Ontario Center For Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Canandaigua, New York.
- Location
- 3062 County Complex Drive, Canandaigua, New York 14424
- CMS Provider Number
- 335564
- Inspections on file
- 21
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ontario Center For Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to maintain safe and comfortable room temperatures in accordance with its policy, resulting in multiple residents on two floors experiencing cold rooms with measured temperatures in the low 60s and heaters blowing cold air. Several residents reported feeling very cold, including one who woke during the night because their nose was freezing and another who was observed actively shivering in bed despite being covered with a blanket. Staff, including an LPN manager and other nursing staff, acknowledged that areas were extremely cold, described an office as an “ice box,” and reported that residents had complained of the cold and were given blankets while concerns were reported to maintenance and administration.
The facility failed to ensure accurate and complete MDS assessments for multiple residents when cognitive sections, including the BIMS and Section C, were coded as "not assessed" or left incomplete without evidence that interviews could not be performed. Record review showed several quarterly, annual, and admission assessments missing required cognitive data, even when documentation indicated the resident should have been interviewed. A regional social worker reported that interviews not completed within the look-back period were coded as not assessed, while the DON and Administrator stated they were unaware of the incomplete sections and that these issues were not identified through the QAPI process.
Surveyors found that the facility failed to follow its infection control policies in multiple areas. A resident with dysphagia, dementia, and multiple sclerosis, who required assistance with eating, was fed a meal tray that had been stored on a cart containing soiled trays. Another resident with malnutrition, Parkinson’s disease, open wounds, and unhealed pressure ulcers, who was on enhanced barrier precautions, was repositioned in bed by two CNAs wearing only gloves despite posted signage and care plan directives requiring gowns and gloves for high-contact care. In the laundry area, staff reported and were observed sorting soiled linens while wearing gloves and cloth, non-impervious aprons instead of the required impervious gowns, and the Infection Preventionist confirmed this practice did not comply with facility policy and posed contamination concerns.
The facility failed to maintain a functional nurse call system on one resident-use floor, where corridor indicators and audible tones for call stations in multiple rooms did not reset when calls were cleared at the bedside or in bathrooms, and the central nurse call panel had been removed from the nurse station for several months due to malfunction. Maintenance staff reported recurring shorts in the system causing corridor stations to remain lit and sounding until manually reset, while inspection logs from the prior year documented no issues despite these ongoing problems, and the Administrator acknowledged that the second-floor call system had been problematic for an extended period.
The facility failed to follow physician orders and document care for multiple residents. One resident with heart failure and dementia had weekly weights ordered, but several ordered weights were either not obtained or not documented in the electronic record. Another resident with hypertension, dementia, and prior stroke had daily BP and heart rate ordered; however, on multiple days the BP and pulse were signed off as completed without numerical values documented, preventing verification that the vitals were actually taken. A third resident with CHF, COPD, and oxygen dependence was observed on continuous oxygen at a specified liter flow without any corresponding provider order in place at the time, despite staff acknowledging that oxygen is considered a medication and requires a medical order specifying flow rate.
A LTC facility failed to provide adequate care, resulting in neglect of residents' needs. Several residents did not receive timely incontinence and wound care, with some waiting up to 21 hours for assistance. Staffing shortages were a significant issue, as reported by CNAs and LPNs, leading to residents being left in soiled conditions and untreated wounds. The administration was aware of these grievances but did not address the staffing problems, resulting in Immediate Jeopardy being declared by the New York State Department of Health.
During a survey, a facility was found to have insufficient staffing, resulting in residents experiencing extended periods of incontinence and going weeks without showers. Observations revealed that residents were not receiving timely care, with some waiting hours for assistance. Staff confirmed the ongoing staffing issues, citing high call-in rates and difficulties in retaining staff. Despite efforts to address the problem, the facility struggled to maintain adequate staffing levels.
Several residents in the facility did not receive timely incontinence care or assistance with toileting, leading to situations where they were left soiled for extended periods. A resident was found multiple times with urine-soaked clothing and linens, feeling dehumanized by the lack of care. Another resident experienced delays in receiving incontinence care and had not been showered for weeks, leading to embarrassment. Interviews with staff revealed that care was not consistently performed every two to four hours as required, impacting residents' dignity and quality of life.
The facility was found deficient in resident care and management, with issues including neglect in incontinence and wound care, insufficient nursing staff, and a malfunctioning nurse call system. Residents experienced extended periods without necessary care, leading to Immediate Jeopardy. Grievances were not properly investigated, and the facility's Quality Assurance and Performance Improvement committee failed to address these concerns effectively.
The facility failed to maintain a functioning nurse call system, with panels either missing or not operational, and no audible alerts. Observations showed that call buttons in resident rooms did not produce sounds, and overhead lights remained on after cancellation. Staff interviews revealed reliance on visual checks due to non-functional panels, and incomplete testing logs were noted.
The facility failed to ensure proper use of PPE and adherence to masking policies, leading to infection control deficiencies. Staff did not wear gowns during high-contact care for residents on Enhanced Barrier Precautions, and unvaccinated staff were observed without masks during the influenza season. These lapses were acknowledged by the staff involved and the facility administrator.
The facility failed to resolve grievances for two residents, one with bipolar disorder and another with diabetes and ulcers, by not conducting thorough investigations or follow-ups. Despite grievances about inadequate incontinence care and wound dressing changes, the facility did not document staff interviews or actions taken, leading to unresolved issues and dissatisfaction.
