policy on Accident/Incidents was reviewed by the Administrator and Director of Nursing and determined to be in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy of Accident and Incidents and timely reporting requirements. The in-service will focus on reporting incidents to the Administrator and DON immediately, reporting requirements of 2 hours to the DOH for reportable events. The Administrator/designee will audit all reported incidents for compliance with the 2-hour reporting time frame. The audits will be completed weekly x 4 weeks, then monthly until compliance is met. The results of these audits will be submitted at monthly QAPI to the committee for review. The administrator is responsible for the execution of this plan of correction.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent the elopement of a resident identified as being at high risk for elopement. The resident, who had diagnoses including schizophrenia, unspecified dementia, and atherosclerotic heart disease, was able to exit the facility undetected. The resident was known to have impaired cognition and was assessed as high risk for elopement, with a care plan that included enhanced monitoring for exit-seeking behavior. However, there was no documented evidence of close supervision or frequent monitoring prior to the resident's elopement. On the day of the incident, the resident was last seen in the lobby around 11:30 am, waiting for the mailman, which was part of their usual routine. The receptionist observed the resident handing mail to the mailman and then walking past the desk, but did not see the resident again. The resident was not accounted for during the afternoon, and it was not until after 5:00 pm that staff realized the resident was missing. A Code Gray was initiated, but the facility's search was unsuccessful, and the resident was later found by the Los Angeles Police Department. The facility's investigation revealed that the resident exited through the front door during a busy holiday period when the reception staff was occupied. The facility's cameras in the lobby were not functional, and there was no live feed or recordings to assist in the investigation. The facility's policy required residents at risk for elopement to be closely supervised and frequently monitored, but there was no documentation to support that this was done for the resident prior to their elopement.
Plan Of Correction
Plan of Correction: Approved January 10, 2025 Resident #1 remains in Los Angeles. Upon return to the facility, resident will be re-evaluated for elopement risk with updated care plan and interventions. All residents with wander guards, exiting seeking behaviors, and those spending excessive time off the unit in the lobby or recreation room have the potential to be affected. All residents with wander guards, high risk for elopement, exit seeking behaviors, and those who spend excessive time off units were re-evaluated for elopement risk, and audits and chart reviews completed. Elopement Binders, Care plans, and interventions were updated accordingly. The facility policy on Elopement Prevention was reviewed by the Administrator and Director of Nursing and determined to be in compliance with state and federal guidelines. No revision made. Staff Educator/designee will educate all staff on facility policy on Elopement Prevention with a focus on closely supervising residents high risk for elopement. Unit sign-in/out sheets at nursing stations were implemented to account for residents being taken on or off the unit by rehab, recreation, etc. Staff rounding tool was implemented to account for unit residents during the shift, indicating resident location. Residents identified as high risk for elopement and are non-compliant with wander guard will receive enhanced monitoring/supervision every 1-3 hours. Staff Educator/Designee will in-service all staff on implemented procedures and forms. Front desk staff re-educated on emergency codes, monitoring of lobby, elopement policy, and awareness of door alarms. Facility elopement drills will be conducted weekly for 4 weeks and then monthly. The audit results will be submitted to the monthly QAPI meeting for review and recommendations. The Responsible Party: Assistant Administrator.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance appraisals were completed at least once every 12 months, as required by their policy. Specifically, the personnel records for two CNAs, hired on 7/1/2022 and 6/20/2017 respectively, lacked documented evidence of annual performance evaluations. CNA #2 had no performance evaluation since their hire date, and CNA #3 had not received an evaluation since 9/5/2018. This deficiency was identified during an abbreviated survey (NY00362050) through record reviews and interviews. Interviews with the Director of Nursing and the Director of Human Resources revealed that the responsibility for conducting these evaluations lies with the nursing department, while Human Resources reviews and notifies the nursing department if evaluations are not completed. The Director of Nursing, who had been in the facility for two months, admitted to not having completed any performance evaluations. The Director of Human Resources confirmed the absence of recent evaluations for the two CNAs, acknowledging that the evaluations were not completed according to the facility's policy.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 Certified Nurse Aide #2 yearly performance review was conducted on 12-20-24. Certified Nurse Aide #3 yearly performance review was conducted on 12-20-24. The facility conducted an audit of all employees’ files. Director Human Resources/Designee and department manager will ensure all identified employees with outstanding yearly evaluation be completed by 1/8/25. Policy and Procedure was reviewed on 12/19/24 for yearly evaluations. No revisions made. Director of Human Resources, Department Heads and Managers were educated on 12/20/24 on the importance of conducting employee yearly evaluation. The Director of Human Resources/Designee will conduct weekly audits and to track and meet with all employees who are due for yearly evaluations. Director of Human Resources/Designee will meet with department manager and employee to complete evaluation in accordance with the facility policy and procedure. Director of Human Resources will conduct weekly audit x3 months, then monthly x3 months. The audit results will be submitted to the monthly QAPI committee for review. The Responsible Party: Director of Human Resources.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, leading to a deficiency. Specifically, the MDS assessments for a resident with Parkinson's disease, Schizophrenia, and Dementia showed inconsistencies in the level of assistance required for daily activities. The assessments varied between requiring a one-person assist and a two-person assist for tasks such as bed mobility, which did not accurately represent the resident's dependence level. Interviews with Certified Nurse Assistants (CNAs) revealed discrepancies in the care provided to the resident. Some CNAs recalled that the resident required assistance from two people due to their immobility and the absence of bed rails, while others believed a one-person assist was sufficient. This inconsistency in staff understanding and documentation contributed to the inaccurate MDS assessments. The Registered Nurse Minimum Data Set Coordinator admitted that assessments were sometimes completed offsite, relying on unit nurses' documentation. This practice, along with the lack of direct observation and communication with care staff, led to the inaccurate reflection of the resident's needs in the MDS. The facility's failure to ensure accurate assessments and consistent care instructions resulted in the identified deficiency.
