Rosewood Rehabilitation And Nursing Center

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure residents were afforded their right to formulate advance directives, have corresponding physician orders for code status, and have those choices documented and communicated to staff. Facility policy required that advance directives be provided on admission, that residents’ wishes for code status be established before CPR through a code status identifier, and that the EMR contain a written MD order and a physical MOLST form. An additional policy required that upon admission and as needed thereafter, residents or their legal representatives be informed of their rights regarding advance directives, that the facility inquire about existing directives, and that the resident’s status be documented in the medical record. Despite these policies, surveyors found multiple residents without documented code status orders, without MOLST forms, and one resident with conflicting documentation of code status. One resident with a history including wedge compression fracture, ischemic heart disease, and hypertensive heart disease was cognitively intact and had no documented physician order for basic life support interventions or code status in the record. When this resident was found unresponsive with low oxygen saturation and no obtainable blood pressure, staff initiated CPR and called 911. Nursing notes and a provider note documented that there was no MOLST or advance directive limiting resuscitation on file at the time of the event, and the NP instructed staff to treat the resident as full code. Interviews with two LPNs revealed they could not identify the resident’s code status, found no MOLST in the binder or code status in the EMR, and followed an understood practice of treating residents as full code when no directive was found. The NP stated a MOLST had been completed at admission and verified, but it was missing from the binder and the code status had not been entered into the EMR because the nurse manager was responsible for that task. The NP also did not document the code status in the admission physical because it was not on the resident’s EMR profile. Additional residents were found without proper documentation of advance directives or code status. One resident with acute and chronic respiratory failure, COPD with acute respiratory infection, and interstitial pneumonitis was cognitively intact, had no MOLST form on the unit, no physician order for basic life support interventions, and no documented code status in the admission provider assessment; the resident and a family member reported that no admission paperwork or advance directive had been completed, though the resident stated a preference to be full code. Another cognitively intact resident with encephalopathy and acute respiratory failure had no physician order for basic life support interventions and no documented code status in the admission assessment; this resident reported not signing admission paperwork, did not know what advance directives were, and after explanation stated a preference for DNR. A further cognitively intact resident with acute respiratory failure, COVID-19 pneumonia, and acute pulmonary edema had no MOLST on the unit, no physician order for basic life support interventions, and no documented code status in the admission assessment, and did not recall signing admission paperwork or knowing about advance directives, later expressing a preference to be full code. Another resident with traumatic ischemia of muscle, dehydration, and muscle weakness, and mild cognitive impairment, had conflicting documentation regarding code status. A MOLST form dated in late January documented that this resident was to have CPR and was signed by the NP several days later. However, physician orders for the same resident included an order entered by an RN for DNR/DNI, which was signed by the NP on a subsequent date. This created a direct conflict between the MOLST form indicating CPR and the physician order indicating DNR/DNI. Interviews with facility leadership confirmed that the facility’s practice was to treat residents as full code when no advance directive was in place and that code status orders were supposed to be matched to the MOLST form when entered into the EMR. The survey identified that for multiple cognitively intact residents, there was either no documented physician order for code status, no MOLST form, or conflicting documentation, leading to an Immediate Jeopardy finding and substandard quality of care for the affected residents.

Removal Plan

• The admission nurse was educated by the Administrator on their responsibilities to educate all residents/representatives on admission/re-admission of their right to formulate advance directives and to ensure a corresponding physician order for code status and/or a MOLST form are entered into the resident's medical record.
• The facility management team conducted a facility-wide audit of each current resident to ensure residents had physician orders for code status and/or a MOLST form.
• All residents without a MOLST had advance directives discussed with them or their representative by nursing staff.
• Corresponding MOLST forms and physician orders for advance directives were entered into the electronic medical record by the unit manager and approved by the Nurse Practitioner.
• The Administrator and Assistant Administrator reviewed the facility policy on advance directives and made no revisions.
• The facility initiated mandatory education for the Nurse Practitioner, all registered nurses, and a licensed practical nurse on the facility policy regarding educating all residents/representatives on admission of their right to formulate advance directives and ensuring a corresponding physician order for code status and/or a MOLST form are entered into the resident's medical record.
• Education was conducted verbally by the Nursing Supervisor and/or designee.
• Facility staff not reached by telephone would not be permitted to work until they received the education.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for two residents. One resident with recurrent moderate major depressive disorder, atrial fibrillation, seizures, and severe cognitive impairment was found asleep in bed with a clear plastic bag on the nightstand containing three prescription medication bottles: Sertraline 50 mg, Eliquis (Apixaban) 5 mg, and Levetiracetam 500 mg. These bottles were labeled with the resident’s name and contained medication. Facility policy on administering medications stated that medications were never to be left at the bedside and that medications brought in with a resident would be returned to the family or health care proxy, with medications to be reordered and filled by the facility or vendor pharmacy. Staff interviews revealed that a CNA stated they would remove medications found at the bedside and report them to a nurse, and an LPN stated that medications from home were to be locked in the medication cart and then either taken home by family or destroyed. When the surveyor showed the medications on the nightstand to the LPN, the LPN identified the fill dates on the bottles and removed them from the room. Another LPN stated they were not aware the resident had medications on the nightstand and that staff should have seen and removed them, noting that the resident was cognitively impaired and unable to self-administer medications. The Acting DON/Acting ADON stated that the medications at the bedside could have caused serious harm if taken by another resident and described all three as lethal medications that could cause serious harm depending on what and how much was taken. The family member reported that, at admission, a nurse told them the medications were not needed because they would be ordered at the facility and instructed them to put the medications in the bedside table. The second component of the deficiency involved an environmental hazard in another resident’s bathroom. This resident, who had ataxia, a history of falling, spinal stenosis, and used a wheelchair for mobility, was cognitively intact and able to make themselves understood and understand others. During observation, the bathroom door was open and a small electric baseboard heater was seen with its front cover removed and lying on the floor in front of the running heater. The heater was producing heat and a burning smell, and when the surveyor placed a hand close to the exposed heating elements, they were hot enough to cause injury if they came into direct contact with skin or clothing. A CNA reported having seen the heater cover on the floor the previous day and acknowledged they should have reported it to Maintenance but did not, and also did not report it on the day of the survey. The Director of Maintenance and an LPN confirmed that the heater was hot and that the cover had to be put back on, and the LPN stated staff should have reported the missing cover immediately.

Removal Plan

• Resident #2's home medications observed at the bedside were removed from the room and secured.
• Nurse Practitioner #1 was notified regarding the medications found in Resident #2's room.
• The family was to be notified according to facility process.
• Education was provided to all staff on medication administration and continued until all staff were educated.