Three residents in the facility did not receive timely incontinence care and personal hygiene assistance. A resident with morbid obesity and diabetes did not receive showers for four weeks, while another with a stroke was found soaked in urine due to lack of care. A third resident with Parkinson's disease was left incontinent without assistance. Staff cited high resident assignments and assumptions about residents' abilities as reasons for the deficiencies.
Two residents experienced deficiencies in care, with one not receiving timely wound care due to staffing issues, and another facing a delay in a diagnostic x-ray. The facility failed to adhere to physician orders and ensure proper communication and documentation, impacting the residents' treatment and care.
A resident with a history of Parkinson's disease and malnutrition developed a pressure ulcer due to inadequate incontinence care and lack of timely intervention. The resident was left in a saturated brief for several hours, leading to a pressure ulcer on the buttock that went untreated and undocumented. The facility's policies on skin inspection and incontinence care were not followed, resulting in a deficiency identified during the survey.
The facility failed to provide appropriate catheter care and timely urinalysis collection for two residents, leading to potential risks of urinary tract infections. A resident with a history of UTIs had their catheter drainage bag improperly positioned and a urinalysis was not collected as ordered. Another resident's drainage bag was found at the level of the bladder and on the ground without a barrier. Staff interviews revealed inconsistencies in adhering to facility guidelines for catheter management.
The facility failed to properly store controlled medications, with the second-floor north medication cart containing unsecured controlled drugs and the third-floor medication room having undated and unlabeled pills. Controlled medications were not stored in a permanently affixed compartment, and the medication cart was left unattended, increasing the risk of diversion. The DON confirmed that medications should be stored in a secured cabinet, highlighting a deficiency in storage protocols.
The facility failed to document and educate residents on influenza and pneumococcal vaccinations. Three residents lacked evidence of being offered or educated about the vaccines, with one resident overdue for an update. Staff interviews revealed a lack of awareness and documentation, acknowledged by the Administrator.
A facility failed to provide quarterly personal fund statements to a resident with paranoid schizophrenia, high blood pressure, and diabetes, who was cognitively intact. The resident was unaware of their account balance, which was $9,800.12. The facility's policy required these statements to be provided, but there was no evidence that the resident or their representative received them. The Business Office Manager was unsure if the resident had a representative, but it was confirmed that the resident's brother was their Health Care Proxy.
The facility failed to notify the Ombudsman of resident transfers and discharges, as required by regulations. Three residents with various medical conditions were transferred to the hospital multiple times, but the Ombudsman did not receive the necessary notices. The Director of Social Work admitted that notices had not been sent since October 2024, and the Administrator was unaware of this issue.
A resident with multiple health conditions and impaired cognition was left unattended with medications in a common area, contrary to facility policy. The resident was not assessed for self-administration, and the responsible LPN did not confirm medication ingestion. The DON acknowledged the error, emphasizing the need for supervision during medication administration.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers, as required. Three residents were transferred without receiving the necessary notification. Interviews revealed that staff, including the Business Office Manager and Unit Manager, were unaware of the notification process, leading to non-compliance with regulations.
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary personal hygiene services. Two residents with significant medical conditions did not receive assistance with shaving, hair washing, and nail care, despite being scheduled for showers and requiring assistance. Observations revealed unshaven appearances, unwashed hair, and dirty fingernails, indicating a lack of adequate care.
A resident requiring a Hoyer lift for safe transfers was moved without the device due to a lack of available slings. Despite staff complaints and management's awareness of the issue, no adequate follow-up or assessment was conducted to resolve the shortage of slings.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room temperatures within its own policy range of 71 to 81 degrees Fahrenheit on the second and third floors, resulting in multiple residents being exposed to cold ambient air. On a day when outside temperatures ranged from 20 to 29 degrees Fahrenheit with snow, surveyors measured room temperatures as low as 60.3 degrees Fahrenheit, with heaters blowing cold air. One resident reported their room was “freezing,” stated they were always cold, and indicated maintenance had said the heater needed bleeding but had not returned; temperatures in this room were measured between 65.8 and 69.1 degrees Fahrenheit. Another resident reported waking in the middle of the night because their nose was freezing, with room temperatures measured at 60.3 degrees Fahrenheit and 57.6 degrees Fahrenheit above the heater, which was also blowing cold air. Additional observations showed a resident in bed with a blanket up to their neck, actively shivering, in a room where the ambient temperature was 64.8 degrees Fahrenheit. Staff interviews corroborated that the environment was very cold: an LPN manager stated they were working at the nurse’s station because their office was “an ice box,” and another LPN reported that residents had complained of feeling cold at the start of their shift and that they had provided blankets and reported concerns to maintenance and administration. A resident in a common area on the second floor also stated it was really cold and that they had just been given a blanket. Leadership interviews confirmed awareness that the heating system had shut off and that pumps had been shut down and restarted, during which time residents on the affected floors experienced cold room temperatures below the facility’s stated comfort range.
