Prestige Nursing Care & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bronx, New York.
- Location
- 3400 -26 Cannon Place, Bronx, New York 10463
- CMS Provider Number
- 335028
- Inspections on file
- 19
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Prestige Nursing Care & Rehab Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, homelike environment in two shower rooms when overhead light covers in one unit were cracked or broken and a sink faucet in another unit was loose and partially detached during use. Facility policies required maintaining safe, functional electrical fixtures and plumbing, and a prior maintenance log entry had documented needed repairs to the bathroom ceiling area, but the work on the lights had been delayed. A maintenance worker reported not being aware of the loose faucet because it was not in the unit’s repair log, and leadership stated that earlier environmental issues identified by an external assessment had been addressed, yet they had not identified these specific problems during their own environmental rounds.
Surveyors found multiple food storage and labeling violations, including unlabeled almond milk in a walk-in refrigerator, cooked chicken and vegetables held beyond the facility’s 72-hour limit, and a defrosted container of whole eggs without a defrost date. In a pantry refrigerator, several 4-oz fruit and pudding cups were undated, illegibly dated, or past the facility’s allowed holding time, despite policies requiring all perishable and pantry-refrigerated items to be labeled, dated, and discarded after 72 hours. The Food Service Director and dietary staff confirmed the 72-hour standard and labeling requirements and acknowledged that daily rounds intended to remove outdated or improperly labeled items did not prevent these issues.
The facility failed to develop and implement person-centered comprehensive care plans for two residents’ identified needs. One resident with multiple medical conditions and malnutrition had an inaccurate dental care plan that described functioning with dentures, while the resident actually had many missing teeth, had never seen a dentist since admission despite repeated requests, and was observed struggling to chew food. Another resident with severe cognitive impairment and behavioral symptoms was consistently provided plastic utensils with no knife due to behavioral concerns, but this intervention was not documented in the ADL or behavior care plans or in CNA accountability records, contrary to facility policy and staff descriptions of required practice.
A resident with dementia, depression, psychotic disorder, and severely impaired cognition was receiving Olanzapine 5 mg daily. A pharmacy drug regimen review, reflecting a psychiatry consult, recommended a gradual dose reduction of the antipsychotic due to drowsiness. The attending physician documented agreement with the recommendation but did not change the medication order or document any action in the medical record. Although staff later reported the resident was aggressive and refused care, no follow-up note or rationale for not implementing the agreed-upon gradual dose reduction was entered, contrary to facility policy requiring timely prescriber response and documentation to drug regimen review recommendations.
A resident with chronic pain and multiple comorbidities was maintained on Morphine ER 15 mg ordered every 12 hours PRN, without a clear PRN indication or defined duration, contrary to appropriate opioid prescribing standards. Facility records showed intact cognition and no documented pain or PRN pain medication use on the MDS, yet the MAR reflected several administrations of Morphine ER. The care plan cited osteoarthritis-related pain and directed staff to administer medications as ordered, while interviews with an NP, MD, DON, and Medical Director revealed that the resident refused scheduled dosing, insisted on PRN use, and was non-compliant with pain clinic follow-up. The attending MD acknowledged ER Morphine should not have been ordered PRN, and the DON was unaware of the PRN ER regimen, demonstrating a lack of proper oversight and justification for this extended-release opioid order.
A resident with severe cognitive impairment and multiple diagnoses fell and sustained fractures after a CNA provided bed mobility care alone, contrary to the care plan requiring two-person assistance. The CNA did not review care instructions or receive a proper report, leading to the incident being deemed neglectful.
The facility failed to report alleged abuse and a resident altercation to the New York State Department of Health within the required 2-hour timeframe. One resident with severe cognitive impairment was found with injuries of unknown origin, and an altercation between two residents with dementia was reported late. The Director of Nursing acknowledged the delays in reporting.
Failure to Maintain Safe and Homelike Shower Room Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in two shower rooms. During an environmental observation of the Six [NAME] unit shower room, two of three clear overhead light fixture coverings were found in disrepair: one was cracked and another was broken with two circular holes visible. The facility’s Homelike Environment policy requires maintaining a clean, comfortable, and safe environment with appropriate lighting, and its Routine Maintenance policy requires that essential electrical and structural elements be kept in safe operating condition. A maintenance repair log entry dated more than a month earlier documented a request for repair of bathroom ceiling tiles in this area, and a maintenance worker acknowledged that the ceiling tiles and lights in the Six [NAME] unit shower room were supposed to have been repaired about a week prior to the observation but had been delayed. In the Four East unit shower room, a sink faucet was observed to be loose and became partially detached from the sink base when used. A maintenance worker on that unit stated they had not been made aware of the loose faucet and were only following up on repairs already documented in the floor’s maintenance logbook. The Director of Housekeeping and the Administrator both referenced a prior unannounced physical environment assessment by the Comptroller’s Office, which had identified needed repairs and was verbally reported at exit; both stated that all needed repairs from that assessment had been completed, and the Administrator reported conducting environmental rounds. However, the Administrator stated they did not notice the need for repair of the Six [NAME] shower room light fixtures or the Four East shower room faucet during those rounds, while also characterizing the loose faucet base as normal wear and tear. These conditions resulted in the facility not honoring residents’ right to a safe, homelike environment as required by policy and regulation.