• Staff rounds occurred during care delivery, activities, therapy, and routine safety checks multiple times a day.
• A full-house in-service was conducted to reinforce medication safety, admission procedures, and environmental monitoring.
• Administrator #1 was notified regarding the prescription medications left at Resident #2's bedside.
• A facility-wide audit of each resident room (including drawers and cabinets) was conducted to ensure no other residents had medications in their rooms.
• A second facility-wide audit of each resident room (including drawers and cabinets) was conducted to ensure no other residents had medications in their rooms.
• Administrator #1 and Assistant Administrator #1 reviewed the facility policy 'Administering Medications' and made no revisions.
• Medications from Resident #2's room were returned to Family Member #3 to take home and destroy.
• Mandatory education/re-education was initiated for all staff that residents were not to have medications in their room and any medications found must immediately be given to a nurse.
• Education was to be conducted verbally (in person or by telephone) by the Nursing Supervisor and/or designee.
• Staff not reached by telephone would not be permitted to work until they received the education.
• Director of Maintenance #1 replaced the cover on the baseboard heater in Resident #3's bathroom.
• Director of Maintenance #1 conducted an audit of the electric baseboard heaters in the facility to ensure covers were in place.
• Assistant Administrator #1 and Director of Maintenance #1 reviewed the facility Work Request Policy and made no revisions.
• Mandatory education was initiated for all staff regarding the process for reporting damaged, broken and/or malfunctioning equipment.
• Education on reporting damaged/broken/malfunctioning equipment was to be conducted verbally (in person or by telephone) by the Nursing Supervisor and/or designee.
• Staff not reached by telephone would not be permitted to work until they received the education on reporting damaged/broken/malfunctioning equipment.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and person-centered care plans for multiple residents, particularly in bowel management, infection assessment, and post-fall evaluation. One resident with chronic idiopathic and slow-transit constipation, a history of large bowel obstruction, and recent hospitalizations for severe constipation returned from the ED with instructions from a nurse practitioner to continue bowel regimen, closely monitor bowel movements, abdominal distention, nausea, vomiting, and overall comfort, and to update the plan of care. Despite this, the resident’s constipation care plan was not revised after mid-October, and there was no documented evidence that the nurse practitioner’s instructions were incorporated into the care plan or physician orders. Review of bowel movement records, MARs, and nursing notes for December and January showed no routine abdominal assessments when bowel movements were absent, no administration of PRN bowel medications per orders and facility policy, and no timely provider notification when the resident went more than 24 hours without a bowel movement, even on multiple multi-day stretches without documented bowel movements. The resident ultimately required repeated hospitalizations, including treatment for severe sepsis and proctocolitis and later fecal impaction requiring disimpaction under general anesthesia. The facility also failed to ensure timely assessment and intervention for suspected urinary tract infection in another resident with severe dementia, diabetes, and chronic kidney disease. A nurse practitioner note documented that the family was concerned about a possible UTI and that a urinalysis would be considered, and a subsequent note documented decreased oral intake with a plan to provide extra fluids and obtain a urine sample for urinalysis. However, there was no documented evidence of an order for a urinalysis on the date specified, and progress notes lacked documentation of the resident’s condition around the time of the planned testing. The resident was later diagnosed with septic shock secondary to UTI, indicating that the infection progressed without documented timely diagnostic follow-up as initially planned. Additional deficiencies involved failure to assess and document a reported fall and failure to administer PRN bowel medications or notify providers for other residents. One newly admitted resident reported a fall on an evening shift, but there was no nursing assessment documented at the time of the fall, no incident report initiated, and no documentation of family notification by the nurse on that shift. The resident later complained to a family member about the fall and was sent back to the hospital within 24 hours of admission. For two other residents with bowel management needs, the facility did not ensure administration of ordered PRN bowel medications during specified months and did not notify the provider when these medications were not given. Interviews with CNAs, LPNs, an RN, the nurse practitioner, the medical director, the DON, and the administrator revealed inconsistent understanding and implementation of the bowel protocol (including differing beliefs about when bowel alerts should trigger interventions and provider notification), lack of awareness of specific monitoring expectations, and acknowledged issues with documentation and processes for adverse event reporting and follow-through.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor residents’ rights to dignity, respect, self-determination, and privacy, as required by its Quality of Life/Dignity policy and 10 NYCRR 415.12(h)(1)(2). The policy states that residents are to be treated with dignity and respect at all times, that staff will knock and obtain permission before entering rooms, will not handle or move resident belongings without permission, and will speak respectfully to residents, addressing them by their chosen names. Despite this, surveyors observed and residents reported multiple instances where staff behavior and administrative actions did not comply with these standards. Resident #1, who was cognitively intact and able to understand and be understood according to the MDS, reported that staff called them “honey,” “sweetie,” and “big-butt,” and that they did not like being addressed with these pet names. Resident #1 also stated that their Refresh eye drops, which they had been self-administering for a long time, were taken away by staff, and they did not believe staff considered evaluating whether they could continue to keep and use the drops. Additionally, the resident reported that staff had moved their denture cream approximately two nights prior and that they were still unable to locate it. Resident #1 further stated that nurses continued to try to administer melatonin at bedtime despite the resident informing the nurse that they did not want it. Resident #4, who was also cognitively intact per the MDS, reported that Administrator #1 entered their room and searched through three nightstand drawers without first obtaining permission. Resident #4 stated they had to ask Administrator #1 what they were doing, and Administrator #1 explained they were looking for medications, scissors, or clippers, and then asked the resident about the location of their money. Separately, during an observation on the first-floor rehabilitation unit, the Maintenance Director was heard loudly stating, “Can’t get fucking lucky,” in a hallway near the nursing station. Multiple CNAs and LPNs interviewed described that proper practice is to knock, introduce themselves, and obtain resident permission before going through belongings, and several acknowledged that cursing or arguing in front of residents constitutes a dignity issue, indicating that the observed and reported behaviors were inconsistent with facility expectations and policy.