Inaccurate and Incomplete MDS Cognitive Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected resident status, particularly in the area of cognitive assessment. Surveyors’ review of MDS records showed that multiple residents had assessments in which the Brief Interview for Mental Status (BIMS) or Section C (cognitive patterns) was coded as “not assessed” or left incomplete without documentation that the interview could not be completed. One resident’s quarterly assessment, another resident’s annual assessment, and a third resident’s comprehensive admission assessment all documented the BIMS as not assessed. Another resident’s admission assessment showed Section C as not assessed, and a further admission assessment documented Section C as not assessed despite indicating the resident should have been interviewed. Two quarterly assessments for another resident also documented the BIMS as not assessed. During interviews, the Regional Social Worker stated that if interviews were not completed within the look-back period, the assessment would be coded as not assessed. The DON reported being unaware that sections of assessments were incomplete. In a joint interview with the Administrator, DON, and Regional Administrator, the Administrator stated they did not know why assessments were missing information and acknowledged that incomplete assessments had not been identified through the facility’s Quality Assurance and Performance Improvement (QAPI) process. The MDS Coordinator was unavailable for interview during the recertification survey. These findings were cited under 10 New York Codes, Rules and Regulations 415.11(a)(1).
Failure to Implement Infection Control Practices for Meal Service, PPE Use, and Soiled Linen Handling
Penalty
Summary
The facility failed to implement its infection prevention and control program as required by policy and regulation. For one resident with dysphagia, dementia, progressive multiple sclerosis, severe cognitive impairment, and a need for staff assistance with eating, staff did not provide a clean meal tray. Surveyors observed that after lunch carts arrived on the unit and staff began placing used trays into one of the carts, a certified nursing assistant (CNA) retrieved this resident’s untouched meal tray from the same cart that already contained soiled trays. The CNA then provided this tray and fed the resident at bedside. The LPN manager, Infection Preventionist, and Director of Nursing each stated that the tray should not have been retrieved from a cart containing soiled trays and that this practice posed an infection control concern and a risk for contamination and potential spread of infection. The facility also did not follow its Enhanced Barrier Precautions policy for a second resident who had malnutrition, Parkinson’s disease, several open wounds, severe cognitive impairment, and several unhealed pressure ulcers. The resident’s care plan and CNA Kardex documented that the resident was on enhanced barrier precautions, with interventions including wearing a gown and gloves during high-contact care. Despite a sign posted outside the room indicating enhanced barrier precautions, surveyors observed two CNAs repositioning the resident in bed while wearing only gloves and no gowns. The Infection Preventionist stated that failure to wear appropriate PPE during high-contact care posed a risk for contamination and potential spread of infection to other residents. In addition, the facility did not ensure proper handling of soiled linens in accordance with its policies. The facility’s policies required staff to wear gloves and impervious (waterproof) gowns or yellow precaution gowns when sorting soiled linen. However, in the designated laundry area, a laundry assistant reported that staff wore gloves and cloth aprons while sorting soiled laundry and that the aprons were laundered every few days. The Infection Preventionist examined the aprons and confirmed they were cloth and not impervious, and stated that sorting soiled laundry without an impervious gown posed a risk for contamination and potential spread of infection due to lack of protection against soak-through contamination. Leadership later stated they were unaware that staff were sorting soiled laundry wearing cloth aprons and that this practice was not sanitary.
Failure to Maintain Functional Nurse Call System on Second Floor
Penalty
Summary
The deficiency involves the facility’s failure to properly maintain a functional nurse call system on the second floor, including resident bathrooms and bathing areas. The facility’s electrical equipment policy required patient care related electrical equipment to be tested before first use, after repairs or modifications, and at least annually, with documentation of all tests, repairs, and modifications maintained on site. During observation, the surveyor noted a nurse call system visible indicator with an audible tone on the ceiling at the intersection of the East and North corridors on the second floor. When nurse call stations in several resident rooms (205, 206, 209, 216, and 231) were activated and then reset at the bedside or in the bathrooms, the corridor visible indicator and audible tone remained on and would not reset as intended. Further observation showed that there was no central nurse call panel at the second-floor nurse station. Maintenance staff reported that the panel had been removed for a few months because it had stopped working and that the system was in the process of being bid out for replacement. Maintenance also acknowledged ongoing issues with shorts in the system, causing corridor stations to stay lit and the tone to continue sounding until the system was manually reset, after which it would work properly only for a time. Record review revealed that the most recent inspection logs for the second-floor nurse call system were dated several months earlier and did not document any problems or recommendations, despite the ongoing issues described by staff. The Administrator confirmed that the second-floor call system had been problematic shortly after the last survey and that the main panel had been removed from the second floor months prior to the current survey.