Improper Labeling and Storage of Refrigerated and Defrosted Food Items
Penalty
Summary
The deficiency involves failure to store and label food in accordance with the facility’s own food storage policies and professional standards. During an initial kitchen observation, surveyors found that walk-in refrigerator #1 contained two unlabeled and undated Styrofoam cups of almond milk, contrary to the policy requiring all perishable food to be dated and stored immediately upon receipt. In walk-in refrigerator #2, surveyors observed a metal pan of cooked ground chicken and a metal pan of mixed vegetables, both labeled with the date 04/02/2026, which exceeded the facility’s stated 72-hour limit for use or discard of cooked foods. A one-gallon container of whole eggs in citric acid was also found defrosted without a defrost date, despite the policy that frozen food placed in the refrigerator for defrosting must be clearly labeled with the date it was placed there. Surveyors also identified multiple issues in the kitchen pantry refrigerator, where several 4-ounce fruit cups and a 4-ounce chocolate pudding cup were either undated, illegibly dated, or labeled with dates beyond the facility’s 72-hour standard for prepared items. Interviews with the Food Service Director and dietary staff confirmed that prepared or cooked foods and prepared fruit cups should be labeled with preparation dates and used or discarded within three days, and that any food placed in the pantry refrigerator must be labeled, dated, and discarded after 72 hours or if undated. Staff acknowledged that the cooked chicken and vegetables should have been discarded if not used within three days, that defrosting items should be dated, and that daily rounds are intended to identify and discard outdated or improperly labeled items, but these processes did not prevent the observed deficiencies.
Failure to Develop and Implement Person-Centered Care Plans for Dental Needs and Plastic Utensil Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement person-centered comprehensive care plans addressing identified dental and safety needs for two residents. For one resident with anemia, renal insufficiency, renal failure, and malnutrition, the MDS documented intact cognition, independence with most ADLs, and no swallowing or oral/dental concerns, while the existing dental care plan stated the resident was partially edentulous with full upper and partial lower dentures, functioning well and to be treated symptomatically. However, the resident reported having many missing teeth, never having seen a dentist since admission despite repeated requests, and not receiving help from staff to obtain a dental appointment. During a dining observation, the resident was seen with only one upper front tooth and many missing lower teeth, having difficulty chewing chopped meat and stating eating would be easier with dentures and that they had been waiting a long time to see a dentist. There was no documented evidence that a person-centered comprehensive care plan was developed and implemented to address this resident’s actual dental care needs. Interviews with nursing staff revealed that the unit RN was unsure whether the resident had dentures or when they were last seen by a dentist, and that the night nursing supervisor responsible for reviewing the comprehensive care plan had copied and pasted an inaccurate dental note into the care plan. Facility leadership and nursing staff acknowledged that the existing dental care plan did not reflect the resident’s true dental status or needs and that care plan reviews by the night shift supervisor had not ensured accuracy or appropriateness. For another resident with seizure disorder, dementia, and traumatic brain injury, the MDS documented severely impaired cognition, behavioral symptoms including rejection of care and wandering, and a need for supervision or touching assistance with eating, all personal care, ADLs, and mobility. This resident was repeatedly observed eating meals in their room using plastic cutlery, with tray tickets specifying plastic utensils and no knife. Facility policy and staff interviews indicated that plastic utensils are used for residents with behavioral issues such as suicidal or homicidal ideation or threatening behaviors, and that such interventions are to be documented in the ADL or behavior care plans and carried over to CNA accountability records. Despite this, the resident’s ADL and behavior care plans and CNA accountability documentation did not include the intervention for plastic utensils, and nursing staff, including the nurse manager, acknowledged that the care plan had not been completed or updated to reflect this intervention.