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely report and investigate multiple allegations and incidents of abuse, neglect, and injuries of unknown source, and to notify the administrator and the State Survey Agency within required timeframes. Facility policy required that all alleged violations and injuries of unknown source be reported immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not involve abuse and did not result in serious bodily injury. The policy also required immediate notification of the nursing supervisor, DON, or administrator, initiation of an investigation, and reporting to the New York State Department of Health (NYSDOH). Surveyors found that these requirements were not followed for several residents. For two residents involved in a resident-to-resident altercation, the facility did not ensure timely reporting or investigation. One resident with moderate cognitive impairment reported that another resident entered their room during the night, yelled at them, and dumped water from a refillable water bottle on them, leading the resident to call 911 when staff did not respond to their calls for help. The family later learned of the incident directly from the resident and filed a grievance. The grievance form lacked documentation of who received it, whether further investigation was required, and any investigation or follow-up details, although it noted the complainant was notified of actions taken. Nursing progress notes for the month did not document the altercation or any post-incident assessment, and the comprehensive care plans for both residents did not include interventions related to abuse or neglect. The facility could not provide an incident report or investigation, and there was no evidence the incident was reported to NYSDOH or that the administrator was notified at the time of occurrence. For another resident, the facility failed to meet reporting requirements after an allegation of staff-to-resident abuse. This resident reported an allegation of abuse by a CNA on a specific evening. The allegation was not reported to the administrator within two hours as required for abuse allegations, and it was not reported to NYSDOH until approximately 24 hours after the allegation was made. Additionally, a resident who sustained an unwitnessed fall and was later found to have a hip fracture was not reported to NYSDOH, despite the serious injury. Another resident with dementia and severe cognitive impairment experienced two unwitnessed falls with head lacerations, was sent to the hospital, and later was found to have an acute left hip fracture of unknown source after returning to the facility and developing acute hip pain and functional decline. Staff interviews indicated that this resident had been ambulatory and independent with a walker before the fracture and experienced a significant decline afterward. The acting DON and administrator stated that injuries of unknown origin should be reported to NYSDOH, but there was no evidence that this fracture of unknown source was reported or that an investigation consistent with policy and regulatory requirements was completed. Interviews with facility leadership and clinical staff confirmed that required notifications and investigations did not occur as expected. The assistant administrator reported they were not notified of the resident-to-resident incident and could not locate an incident report or investigation, and acknowledged the event was reportable and should have triggered a full investigation and assessments of both residents. The DON and administrator, who were not in their roles at the time of some incidents, stated their expectations that resident-to-resident altercations, abuse allegations, and injuries of unknown origin be immediately reported to them and to NYSDOH, and that thorough investigations be conducted. The medical director stated they were not always notified of reportable incidents and expected investigations for injuries of unknown origin. Overall, surveyors determined that for multiple residents, the facility did not ensure immediate reporting of alleged violations and injuries of unknown source to the administrator and appropriate authorities, and did not ensure that required investigations and documentation were completed in accordance with facility policy and 10 NYCRR 415.4(b)(2).

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to thoroughly investigate, protect residents during, and properly report multiple allegations and incidents of potential abuse, neglect, falls, and injuries of unknown origin. Facility policy required immediate reporting of suspected abuse, mistreatment, neglect, exploitation, or misappropriation of property to the New York State Department of Health (NYSDOH) and facility leadership, initiation of an investigation coordinated by the DON, immediate actions to prevent further potential abuse, completion of RN and psychosocial assessments, and suspension of any accused staff member pending investigation. Surveyors found that for several residents, there was no documented evidence that these steps were followed, and key staff interviews confirmed that expected processes were not consistently carried out. For two residents involved in a resident-to-resident altercation, the facility lacked documentation of an investigation into a reported verbal and physical incident in which one resident entered another resident’s room at night, allegedly harassed them, and struck them with a water bottle. The resident who reported being assaulted told a family member they felt shaky and scared whenever they saw the other resident and did not feel safe with that resident remaining on the same floor. The grievance form documenting this allegation was incomplete: the staff recipient’s name/signature was blank, the section asking whether further investigation was required was left blank, and there was no documented investigation or follow-up narrative. There was also no evidence that the incident was reported to NYSDOH, and the care plans for both residents did not include abuse/neglect interventions related to this event. Another deficiency involved a resident who reported being hurt by a CNA, where the facility did not initiate an immediate investigation or measures to prevent further potential abuse at the time of the report. As a result, the accused staff member was not identified when the allegation was made and continued to provide care to residents. For additional residents with multiple falls and an injury of unknown origin, including several unwitnessed falls and a hip fracture discovered after reports of acute hip pain and functional decline, there was no documented evidence of thorough investigations. In one case, an unwitnessed fall with head lacerations and a second fall with a larger scalp laceration requiring hospital treatment were not supported by complete Accident and Incident Reports, RN assessments, or staff and resident statements. The hip fracture was also not accompanied by an Accident and Incident Report or investigation to rule out possible abuse or neglect. Interviews with nursing and medical staff revealed uncertainty and inconsistency regarding who initiated and completed Accident and Incident Reports and investigations, and the Medical Director reported not having seen or signed any such reports in recent months, despite expecting investigations and reporting for injuries of unknown origin and falls. Additional interviews with facility leadership and clinical staff confirmed that the expected processes for incident/accident reporting and investigation were not followed. A nurse manager stated they were not notified of the resident-to-resident altercation until a later family meeting and did not conduct any staff interviews or investigation. The assistant administrator, medical director, DON, and administrator each stated they would have expected immediate reporting of resident-to-resident altercations, completion of incident/accident reports, and thorough investigations, including interviews and documentation, but acknowledged these did not occur in the cited cases. Staff also reported that turnover and vacant positions contributed to incident and accident reporting not occurring as it should have, and the acting DON was unsure how Incident and Accident Reports were being completed. Collectively, these findings show that the facility did not ensure all alleged violations and injuries of unknown origin were thoroughly investigated, that residents were protected from further potential abuse or neglect during investigations, and that results were reported to the administrator and State Survey Agency within required timeframes.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans with measurable objectives and timetables for multiple residents, as required by its own care planning policy and professional standards. For one resident with dementia, Parkinsonism, and age-related debility, the record showed that after the resident was identified as the aggressor in a resident-to-resident altercation, there was no documented care plan addressing abuse or risk for abuse, despite an order for CNAs to complete safety checks every two hours. Another resident with obstructive sleep apnea, diabetes mellitus type 2 with hyperglycemia, and hemiplegia/hemiparesis following cerebral infarction had a documented diagnosis of obstructive sleep apnea, a consultation recommending an auto-CPAP, and a physician order for CPAP use at bedtime, but there was no documented respiratory care plan addressing this condition and its management. A further resident with noninfective gastroenteritis and colitis, chronic idiopathic and slow transit constipation, and type 2 diabetes had a grievance filed on their behalf stating that another resident entered their room at night and harassed and assaulted them with a water bottle, and that they no longer felt safe with the aggressor on the same floor. Although staff reported placing a stop sign across this resident’s door after learning of the grievance, there was no documented evidence that a care plan for abuse or risk for abuse was developed and implemented with specific interventions after the resident was identified as the victim of a resident-to-resident altercation. Interviews with staff further described systemic issues with care planning. One LPN stated that if they noticed something that needed to be added to a resident’s care plan, such as fall risk, they would notify the unit manager, indicating reliance on informal communication rather than a documented, comprehensive process. The DON stated that care planning was a significant issue at the facility and cited a lack of RNs to assist with care planning. The Administrator stated that care plans should be individualized and that care plans assure residents are safe and cared for accordingly, underscoring that the identified omissions in abuse, respiratory, and other condition-specific care plans were inconsistent with the facility’s stated expectations and written care planning policy.