Failure to Follow Physician Orders and Document Weights, Vitals, and Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure services were provided in accordance with professional standards of quality for multiple residents in the areas of nutrition, medication monitoring, and respiratory care. For a resident with hypertension, heart failure, and dementia, the comprehensive care plan and a physician’s order required weekly weights and notification of a provider for a weight gain of five pounds or more. Review of the electronic medical record, including the Medication and Treatment Administration Records, progress notes, and Weights and Vitals Summary, showed that weights were not obtained for 2 of 10 ordered instances and that there was no documented evidence of recorded weights for 4 of 10 instances. The DON acknowledged that weights were expected weekly per orders and that the nurse should document them in the Weights and Vitals Summary, but could not verify whether the weights had been obtained or documented as ordered. Another deficiency occurred in the monitoring and documentation of vital signs for a resident with hypertension, dementia, and a history of stroke who was receiving antihypertensive medication. The care plan directed staff to monitor vital signs as ordered, and a physician’s order required daily blood pressure and heart rate checks with provider notification for specific abnormal values. Record review showed that for 5 of 10 instances there was no documented blood pressure, and for 4 of 10 instances there was no documented heart rate with numerical values, even though the treatments were signed off as completed in the electronic Treatment Administration Record. Staff interviews confirmed that nurses were responsible for checking vital signs and that results should be documented in the Weights and Vitals Summary or treatment record; however, the LPN manager and DON both stated they could not verify that the blood pressure and heart rate had actually been obtained because the numerical results were not documented. A further deficiency was identified in the administration of oxygen therapy for a resident with congestive heart failure, COPD, and supplemental oxygen dependence. The care plan and Kardex indicated that oxygen was to be administered per medical orders and that staff should use oxygen as ordered and notify the provider if oxygen was not in use. During observation, the resident was in bed with a nasal cannula connected to an oxygen concentrator running at three liters per minute, but review of current medical orders revealed no physician’s order for continuous oxygen at that time. An order for supplemental oxygen via nasal cannula at three liters per minute was only obtained the following day. Nursing staff and the nurse practitioner stated that a provider order was required for oxygen, that oxygen is considered a medication, and that a medical order specifying the liter flow is needed because of the risk of over-oxygenation.
Neglect and Inadequate Care in LTC Facility
Penalty
Summary
The facility failed to protect residents from neglect, resulting in multiple instances of inadequate care. Six residents were identified as not receiving timely incontinence care, with some waiting up to 21 hours for assistance. This neglect was compounded by the failure to provide necessary wound care, as evidenced by residents with untreated wounds for several days, leading to soiled dressings and compromised rehabilitation sessions. The lack of response to call lights and the inability to provide basic care needs were prevalent, with residents left in soiled conditions for extended periods. Resident #350, with a history of diabetes and chronic venous ulcers, did not receive daily dressing changes as ordered, resulting in heavily soiled dressings and interrupted rehabilitation sessions. Similarly, Resident #65, who required wound care for a right thigh injury, had dressing changes missed on multiple occasions, and was found in a saturated brief with a strong odor of urine. Resident #48, dependent on staff for toileting, was left in a soaked brief for hours, with family members reporting the neglect to staff. The facility's staffing issues were highlighted by staff interviews, where CNAs and LPNs reported being unable to complete all required care due to short staffing. This was corroborated by observations of residents left without necessary assistance, such as Resident #73, who was left in a wheelchair for 15 hours without incontinence care, and Resident #76, who waited 21 hours for assistance. The administration was aware of these grievances but failed to address the underlying staffing problems, leading to a declaration of Immediate Jeopardy by the New York State Department of Health.
Removal Plan
- A QAPI meeting was held with all members present to discuss Immediate Jeopardy issues.
- 100% of staff working the previous three shifts, including staff on-site at the time of Immediate Jeopardy removal, received education on Abuse, Neglect, Mistreatment; Call Bells; Activities of Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly implemented shift-to-shift report.
- Interviews completed with multiple staff, including direct care staff and licensed nursing staff on two of two resident care units, revealed appropriate knowledge of the Abuse, Neglect and Mistreatment; call light response and accessibility; incontinence care; wound prevention and wound care; shift-to-shift report; and grievance process.
- Observations of random call bells on two of two units revealed call bells in working order. Two resident call bells on Unit 3 were not in reach of the resident. Observations of the two rooms were made with Administration present. Both residents will be evaluated by therapy for ability to use call bell and call bell placement.
- Approximately 30/40 total active nursing staff, including licensed nurses and Certified Nursing Assistants, were educated on Abuse, Neglect, and Mistreatment; call light response; Activities of Daily Living Care and Support; Grievances; Skin and Pressure Injury Prevention; and a newly implemented shift-to-shift report.
- Five per diem staff members and four staff members who are on vacation and/or sick leave have been notified and will be educated prior to their next scheduled shift.
- Four of four leadership staff, including Administrator, Director of Nursing, Assistant Director of Nursing and Director of Social Work, were educated on the grievance process.
- A weekly on-call rotation for clinical leadership was implemented.
- A full house skin sweep audit was completed, newly identified wounds had treatments ordered and were scheduled for wound rounds.
- Full house treatment completion audit conducted with no wound care treatments identified as missing or incomplete.
- Full house call bell audit completed with three call bells replaced.
- Full house incontinence rounding completed with incontinence care provided as needed.
- Audits to be continued each shift for wound treatment completion, call light accessibility and function, and incontinence care.