Failure to Implement and Document Drug Regimen Review Recommendation for Antipsychotic GDR
Penalty
Summary
The deficiency involves the facility’s failure to ensure that recommendations from the monthly drug regimen review were acted upon and appropriately documented for one resident receiving antipsychotic medication. Facility policy required the consultant pharmacist to perform monthly medication regimen reviews, provide written recommendations, and for the prescriber or designee to respond within 7–14 days, documenting agreement or disagreement and a brief clinical rationale. For a resident with non-Alzheimer’s dementia, depression, psychotic disorder, severely impaired cognition, and receiving antipsychotic and antidepressant medications, the consultant pharmacist’s drug regimen review dated 02/09/2026 noted that the most recent psychiatry consult recommended a gradual dose reduction (GDR) of Olanzapine 5 mg daily, tapering to discontinuation. The attending physician documented on 02/11/2026 that they agreed with the recommendation and would implement it. Despite this documented agreement, a review of physician orders from 02/11/2026 to 04/15/2026 showed no change in the Olanzapine order to reflect the recommended GDR, and the resident’s medical progress notes contained no documentation that any action was taken to address the recommendation. The psychiatric NP reported that the resident was drowsy, leading to the GDR recommendation, but stated the recommendation was not carried out and was beyond their control. The attending physician confirmed agreement with the pharmacy consultant’s recommendation but stated the order was not changed after staff reported the resident was aggressive and refused care, and no follow-up note was added. The Medical Director and DON both stated that clinicians are required either to implement accepted recommendations or document the rationale if they do not, and the DON confirmed there was no documentation in the resident’s chart explaining why the recommendation was not followed.
Unnecessary PRN Use of Morphine ER Without Clear Indication or Duration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs, specifically related to the use of Morphine ER 15 mg ordered on an as-needed (PRN) basis without an adequate indication or duration for its use. The facility’s pain policy required evaluation of pain regimens and assessment of medication effectiveness, but the resident’s records showed inconsistencies. The Quarterly MDS documented intact cognition, no pain, no behavioral symptoms, and no scheduled or PRN pain medication use, despite the presence of a PRN Morphine ER order and documented administration of the drug on several dates. Resident #131 had diagnoses including COPD, renal insufficiency, and obstructive uropathy, and a care plan for pain related to primary generalized osteoarthritis with interventions to administer medications as ordered. The physician’s order, originally written and later renewed, specified Morphine ER 15 mg by mouth every 12 hours PRN, and the MAR showed the resident received this medication on multiple mornings in April. However, the MDS indicated the resident did not receive scheduled or PRN pain medications, and there was no clear documentation of an appropriate PRN indication or defined duration for the extended-release opioid. Interviews with clinical staff revealed further issues with the appropriateness and oversight of the Morphine ER regimen. The NP reported that an outside pain management specialist had ordered a standing Morphine regimen, but the resident was non-compliant with the scheduled dosing, refused appointments, and insisted on taking the medication only when they felt it was needed. The attending MD acknowledged that Morphine ER should not have been ordered on a PRN basis and that an immediate-release formulation would have been more appropriate for PRN use. The DON stated they were not aware the resident was receiving Morphine ER PRN, while the Medical Director stated the regimen worked for the resident and that residents can determine what is best for them, indicating reliance on resident preference rather than adherence to appropriate prescribing standards for PRN extended-release opioids.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to a resident, resulting in a fall and subsequent injuries. A resident with severe cognitive impairment and multiple diagnoses, including Non-Alzheimer's Dementia and Osteoporosis, was dependent on two or more helpers for bed mobility. However, a Certified Nursing Assistant (CNA) provided care alone, without reviewing the resident's care instructions or receiving a proper report from the charge nurse. This led to the resident falling off the bed and sustaining multiple fractures. The CNA, who was new to the unit, was informed by other CNAs that the resident required one person for washing and two for transfers. Despite this, the CNA proceeded to provide bed mobility care alone, without the bed rails up, and without consulting the Resident Nursing Instructions. The CNA had received training on reviewing care instructions and was aware of the need to call for assistance but failed to do so. The incident was reported to the charge nurse, and the resident was assessed and transferred to the hospital with significant injuries. The facility's policies on falls and accident investigations were not followed, and the CNA's actions were deemed neglectful. The facility concluded that the fall was avoidable, and the CNA was subsequently terminated for not adhering to the care plan.
Failure to Timely Report Alleged Abuse and Resident Altercation
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse were immediately reported to the New York State Department of Health within the required 2-hour timeframe. This deficiency was evident in the cases of three residents. Resident #265, who had diagnoses of non-Alzheimer's dementia and aphasia, was found with an abrasion and bruise on the left side of their face and back of their head. These injuries of unknown origin were not reported to the New York State Department of Health within 2 hours of discovery. The Director of Nursing confirmed that they were informed of the injuries more than 2 hours after they were discovered and could not explain the delay in reporting to the state authorities. Additionally, a resident-to-resident altercation between Resident #181 and Resident #66 was not reported within the required timeframe. Resident #181, who had severe cognitive impairment, and Resident #66, who had Alzheimer's dementia and displayed behavioral symptoms, were involved in an altercation where Resident #66 alleged they were slapped by Resident #181, and Resident #181 alleged Resident #66 threw coffee at them. The incident was reported to the New York State Department of Health more than 2 hours after it occurred. The Director of Nursing acknowledged that the delay in reporting was not in compliance with regulatory requirements.
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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