Failure to Implement Comprehensive Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed and implemented for a resident who was dependent on assistance for all activities of daily living. The deficiency was identified during an abbreviated survey, where it was found that there was no documented evidence of a comprehensive care plan being initiated after a Quarterly Minimum Data Set assessment. This assessment indicated that the resident had severe cognitive impairment and was dependent on assistance for eating, toileting, bed mobility, and transfers. Despite this, the care plan did not accurately reflect the required assistance level, leading to an incident where the resident fell out of bed and sustained injuries. Interviews with various staff members revealed inconsistencies in the understanding and implementation of the resident's care needs. Certified Nurse Assistants (CNAs) provided conflicting accounts of whether the resident required one or two-person assistance for bed mobility and care. Some CNAs stated that they would seek additional help due to the resident's physical condition, while others believed the resident was a one-person assist. The Registered Nurse Minimum Data Set Coordinator mentioned that assessments were sometimes conducted offsite, relying on unit nurses' documentation, which could lead to discrepancies in care planning. The facility's leadership, including the Medical Director, Director of Nursing, and Administrator, maintained that the care plan was appropriate and followed protocol. They stated that there was no change in the resident's condition that warranted an update to the care plan. However, the incident highlighted a gap in communication and assessment processes, as staff members were not aligned on the resident's care needs, and the care plan did not reflect the necessary assistance level, contributing to the resident's fall and subsequent injuries.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was reviewed and revised for a resident who experienced a self-reported fall. The resident, who had severe cognitive impairment and was dependent on assistance for mobility and toileting, reported a fall on 07/24/2024. Despite the incident being documented, the resident's fall care plan was not updated to reflect this event. The facility's policy requires care plans to be revised as the resident's condition changes, but this was not adhered to in this case. The incident report noted that the resident was found in a left lateral position with a bump on the back of their head, and several actions were taken, including assessments and referrals. However, the care plan was not updated to include the fall. Interviews with the facility staff revealed that the Registered Nurse Unit Manager was responsible for updating the care plan but failed to document the fall in the care plan, although they did update the enabler section. This oversight led to a deficiency in the care planning process for the resident.
Inadequate Supervision and Safety Measures Lead to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to a significant accident. The resident, who was totally dependent on staff for all activities and had severe cognitive impairment, fell off the bed while being turned by a Certified Nursing Assistant (CNA). The resident sustained serious injuries, including an unstable cervical spine fracture and a possible femoral neck fracture, along with lacerations and swelling. The care plan indicated the resident required a one-person assist, but the incident revealed that the resident's condition might have necessitated more assistance. Interviews with staff highlighted discrepancies in the understanding of the resident's care needs. While the CNA involved in the incident believed the resident required two-person assistance, they did not communicate this to the nurse or supervisor. Other CNAs also expressed that they would typically seek additional help when caring for the resident due to their immobility and contractures. Despite these observations, the facility's documentation and care plan continued to reflect a one-person assist requirement. The facility's policies and procedures, including the use of side rails, were also scrutinized. The Registered Nurse Unit Manager and the Medical Director both stated that side rails were not appropriate for the resident, citing safety concerns and CMS guidelines. However, the lack of side rails and the resident's immobility contributed to the fall. The incident report and subsequent interviews revealed a lack of preventive measures and communication among staff regarding the resident's care needs, ultimately leading to the accident.
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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