Insufficient Staffing Leads to Resident Neglect
Penalty
Summary
The facility was found to have insufficient staffing levels during an Extended Recertification Survey, which took place from January 21, 2025, to January 31, 2025. Observations and interviews revealed that the facility did not provide adequate nursing services to meet the needs of residents, resulting in psychosocial harm to several residents. Specifically, residents were observed to be incontinent of bladder or bowel for extended periods, and some reported going weeks without showers, leading to unkempt appearances and unclean hair. The facility's staffing plan did not specify a direct care staff-to-resident ratio, and the minimum staffing pattern was not consistently met, particularly during shifts with high call-ins. On the second-floor resident unit, which had a census of 46, there were only two Certified Nursing Assistants (CNAs) on duty due to nine call-ins. Residents reported long wait times for care, with one resident stating they had not received assistance since 5:00 AM, resulting in a saturated brief and a strong odor of urine. Another resident mentioned that they had to wait hours for care, including incontinence care and dressing changes. On the third-floor unit, with a census of 49, similar issues were observed, with residents reporting that they had not been changed or showered for extended periods. One resident was visibly incontinent of stool and had been waiting for hours to be changed. Interviews with staff, including CNAs and Licensed Practical Nurses (LPNs), confirmed the ongoing staffing issues. Staff reported that they were unable to provide adequate care due to the low number of staff on duty, leading to missed showers, infrequent rounds, and delayed wound care. The Director of Nursing and other administrative staff acknowledged the staffing challenges, citing high call-in rates and difficulties in retaining newly hired staff. Despite efforts to address the issue, such as using agency staff, the facility continued to struggle with maintaining sufficient staffing levels to meet the needs of its residents.
Failure to Provide Timely Incontinence Care and Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promoted the maintenance or enhancement of their quality of life. Specifically, several residents did not receive timely incontinence care or assistance with toileting, leading to situations where they were left soiled for extended periods. Resident #48, who was cognitively intact and dependent on staff for toileting, was found multiple times with urine-soaked clothing and linens, and reported feeling dehumanized by the lack of care. Similarly, Resident #28, also cognitively intact, experienced delays in receiving incontinence care and had not been showered for four weeks, leading to feelings of embarrassment and neglect. Resident #8, with moderately impaired cognition and a history of antibiotic-resistant infection, reported waiting for hours to be cleaned after incontinence and sometimes having to urinate on themselves due to a full urinal. The resident expressed frustration with the lack of timely assistance, which sometimes forced them to eat meals while soiled. Resident #350, who was cognitively intact and required assistance for toileting, also experienced issues with their urinal not being emptied in a timely manner, leading to spillage and further discomfort. Interviews with staff, including Certified Nursing Assistants and Nurse Managers, revealed that incontinence care and urinal emptying were not consistently performed every two to four hours as required. The Director of Nursing and Medical Director acknowledged that such neglect could have negative psychological effects on residents, making them feel anxious, frustrated, or upset. The report highlights a systemic issue in the facility's ability to provide timely and adequate care to its residents, impacting their dignity and quality of life.
Deficiencies in Resident Care and Facility Management
Penalty
Summary
The facility was found to be deficient in several areas during an Extended Recertification Survey and complaints investigation. The administration failed to ensure that residents were free from neglect, as evidenced by multiple instances where residents did not receive timely incontinence care, wound care, or assistance with toileting. Specific cases included residents being left in soiled conditions for extended periods, with one resident waiting approximately 21 hours for incontinence care and another left in a wheelchair for 14 hours without care. These failures resulted in the likelihood of serious injury, harm, or death for the residents, leading to an Immediate Jeopardy situation. The facility also failed to maintain resident rights, as some residents did not receive timely emptying of urinals, leading to unsanitary conditions. Additionally, residents reported going weeks without showers, and some were observed with unclean hair, indicating a lack of sufficient nursing staff to provide necessary care. Interviews with staff, including the Director of Nursing, confirmed that there were not enough staff to meet the residents' needs, and requests for additional staff had been made to the Administrator. Furthermore, the facility did not properly maintain the nurse call system, with issues such as non-functioning central panels and audible components. Grievances filed by residents regarding care issues were not thoroughly investigated or followed up on by the administration. Despite awareness of these concerns, the facility's Quality Assurance and Performance Improvement committee had not effectively addressed the issues, contributing to the overall deficiency in care and services provided to the residents.
Deficient Nurse Call System Maintenance
Penalty
Summary
The facility failed to maintain a properly functioning nurse call system across all three resident use floors, as observed during the Extended Recertification Survey. The central nurse call system panels were either not present or not functioning properly, and the audible component of the call system was not operational. There was also no documented testing of nurse call devices on the first floor. Observations revealed that the nurse call panel on the third floor was unplugged and not operational, and the second-floor panel had been removed five months prior due to being unfixable. The Director of Facilities admitted to being unaware of the reasons for these issues and the meanings of different colored lights on the overhead call lights. During testing, the nurse call buttons in several resident rooms failed to produce an audible tone, and the overhead corridor lights remained on even after the activation was canceled. In one instance, a resident was unable to reach their tray table and pressed their call light button, which did not light up or make a sound. A Certified Nursing Assistant (CNA) confirmed the malfunction after being alerted by the surveyor. Another CNA mentioned that the call button would only make a noise if pressed repeatedly, indicating a lack of consistent functionality. Interviews with staff, including the Administrator and Corporate Administrator, revealed that the call bell system was installed in 2018 and was intended to have both visual and audible alerts. However, staff were expected to visually check for call lights in the hallways due to the absence of operational panels. The facility's records showed incomplete testing logs, with no documentation of testing in common bathrooms and shower areas on the first floor, and no mention of the annunciator panels being tested or needing repairs. The manufacturer's manual specified the intended use and installation requirements for the system, which were not being met, as evidenced by the lack of power and network connections for the tablets.