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff, including licensed nurses and CNAs, to meet residents’ needs as outlined in its own facility assessment. The assessment dated January 2026 specified required nursing administration and direct-care staffing per unit and per shift, including RN/LPN supervisory coverage and minimum CNA numbers on days, evenings, and nights. Review of staffing sheets from late November 2025 through late February 2026 showed repeated and sometimes severe understaffing compared to these minimums, including multiple shifts with fewer nurses and CNAs than required and numerous night shifts with no scheduled nurses or no CNAs. On several dates, there were zero nurses scheduled for the night shift aside from a nurse supervisor, and on some nights there were no CNAs scheduled at all. Residents reported that this staffing pattern affected their care. One resident stated staffing was an issue, turnover was very high, and they were sometimes scared to ask for pain medication because staff were so busy; this resident reported receiving only one shower per week and feeling that staff became upset if they asked for more assistance. Another resident described being suspicious of staff and believed the facility was short staffed, reporting that getting help to clean up was inconsistent and that they sometimes had to wait a long time for pain medication. A different resident reported that staffing was too often short, especially at night, and described waking up in the morning with the bed soaked from overnight because no one had been available to change them; this resident stated they would ring the call bell when needing the bathroom or incontinence care, but no one would come, and that call bells often took 30 minutes or more to be answered, particularly on nights. Additional residents and staff corroborated ongoing staffing shortages. Several residents stated there were not enough staff, particularly on the overnight shift, and that medications were not always given on time and they had to wait a long time for help. A CNA reported that it was difficult to get to all residents on their assignment, especially on the 3 PM–11 PM shift when some residents became more confused, and that they often had to complete documentation an hour after their shift ended due to workload. The staffing coordinator, who assumed responsibility for staffing in mid-February 2026, acknowledged that staffing levels were based on the facility assessment and that call-outs and no-call/no-shows disrupted staffing. An LPN described typical patterns of having fewer aides than expected on days and evenings and only one aide per floor and one LPN for both floors at night, with situations where the supervisor was the only LPN and had to perform both medication passes and supervisory duties. Dietary staff and the ombudsman also reported inconsistent staffing, including an instance when breakfast was delayed until late morning and prepared by maintenance because kitchen staff had called out.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that licensed nurses and certified nurse aides possessed and maintained the specific competencies and skills required to meet residents’ needs, as outlined in the facility assessment. The facility assessment dated 1/2026 listed numerous required staff training and competency areas, including communication, resident rights and facility responsibilities, emergency planning, person-centered care, dementia and behavioral management, substance abuse identification, trauma-informed care/PTSD, proper body mechanics, abuse/neglect/exploitation, infection control, culture change, required in-service training for nurse aides, identification of resident changes in condition, and cultural competency. It also specified that nurse aides must receive at least 12 hours of annual in-service training, including dementia management and resident abuse prevention, and that training should address areas of weakness and special resident needs. Additional competencies such as ADLs, disaster planning, infection control, medication administration, measurements, resident assessment/observation, Alzheimer’s/dementia care, and specialized mental/psychosocial care were also identified as necessary. Record review showed that multiple staff did not have complete or verifiable education records consistent with these requirements. One CNA’s education file lacked evidence of completion of all annual education after 1/09/2022, and the electronic record showed less than 12 hours of annual education completed by the time of survey. Another CNA’s file contained multiple in-service sign-in sheets and some posttests, but it could not be determined from the documentation whether all required annual education had been completed; this CNA’s electronic record also showed less than 12 hours of annual education. A third CNA’s file contained no evidence of annual education other than a written statement of verbal education related to a specific incident in 2/2026, and the electronic records contained no education topics for this aide. For LPNs, one nurse’s file had no documented evidence of annual education since 2022 except for a single 2024 posttest and part of an untitled answer sheet, and the electronic record showed only 2 of 10 required topics completed for 2025. Another LPN’s file lacked documented annual education since 2024, and the electronic record showed only 1 of 6 required topics completed for 2025. Interviews further demonstrated a lack of clear oversight and consistent implementation of the education program. The assistant administrator stated that the nurse educator role was typically filled by the assistant DON, and that an RN had been filling in, but also acknowledged that with staff changes, education had stopped for a period and that a binder of education information maintained by the prior assistant DON could not be located. The assistant administrator and other leaders described reliance on an electronic education system and on-the-spot or group in-services, but staff interviews revealed confusion about how to access online education, awareness of overdue modules, and reports of not having enough time to complete them. Several CNAs and an LPN reported not receiving education in the last year or not having training on key topics such as abuse, neglect, infection control, dementia/behavioral health, or QAPI. The acting DON stated they did not conduct education, and a unit manager LPN was unsure who was responsible for assigning education. A laundry attendant reported receiving only task-specific training and no house-wide education such as abuse and neglect. Overall, the documentation and interviews showed incomplete education records, insufficient annual hours for CNAs, missing required topics, and no clearly designated person overseeing education, contrary to the facility’s own assessment and regulatory requirements.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The governing body failed to establish and implement effective policies for managing and operating the facility and did not maintain a consistent, properly functioning Administrator responsible for regulatory compliance. Surveyors identified multiple deficiencies across numerous regulatory areas, including repeat deficiencies related to providing a safe, clean, comfortable, homelike environment (F584), developing and implementing comprehensive care plans (F656), revising care plans in a timely manner (F657), and ensuring influenza and pneumococcal immunizations (F883). Additional cited deficiencies included failures in resident dignity (F550), notification of providers and resident representatives about changes in condition (F580), protection from abuse and neglect (F600), reporting injuries of unknown origin to the State Survey Agency (F609), and thoroughly investigating all allegations of abuse, neglect, exploitation, or mistreatment (F610). The scope of deficiencies also extended to discharge/transfer documentation and notification (F628), activities programming (F679), and ensuring that services, including respiratory care, met professional standards (F684, F695). The facility’s Quality Assurance and Performance Improvement (QAPI) program, as documented in an undated policy, described a structure for feedback, data systems, monitoring, and Performance Improvement Projects (PIPs) based on high-volume, high-risk, or problem-prone activities, and input from various data sources such as