Infection Control Deficiencies in PPE Use and Masking Policy
Penalty
Summary
The facility failed to maintain an effective Infection Control Program, as evidenced by the improper use of Personal Protective Equipment (PPE) by nursing staff during high-contact care for residents on Enhanced Barrier Precautions. Resident #350, who had multiple venous and arterial ulcers, was observed receiving wound care from a Nurse Practitioner and a Registered Nurse, both of whom wore gloves but not gowns, despite the Enhanced Barrier Precautions sign indicating the need for both. The Registered Nurse admitted to not being aware of the precautions for Resident #350 and not recalling any education on Enhanced Barrier Precautions at the facility. Similarly, Resident #65, who had a skin impairment and was on Enhanced Barrier Precautions, received wound care from a Licensed Practical Nurse who wore gloves but not a gown. The nurse acknowledged the oversight and stated that they should have worn a gown. Resident #351, with an indwelling urinary catheter, was also on Enhanced Barrier Precautions, yet a Licensed Practical Nurse was observed handling the catheter drainage bag without wearing a gown. The nurse admitted to the error and recognized the need for a gown during such procedures. Additionally, the facility did not enforce its policy requiring unvaccinated staff to wear masks during the influenza season. Observations revealed that staff members without the influenza vaccine, identifiable by the absence of a purple sticker on their ID badges, were not wearing masks in resident care areas. This included a Licensed Practical Nurse and the Director of Maintenance, both of whom admitted to not receiving the flu vaccine and acknowledged the requirement to wear masks. The facility administrator was aware of the non-compliance with the masking policy as mandated by the state Department of Health.
Failure to Resolve Resident Grievances Promptly and Thoroughly
Penalty
Summary
The facility failed to ensure thorough and prompt resolution of grievances for two residents, leading to deficiencies in addressing their concerns. Resident #88, who had diagnoses including bipolar disorder, diabetes, and anxiety, filed multiple grievances regarding inadequate incontinence care during overnight shifts. Despite the facility's policy requiring investigations and follow-ups, there was no documented evidence of staff interviews or actions taken to address the resident's dissatisfaction. The resident continued to experience the same issues, indicating a lack of effective resolution. Resident #350, with diagnoses including diabetes and chronic venous ulcers, reported a grievance about not having their wound dressing changed. The facility's documentation lacked evidence of a thorough investigation, including ruling out abuse or neglect, and there was no indication that the resident was informed of any actions taken. The facility's failure to document a complete investigation and follow-up with the resident highlights a deficiency in handling grievances related to care concerns. Interviews with facility staff, including the Director of Social Work and the Director of Nursing, revealed inconsistencies in the grievance investigation process. The Director of Nursing acknowledged receiving grievances about inadequate assistance with activities of daily living and stated that staffing levels were reviewed. However, the investigations did not consistently include obtaining staff statements or ruling out abuse or neglect. The Regional Director of Clinical Services confirmed that the investigations were incomplete and lacked follow-up, further emphasizing the facility's failure to adhere to its grievance policy.
Failure to Provide Timely Incontinence Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically incontinence care and personal hygiene, for three residents. Resident #28, who has diagnoses including morbid obesity, diabetes, and heart failure, reported not receiving timely incontinence care and had not been given a shower or hair wash for four weeks. Observations confirmed the resident was heavily incontinent and had greasy hair, with staff citing an inability to complete all care tasks due to a high resident assignment. Resident #48, with a history of stroke, hemiplegia, and diabetes, was found to be soaked through with urine on multiple occasions, indicating a lack of timely incontinence care. Despite being dependent on staff for toileting, the resident was not checked or changed for extended periods, with staff attributing the oversight to the resident not calling for assistance and staffing shortages. Resident #65, diagnosed with a right leg fracture, Parkinson's disease, and malnutrition, was also not assisted with toileting, resulting in incontinence. The resident, who requires assistance for transfers and toileting, was found with a saturated brief and reported not receiving help to use the bathroom. Staff acknowledged the resident's need for assistance but failed to provide it, citing assumptions about the resident's ability to self-toilet.
Deficiencies in Wound Care and Diagnostic Follow-Up
Penalty
Summary
The facility failed to provide appropriate wound care for Resident #350, who had multiple diagnoses including diabetes, peripheral vascular disease, and chronic venous ulcers. The resident's physician orders required daily dressing changes for 12 different wounds on their lower extremities. However, observations revealed that the dressings were undated, heavily soiled, and not changed for several days. Interviews with the resident and nursing staff confirmed that the wound care was not completed as ordered due to staffing issues, and the Treatment Administration Records showed multiple instances where the wound care was not documented as completed. Resident #12, who had diagnoses including low back pain, osteopenia, and dementia, experienced a significant delay in receiving a lumbosacral spine x-ray that was ordered by a physician. Despite the order being placed, the x-ray was not performed until 15 days later. Interviews with the resident and staff indicated that the order was not properly communicated or followed up on, leading to the delay. The x-ray eventually revealed a compression fracture that was not identified in a previous study. The deficiencies in care for both residents were attributed to failures in communication, documentation, and adherence to physician orders. The facility's staff, including nurses and management, acknowledged the lapses in care and the impact of staffing shortages on the ability to provide timely and appropriate treatment. These deficiencies were identified during an Extended Recertification Survey and complaint investigation, highlighting the need for improved processes to ensure residents receive care according to professional standards of practice.
Failure to Provide Timely Incontinence Care and Pressure Ulcer Management
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure ulcer and prevent new ulcers from developing for Resident #65. The resident, who preferred to spend most of their time in bed, was not assisted with toileting and was left incontinent of urine for multiple hours. This neglect led to the development of a pressure ulcer on the resident's right buttock, which went untreated for several days. The facility's policy required staff to inspect the skin during personal care and address moisture causes, such as incontinence, to prevent pressure injuries. Resident #65 had a history of right leg fracture, Parkinson's disease, and malnutrition, and was assessed as being at moderate risk for pressure ulcers. Despite this, the resident was found sitting in bed with a saturated brief and a strong smell of urine, indicating a lack of timely incontinence care. The resident's care plan required assistance with toileting every two to four hours, but this was not adhered to, as evidenced by the resident's statement and the observations of the Certified Nursing Assistant (CNA) who had not provided care for six hours. The facility's failure to document and report the pressure ulcer was further highlighted when the Assistant Director of Nursing assessed the resident and found an open wound that was not documented in the medical record. The Director of Nursing confirmed that any new skin impairment should be reported immediately for assessment and treatment orders. The lack of timely incontinence care and failure to report and document the pressure ulcer contributed to the deficiency identified during the survey.
Inadequate Catheter Care and Delayed Urinalysis Collection
Penalty
Summary
The facility failed to provide appropriate treatment and care to prevent urinary tract infections for two residents, as observed during the Extended Recertification Survey. Resident #20, who had a history of urinary tract infections and was dependent on staff for toileting hygiene, was found with their indwelling urinary catheter drainage bag lying uncovered on a soiled chair and above the level of the bladder. Additionally, a physician-ordered urinalysis for Resident #20 was not obtained in a timely manner, as the sample was never collected, leading to a delay in potential treatment. Resident #351, who had severe cognitive impairment and a history of urinary tract infections, was observed with their urinary catheter drainage bag placed at the level of the bladder and on the ground without a barrier on multiple occasions. Staff interviews revealed a lack of adherence to facility policy regarding the positioning of urinary drainage bags, which should be kept below the level of the bladder and off the floor to prevent infection. The facility's failure to adhere to its own catheter management guidelines, including maintaining the drainage bag below the bladder and ensuring timely collection of urinalysis samples, contributed to the deficiencies observed. Staff interviews indicated a lack of consistent practice in managing catheter care, which could potentially lead to increased risk of urinary tract infections for the residents involved.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with State and Federal Laws, specifically regarding the storage of controlled medications. During the survey, it was observed that the second-floor north medication cart contained controlled medications, including psychotropic, antianxiety, antidepressant, and opioid medications, which were not stored in a permanently affixed compartment as required by regulations. The medication cart was not affixed to the wall and was left unattended in the hallways, increasing the risk of diversion. Licensed Practical Nurse #2 confirmed that controlled medications were stored in the medication cart and not in the double locked cabinet in the medication room, as per facility policy. Additionally, the third-floor medication room was found to contain a narcotic cabinet with a pill box of approximately 80 undated and unlabeled pills. The Licensed Practical Nurse Manager was unaware of the pill box's ownership and stated that any resident pill boxes should be labeled with resident identifiers. The Director of Nursing acknowledged that controlled medications should be stored behind two locks in the secured double door cabinet in the medication room, except during shifts when they are in use. The failure to adhere to these storage protocols was identified as a deficiency during the survey.
Failure to Document and Educate on Vaccinations
Penalty
Summary
The facility failed to ensure that residents were educated and offered influenza and pneumococcal vaccinations, as required by their policies. During the Extended Recertification Survey, it was found that three out of five residents reviewed did not have documented evidence of being provided educational material or being offered, receiving, or declining the vaccines. Specifically, Resident #12, who had dementia and impaired cognition, had no documentation that their Health Care Proxy was informed about the vaccines. Resident #53, who was cognitively intact, had not received an updated pneumococcal vaccine since 2015. Resident #351, with severe cognitive impairment, had no record of receiving the influenza vaccine or any documentation that their Health Care Proxy was educated about the vaccines. Interviews with facility staff revealed a lack of awareness and documentation regarding the vaccination status of the residents. The newly hired Infection Preventionist was unaware of Resident #53's need for an updated pneumococcal vaccine and could not provide documentation for any of the residents' vaccination education or status. The facility's Administrator acknowledged the gaps in vaccination documentation and stated that the Quality Assurance Committee was aware of these issues. The deficiency was cited under 10 NYCRR 415.19(a)(3).