incident reports, infection control reports, consultant reports, and department head meetings. The policy listed objectives to establish and maintain an ongoing QAPI program, assist departments with performance improvement projects, evaluate results of actions taken, and centralize quality improvement activities. However, the document provided to surveyors was incomplete, ending abruptly after the word “All,” and the last two pages consisted of a QAPI test. Administrator #1 reported not recalling ever doing a Performance Improvement Project or Plan with any individuals in the facility, despite the written QAPI policy describing such activities as part of the facility’s quality program. Interviews further demonstrated instability and inconsistency in facility leadership and administration. Ombudsman #1 reported being in the facility weekly and not seeing the Administrator for extended periods, sometimes a month or more, and stated that the Assistant Administrator was effectively administering the building and was viewed by residents as the actual Administrator. Assistant Administrator #1 stated that Administrator #1 was only periodically in the facility but was accessible by phone and in frequent contact. Administrator #1 stated they became Administrator in August 2025 after the prior Administrator abruptly left, that they owned 9% of the facility, and that they had previously been in the building every other week when the prior Administrator was in charge. Administrator #1 acknowledged that residents might not know they were the Administrator and stated they were unaware of some issues identified during the survey and had not conducted PIPs. The DON, who had been in the building for about a week at the time of interview, stated that the facility “needed revamping” and that they were actively interviewing for a local administrator. Collectively, these observations and statements supported the finding that the governing body did not ensure stable, effective administrative leadership or fully implemented policies and systems necessary to manage operations and maintain regulatory compliance. The deficiencies extended into multiple operational domains, including staffing, pharmacy, dietary, maintenance, and training. Surveyors cited failures to ensure sufficient and competent nursing staff (F725, F726), to provide pharmaceutical services that met residents’ needs (F755), and to ensure physician notes were accurately entered and maintained (F711). Dietary-related deficiencies included failure to provide palatable, attractive food at safe and appetizing temperatures (F804) and to store, prepare, distribute, and serve food in accordance with professional food safety standards (F812). The facility also failed to maintain mechanical, electrical, and patient care equipment in safe operating condition (F908). Training-related deficiencies included failure to develop, implement, and maintain an effective training program for all new and existing staff (F940), failure to include mandatory QAPI training as part of the QAPI program (F944), and failure to provide at least 12 hours per year of in-service training to ensure nurse aide competence (F947). The facility was also cited for failing to submit accurate staffing information based on payroll data to CMS (F851) and for failing to ensure effective QAPI feedback, data systems, and monitoring (F867), as well as for failures related to providing and/or documenting required influenza and pneumococcal immunizations (F883). These findings collectively demonstrated that the governing body had not effectively implemented the policies and oversight necessary to ensure compliance with regulatory requirements across multiple areas of facility operation.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure effective housekeeping and maintenance services, and the environment was not maintained in good repair for two units observed. During survey observations on 2/11/2026, 2/12/2026, and 2/19/2026, room air conditioner/heater units were noted not to be flush with the wall, creating large gaps; in one room, the outside yard was visible through the gap. Broken privacy curtains and broken window curtain rods were observed in multiple rooms, causing the drapery to hang incorrectly. Additional observations included stained bed linens, an air conditioner/heater unit with a broken grate, and a room door that would not close completely and got stuck against the molding. During interviews, a CNA stated that maintenance concerns should be reported to the Maintenance Department. A family member stated they had cleaned a resident’s entire room after the resident was moved there and said the floor was sticky and always was. The Assistant Administrator stated there were multiple external forces that ran the building and that major purchases required authorization from others, including the Director of Procurement. The Director of Maintenance stated they had been sealing gaps around the air conditioner/heater units when found, and when the survey issues were pointed out, said they would take care of them as soon as possible. The Administrator stated they had identified issues they wanted to change and had a major update planned for the building.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that written transfer or discharge notifications were completed and sent to the resident, the resident representative, and the Office of the State Long-Term Care Ombudsman for three residents who left the facility. For Resident #75, who had diagnoses including noninfective gastroenteritis and colitis, chronic idiopathic and slow transit constipation, and type 2 diabetes, a nursing progress note documented transfer to the hospital by EMS due to pain and a distended abdomen, but there was no documented evidence that a transfer/discharge notice was completed or sent. For Resident #86, who had diagnoses including metabolic encephalopathy, Parkinson's disease, and peritoneal abscess, a social work progress note documented a family discussion about discharge against medical advice and that the family signed the appropriate paperwork, but there was no documented evidence that a transfer/discharge notice was completed or sent to the resident, representative, or Ombudsman. An Ombudsman email stated discharge notifications for December 2025 and January 2026 had not been received, and Assistant Administrator #1 stated the facility had not sent discharge notifications since before Christmas 2025 because there was no Social Worker. For Resident #87, who had diagnoses including an unspecified fracture of the head of the left femur, malignant neoplasm of cerebral meninges, and anxiety, a nursing progress note documented that the resident stated they fell and refractured their hip and that family called 911 to take the resident to the hospital, but there was no documented evidence that a transfer/discharge notice was completed or sent.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that comprehensive care plans were revised and updated according to professional standards for four residents reviewed. The facility policy stated that care plans were to be revised when a resident’s condition changed, when the desired outcome was not met, when the resident was readmitted from a hospital stay, and at least quarterly. Surveyors found that the care plans for Residents #1, #11, #75, and #85 were not updated to reflect significant changes in condition or events documented in the record. Resident #1 was admitted with encephalopathy, acute respiratory failure with hypoxia, and pneumonitis due to inhalation of food and vomit. The resident’s MDS dated 1/30/2026 documented cognitive intactness. The care plan for risk for injury related to falls, initiated 1/29/2026, documented that the resident fell twice on 2/08/2026, and one new intervention was added that stated “no description provided,” but there were no other documented interventions updated, changed, or added after the falls. Resident #11’s care plan was not updated to reflect urinary tract infections. Resident #75, admitted with noninfective gastroenteritis and colitis, chronic idiopathic and slow transit constipation, and type 2 diabetes, had a grievance documenting a resident-to-resident altercation in June 2025, but there was no documented evidence that the abuse or risk-for-abuse care plan was revised after the resident was identified as the victim. Resident #85, admitted with CKD stage 3, osteoporosis, and severe dementia, was hospitalized for urosepsis related to a UTI and later readmitted for comfort care, but the comprehensive care plan did not include revised documentation for UTI prevention or the recent hospitalization for urosepsis.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure an ongoing activity program that supported residents’ choices and preferences for one resident who was assessed as severely cognitively impaired. The resident was admitted with diagnoses of metabolic encephalopathy, Alzheimer’s disease, and muscle weakness, and the MDS documented that the resident could usually be understood, sometimes understood others, and was severely cognitively impaired. The care plan, revised 12/01/2025, identified preferences to listen to music and be kept informed about the news, with a goal of passive participation in group activities and 1:1 visits, and interventions included transportation to group activities. During observations on 02/11/2026, 02/13/2026, and 02/24/2026, the resident was seen sitting in a wheelchair near the rehab unit nursing station or outside it with no music playing and no personal interactions. No activity attendance logs were provided, and progress notes from 11/23/2025 through 02/24/2026 did not document 1:1 visits by activities. Staff interviews indicated the resident did not really participate in Bingo or group activities, would go when movies were offered, and that 1:1 time was being provided by nursing staff rather than activities. The new Activities Director stated they had just started, had not been given information about prior activities, did not have EMR access to review resident preferences, and did not know whether 1:1 activities were being done.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that controlled drug records were kept in order, that all controlled substances were accounted for and reconciled at shift change, and that narcotic administration was properly documented. The facility policy required controlled medications to be counted at the end of each shift by the nurse coming on duty and the nurse going off duty, with discrepancies reported to the DON. Another policy required the nurse administering medication to initial the eMAR after giving each medication and before administering the next medication. During observation on 2/18/2026, narcotic sheets on both medication carts on Unit 1 and Unit 2 were noted to not be consistently signed by two nurses at shift change. Reviews of the shift-to-shift narcotic reconciliation forms on Unit 1 front cart #1, Unit 1 back cart #2, Unit 2 front cart #1, and Unit 2 back cart #2 documented numerous missing on-coming and off-going nurse signatures across January and February 2026. In several instances, one nurse signature appeared as both the off-going and on-coming nurse for a shift, but there was no documentation that the nurse was working a double shift. Licensed Practical Nurse #8 did not document administration of lorazepam to Resident #5 at the time it was given. A physician order dated 2/05/2026 directed lorazepam 0.5 mg by mouth twice daily for anxiety and agitation, and the February 2026 MAR showed the 8:00 AM dose was given on 2/18/2026 by LPN #8. During interview, LPN #8 stated the facility process was to sign the narcotic count sheets at the time of narcotic administration. The DON and Administrator stated that the narcotic sheets needed to be signed by two nurses at shift change, but they could not explain why this was not being done.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Surveyors determined that administration failed to ensure compliance with multiple regulatory requirements affecting all residents in the facility, including deficiencies related to resident dignity, notification of providers and resident representatives about changes in condition, a safe and comfortable environment, abuse and neglect prevention, reporting injuries from unknown sources, investigation of allegations of abuse or neglect, discharge and transfer documentation, care planning, activities, professional standards of care, respiratory care, physician note accuracy, staffing, nursing competence, pharmaceutical services, food service, governing body oversight, staffing data submission, QAPI monitoring, immunizations, equipment maintenance, staff training, and nurse aide in-service training. During interviews, the Ombudsman stated they visited weekly except for the prior two weeks and did not see the Administrator, and that they would go a month or more without seeing Administrator #1. The Ombudsman stated Assistant Administrator #1 was administering the building and that residents considered that person the actual Administrator. Assistant Administrator #1 stated Administrator #1 was at the facility periodically but always accessible and that they spoke multiple times a day. Administrator #1 stated they became Administrator in August 2025 after the previous Administrator said they would not return, and that they had no choice but to put their name on the building because they owned nine percent of the facility. Administrator #1 stated that when they took over, they asked the Medical Director and the previous DON whether there were any major infection control concerns and were told no. Administrator #1 also stated that DON #1 would be the answer to many of the issues identified during survey, that they were working on a new formula to track issues, and that they were now at the facility Sunday through Thursday each week. Administrator #1 acknowledged residents might not know they were the Administrator and stated they had been identifying issues where they wanted things to change. DON #1 stated the facility needed revamping and that they were actively interviewing for a local administrator. Administrator #1 further stated they were not aware of some issues identified during survey, needed new processes, and would discuss all issues in morning meetings and afternoon wrap-up while monitoring department heads more closely.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program and failed to develop and implement appropriate plans of action to correct identified quality deficiencies. The survey identified repeat deficiencies in comprehensive care planning and implementation (F656), review and revision of comprehensive care plans (F657), and influenza and pneumococcal immunization documentation (F883), which had also been cited on the prior recertification survey completed on 6/23/2023. The same deficient practices were again found on the current survey. The facility also did not have complete, current, and properly maintained written policies and procedures for QAPI, feedback, data collection systems, monitoring, and adverse event monitoring. Multiple policies provided were undated, unsigned, missing pages, improperly titled, had outdated information, or appeared altered. The Facility Assessment contained conflicting dates and a signature sheet listing prior leadership. The abuse policy was initially provided as a draft and then re-provided without the draft marking, but still without dates or signatures. Other policies reviewed, including those related to incident reporting, smoking, accidents and supervision, admissions, discharge against medical advice, resident condition changes, controlled substances, oxygen administration, grievance handling, medication administration, infection prevention and control, visitation, and role delineation, were also missing required dates, signatures, letterhead, or accurate current information. QAPI committee records showed inconsistencies in required participants, documentation of topics reviewed, and supporting audit forms. Meeting minutes from multiple months listed topics such as MDS review, weight loss, showers, hospitalizations, antibiotics, wounds, dignity, medication pass, discharges, fire drills, generator checks, and environmental audits, but no audit forms were provided for several of the reviewed areas. Attendance sheets included staff who were no longer employed, omitted some required participants, and in some cases had unreadable signatures. Interviews showed that staff had limited understanding of QAPI, incident reporting, and the purpose of the meetings. The Administrator stated they were working on new tracking processes and acknowledged they had not previously done a Performance Improvement Project or Plan with individuals in the facility.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not develop, implement, and maintain an effective training program for all new and existing staff members, including individuals providing services under contract and volunteers, consistent with their expected roles. The facility assessment dated 1/2026 listed required staff training topics such as communication, resident rights, emergency planning, person-centered care, dementia and behavioral management, substance abuse identification, trauma-informed care/PTSD, proper body mechanics, abuse, neglect, exploitation, infection control, culture change, and required in-service training for nurse aides. It also stated that CNA in-service training must total at least 12 hours per year and include dementia management and resident abuse prevention training. Review of five employee education records showed inconsistent and incomplete documentation of required training. CNA #1 had no documented annual training after January 2022, and electronic records showed less than 12 hours of annual education. CNA #5 had sign-in sheets and post-tests, but the documentation did not clearly show completion of all annual training hours. CNA #15 had no documentation showing annual education was received. LPN #1 had only partial documentation of annual education topics, and LPN #12 had no documentation showing annual education was received. Staff interviews showed inconsistent access to and completion of education. One LPN stated education was available on the computer but did not know how to access it, another said overdue assignments were on the electronic system but time was difficult to find to complete them, and another described education being provided through printed sheets and a laptop. A laundry attendant reported receiving only housekeeping and laundry education, not facility-wide topics such as abuse and neglect. A CNA stated they had not received education within the last year and recalled abuse and neglect training about three years earlier, while another CNA said they were unaware of CNA education requirements and had not completed training since hire. The DON and Administrator stated that annual education topics were part of the facility training program and that the facility used an online system to assign and track education, but the records reviewed did not consistently document completion.