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide quarterly personal fund statements to a resident, identified as Resident #10, or their representative, as required by their policy. Resident #10, who was diagnosed with paranoid schizophrenia, high blood pressure, and diabetes, was cognitively intact according to a recent assessment. During an interview, the resident expressed that they had not received any quarterly statements and were unaware of the balance in their personal funds account, which was found to be $9,800.12. The facility's records showed that all quarterly statements had been signed by the facility as the representative payee, but there was no evidence that these statements were provided to the resident or their representative. The Business Office Manager indicated that statements were not sent to residents deemed not cognitively intact, and was unsure if Resident #10 had a representative. However, the Corporate Administrator clarified that both cognitively intact residents and representatives of those with fluctuating cognition should receive these statements. It was later confirmed that Resident #10's brother was their Health Care Proxy. This oversight was a violation of the facility's policy and regulatory requirements, as the facility did not ensure the resident or their representative received the necessary financial information.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to ensure that copies of residents' transfer and discharge notices were sent to a representative of the Office of the State Long Term Care Ombudsman, as required by regulations. This deficiency was identified during an Extended Recertification Survey conducted from January 21, 2025, to January 31, 2025, involving three residents. Resident #20, with diagnoses including urinary retention, benign prostatic hyperplasia, and chronic kidney disease, was transferred to the hospital multiple times between November and December 2024. Resident #76, who had bilateral below-knee amputations, a history of deep vein thrombosis, and anxiety, was transferred on November 28, 2024. Resident #248, diagnosed with a cerebral vascular accident, diabetes, and chronic obstructive pulmonary disease, was transferred on December 12, 2024. Interviews conducted during the survey revealed that the Ombudsman had not received any transfer or discharge notices from the facility for the past year. The Director of Social Work acknowledged that it was the responsibility of the Social Worker to send these notices, but they had not been sent since October 2024. The facility's Administrator was unaware of this lapse in communication. The facility was unable to provide documentation that the Ombudsman had been notified of the residents' transfers and discharges, as required by 10 NYCRR 415.3(i)(1)(iii)(a-c).
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality in medication administration for a resident with multiple diagnoses, including multiple sclerosis, epilepsy, and hypertension. The resident, who had moderately impaired cognition and impaired vision, was not assessed for the ability to self-administer medications. Despite this, medications were left unattended with the resident in a common area. The facility's policy requires licensed nurses to ensure all medications are administered and documented, but this was not adhered to in this instance. On the day of the observation, the resident was found in the dining room with a medication cup containing six pills, which were spilled. The pills were picked up by a Certified Nurse Aide and given to a Unit Clerk, who then passed them to a Licensed Practical Nurse. The nurse responsible for the resident admitted to not confirming that the resident had swallowed the medications. The Director of Nursing confirmed that the nurse should have stayed with the resident until the medications were swallowed and that medications should not have been left unattended with the resident.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital, as required by regulations. This deficiency was identified during an Abbreviated Survey for three residents. Resident #2, who was cognitively intact and had diagnoses including bacteremia and major depressive disorder, was transferred to the hospital but did not receive written notification of the bed hold policy. Similarly, Resident #3, with a below-the-knee amputation and benign prostatic hyperplasia, was transferred to the hospital twice without receiving the required notification. Resident #1, who had moderate cognitive impairment and diagnoses including acute cystitis and pancreatitis, was also transferred to the hospital without documented evidence of receiving the bed hold policy notification. Interviews with facility staff revealed a lack of understanding and communication regarding the bed hold policy. The Business Office Manager, in their position for two years, was unaware of the notification process for hospital transfers and believed the policy was only addressed upon admission. The Administrator stated that clinicians were responsible for providing the bed hold form at the time of transfer, but the Unit Manager, who started in March 2023, had never been involved in this process and did not know who was responsible. This lack of clarity and communication contributed to the facility's failure to comply with the regulatory requirement to notify residents or their representatives of the bed hold policy during hospital transfers.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #11, who had diagnoses including rheumatoid arthritis, diabetes, and depression, did not receive assistance with shaving and washing their hair. Despite being scheduled for a shower, observations revealed that Resident #11's hair appeared unwashed, and they had thick, dark facial hair. The resident expressed that they were unable to care for their hair and facial hair on their own, and it bothered them. The facility's records indicated that Resident #11 required assistance with personal hygiene, but this assistance was not adequately provided as evidenced by their unshaven appearance and unwashed hair during multiple observations. Similarly, Resident #12, who had diagnoses including hemiplegia and hemiparesis following a stroke, did not receive assistance with shaving and nail care. Observations showed that Resident #12 had long facial hair and dirty fingernails with dark, brown debris underneath. Despite being given a shower, the Certified Nursing Assistant did not notice the need for shaving and nail care. The Director of Nursing acknowledged that grooming and hygiene should be completed as needed and during showers, and the Administrator noted that concerns about activities of daily living had been raised at resident council meetings. These deficiencies indicate a failure to provide necessary personal hygiene services to residents who are unable to perform these activities themselves.
Failure to Provide Adequate Assistance Devices for Resident Transfers
Penalty
Summary
The facility failed to ensure that Resident #12 received the appropriate assistance devices to prevent accidents. Resident #12, who had diagnoses including hemiplegia following a stroke, osteoarthritis, and heart failure, required the use of a Hoyer lift for safe transfers. However, during an observation, two Certified Nursing Assistants (CNAs) transferred the resident without using the mechanical lift, citing the unavailability of a Hoyer lift sling. The CNAs admitted to transferring the resident earlier that morning without the mechanical lift for the same reason. The facility's policy mandates the use of a Hoyer lift for such transfers, but this was not followed due to the lack of available slings. Further investigation revealed that the issue of insufficient Hoyer lift slings was known to the facility's management. The Laundry Supervisor confirmed that audits had been conducted due to staff complaints about the lack of slings, and no slings were available in the laundry or clean linen rooms during the survey. CNAs reported that they often had to leave residents in bed or use alternative methods due to the shortage of slings. The Director of Nursing and the Administrator were aware of the issue but had not conducted a thorough assessment or follow-up to resolve the problem. The Administrator mentioned that additional slings had been ordered but had not yet arrived.
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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