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that all new and existing staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program as part of its overall education program. During the recertification and extended survey, surveyors reviewed the facility assessment and the QAPI policy and found that the facility assessment listed multiple staff training and competency topics, but QAPI policy and procedures were not included in the required education topics. The QAPI policy, which was undated, also did not document a requirement that staff be educated on the QAPI policy. Record review of five employee files showed that required annual education was not consistently completed or documented. A CNA file showed no documented evidence that annual education had been completed after 1/09/2022, and the electronic record showed less than 12 hours of annual education. Another CNA file contained multiple sign-in sheets and posttests, but it could not be determined whether all required annual education had been completed, and the electronic record also showed less than 12 hours completed. A third CNA file had no evidence of annual education except for a written statement about verbal education related to an incident, and no education topics were listed in the electronic record. An LPN file showed no documented annual education since 2022 except for one posttest and part of an untitled answer sheet, and the electronic record showed only two of ten education topics completed for 2025. Another LPN file showed no documented annual education since 2024, and the electronic record showed only one of six education topics completed for 2025. Interviews with facility leadership and staff showed that education practices were inconsistent and dependent on who was available. An assistant administrator stated that education was often done on the spot when needed, that education stopped for a period during staff changes, and that records from the prior ADON could not be found. A nurse stated they knew they had overdue education in the electronic system and were unsure whether they had received QAPI teaching. The DON stated education was a priority and identified several required annual topics, while the administrator stated the online education system tracked required hours and that house-wide education included topics such as fire safety, resident rights, abuse, and oxygen control. The report also states that QAPI was not part of nursing education.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures for three of three meals reviewed. During a lunch tray sampling for one resident on 02/13/2026, the resident’s lunch tray required replacement, resulting in a 32‑minute wait from the time of request. Temperature checks of that tray showed coffee at 119.3°F, whole milk at 49.1°F, seafood casserole at 125.5°F, California blend vegetables at 122.2°F, and chocolate cake at 68.5°F. During a breakfast tray sampling on 02/17/2026 for another resident, a replacement tray was also required, and temperatures were recorded as follows: water for tea 144.1°F, whole milk 53.2°F, orange juice 56.1°F, hot cereal 136.9°F, sausage patty 102.0°F, toasted bagel 85.6°F, and cream cheese packets at 41.1°F and 41.5°F. During a lunch tray sampling on 02/17/2026 for a third resident, the tray again required replacement, and temperatures were recorded as: water for tea 140.7°F (with the tea bag missing), apple juice 64.9°F, cranberry juice 64.2°F, Philly steak on bun with peppers, onions, and cheese sauce casserole 128.5°F, mixed vegetables 124.9°F, bow tie noodles 110°F (noted to be underprepared with no sauce), cottage cheese 49°F, and assorted fruit 64.2°F, with the canned oranges noted to be sour to taste. Interviews supported ongoing concerns with food quality and temperature. One resident stated that the food was horrible and delivered cold most of the time, and another resident reported that meals were always cold and that they were the last one on the list for food delivery. A family member described the food as gross. A dietary aide reported responsibilities including tray setup and ensuring items matched meal tickets, noted that requested substitutions were being highlighted, and stated that replacement meals normally took 3–4 minutes to prepare and deliver, while also indicating staffing was usually limited and that the cook tested food temperatures before delivery. A CNA stated that lunch was usually brought to the unit around 12:30 PM, that residents always complained about food not matching meal tickets, and gave an example of a resident missing oatmeal from their tray; they reported that if items were missing, they would call or go to the kitchen to obtain them, and at 12:55 PM on one day, lunch had still not been delivered to the unit. The administrator stated they checked that food arrived to residents and that temperatures were taken randomly.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to store and prepare food in accordance with professional standards and its own Food Receiving and Storage policy. During kitchen tours, one of four thermometers tested in an ice water bath was found out of calibration, reading 37°F instead of the acceptable 32°F. In the walk-in refrigerator, open bags of pepperoni and hot dogs were found without dates, and in the walk-in freezer, open bags of chicken, green beans, sausage patties, and egg patties were also undated. In dry storage, eight bags of English muffins labeled by the manufacturer to be stored frozen were found on shelves instead of in the freezer; all were undated and four bags had visible mold. In second floor kitchenettes, multiple bowls of dry cereal were stored in cabinets without any dates or times labeled. Additional observations showed potential for contamination of food products and improper storage of non-food items in food service areas. Two of five kitchen staff working in the food preparation area were not wearing required hair protection. A bottle of drain cleaner was found improperly stored in the food service area, and clean/dry rags were stored at floor level in an overfilled small garbage can. The facility’s undated Food Receiving and Storage policy requires that all food stored in refrigerators or freezers be covered, labeled, and dated, but the Food Service Director acknowledged awareness that the unlabeled food in the walk-in refrigerator, freezer, and unit kitchenettes should have been dated and was unable to explain why it was not. The Food Service Director also stated they were unaware that the English muffins were required to remain frozen and that someone else must have unpacked them.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that residents received necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, as reflected in failures involving bowel management, infection evaluation and treatment, and resident activities. Survey findings identified three residents affected by these issues, along with observations and interviews showing that residents in common areas were not receiving meaningful activities and that difficult residents were excluded from group activities. An LPN stated that activities were poor, that activity aides were not trained to deal with residents, and that a resident’s scheduled iPad calls to family had only occurred about three times. Resident #75 had diagnoses including chronic idiopathic constipation and slow transit constipation, and the MDS documented moderate cognitive impairment. After returning from the hospital for severe constipation, the facility did not ensure close monitoring of bowel movements, routine abdominal assessments when there was no bowel movement, administration of PRN bowel medications per orders and policy, or reporting of bowel status to the provider. The record states the resident was sent to the hospital on 1/9/2026 and diagnosed with severe sepsis due to proctocolitis. The facility also did not ensure notification to the provider when there was no bowel movement in greater than 24 hours, routine abdominal assessments, and administration of PRN bowel medications, and the resident was later sent to the hospital on 2/17/2026 with severe fecal impaction requiring fecal disimpaction under anesthesia. Resident #85 had severe dementia, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease, and the MDS documented severe cognitive impairment. A nurse practitioner note documented family concern for a UTI and a plan to consider urinalysis, and provider orders later directed urine analysis and culture and sensitivity. The resident was sent to the emergency room shortly after, with nursing documentation describing lethargy and dark red urine obtained by straight catheterization. The hospital discharge summary documented septic shock secondary to UTI. Resident #87 had diagnoses including a left femur fracture, malignant neoplasm of cerebral meninges, and anxiety, and the MDS documented that the resident was independent with making decisions regarding tasks of daily living. After a fall during rounds, nursing documented that the resident was assessed, had stable vital signs, denied pain and head strike, and the family was notified. The next morning, the resident stated they had refractured their hip and had been in bed all shift; the family called 911 and the resident was taken to the hospital. A physician note documented that the on-call provider was not notified prior to the transfer.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure physician/provider notes were entered and maintained accurately for 10 of 10 residents reviewed. The deficiency involved multiple erroneous electronic medical record entries, including the same provider encounter note by Medical Director #1 appearing in the charts of Residents #4, 13, 31, 33, 34, 53, 72, 75, 80, and 90. The report also identified a provider visit note for Resident #33 that was mistakenly placed in Resident #13’s record and a provider encounter note for Resident #75 that was not signed until several months after the documented visit. Resident #13 was admitted with Wernicke's encephalopathy, schizoaffective disorder, bipolar type, and adult failure to thrive. The MDS dated 01/29/2026 documented the resident could be understood, understood others, and was cognitively intact. A provider encounter note in Resident #13’s record documented a routine visit, described the resident as resting comfortably, attending meals, and participating in social activities, and noted no abnormalities on review of systems. Another provider encounter note dated 12/17/2025 in Resident #13’s record was actually for Resident #33 and was signed on 01/04/2026. Resident #34 had diagnoses of dementia, parkinsonism, and age-related physical debility, and the MDS documented severe cognitive impairment. Resident #75 had diagnoses of noninfective gastroenteritis and colitis, chronic idiopathic constipation, and slow transit constipation, with the MDS documenting moderate cognitive impairment. The same routine provider encounter note by Medical Director #1, describing a resident resting comfortably, attending meals, participating in activities, and having no abnormal findings after a witnessed fall from a chair, appeared in multiple residents’ records. The report also states that a provider encounter note for Resident #75 dated 11/13/2025 was not signed by Nurse Practitioner #1 until 01/12/2026.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to notify resident representatives of significant changes in residents’ status, as required by facility policy and 10 NYCRR 415.3(e)(2)(ii)(a). The facility’s written policy, “Change in a Resident Condition or Status” (revised 12/2019), required licensed nursing staff to promptly notify the resident’s representative whenever the resident was involved in any accident or incident, or when there was a significant change in the resident’s physical, mental, or psychosocial status. Surveyors determined that this notification did not occur for two residents following events that met the facility’s own criteria for required notification. For one resident with diagnoses including hematuria, overactive bladder, difficulty walking, and moderate cognitive impairment, a nursing progress note documented that on 8/05/2025 the resident self‑reported a fall to a CNA, who informed the nurse. The nurse then notified the nurse practitioner and assessed the resident, identifying a skin tear on the top of the right hand. However, there was no documentation in the nursing progress notes that the resident’s representative was notified of this self‑reported fall with injury. During interview, the assistant administrator confirmed there was no documentation that the family had been notified of the fall. For another resident with diagnoses including noninfective gastroenteritis and colitis, chronic idiopathic constipation, and slow transit constipation, and with moderate cognitive impairment, a grievance form dated 6/28/2025 documented that a family member reported a complaint that another resident had entered the resident’s room during the night of 6/22/2025–6/23/2025, yelled at the resident, and dumped water from a refillable water bottle onto them. The grievance described that the resident felt shaky, scared, and unsafe when seeing the other resident and requested that the other resident be moved. The grievance form lacked documentation of who received the grievance, whether further investigation was required to rule out abuse/neglect, and any investigation or follow‑up details, although it did note that the complainant was notified of actions taken and was satisfied. There was no documentation in the nursing progress notes that the resident’s representative was notified of the resident‑to‑resident verbal/physical altercation during the night shift, and the family member later stated in interview that no one from the facility had reported the incident to them and that they learned of it directly from the resident.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect residents from abuse and neglect and to respond appropriately to allegations and incidents involving two residents. One resident with moderate cognitive impairment reported that another resident with severe cognitive impairment entered their room during the night, verbally harassed them, and poured water from a refillable water bottle onto them. The resident yelled for help, but no staff responded, and the resident ultimately called 911. The 911 dispatcher then contacted the facility, prompting staff to enter the room. The resident later told a family member they felt shaky, scared, and remained afraid when they saw the other resident. The family member filed a grievance describing the incident and requesting that the aggressor be moved to another unit. The grievance form documenting this incident was incomplete. The section identifying the staff member who received the grievance was left blank, as were the sections indicating whether the grievance required further investigation and the investigation/follow-up to the complaint. Although the form noted that the complainant was notified of actions taken and was satisfied, there was no documented evidence of an investigation of the incident, no nursing progress notes describing the altercation or post-incident assessments for either resident, and no care plan interventions to prevent recurrence of abuse for either resident. The facility was unable to provide documentation that the incident was reported to the state health department. Key leadership staff, including the assistant administrator, current administrator, and current director of nursing, reported they were not notified of the incident and could not locate an incident report or investigation. The second deficiency concerns a different resident who had a history of a left femur fracture, malignant neoplasm of the cerebral meninges, and anxiety, and who was independent in decision-making. An incident report documented that this resident was found on the floor during rounds and stated they had fallen while trying to close their door; a licensed nurse assessed the resident, who reportedly denied pain and head injury, had stable vital signs, and the family was notified. However, the resident later told staff they believed they had re-fractured their hip and called their family to request hospital evaluation. The family member reported receiving multiple calls from the resident stating no one was attending to them, that the resident had lain on the floor for about an hour before being put back to bed, and that when the family called the nurses’ station, an unnamed staff member said the resident was lying and hung up. The family member further reported that staff then entered the resident’s room and yelled at the resident for calling their family and lying about falling, after which the family called 911 for hospital transfer. Communication and reporting failures contributed to the neglect finding for this second resident. The LPN on the night shift stated they were not informed by the prior-shift LPN that the resident had fallen, and only heard from CNAs that the resident “had fallen” without clear confirmation. When the family member called about the fall, the night-shift LPN did not know what they were referring to because they had not been told of the incident. The on-call provider was not notified before the resident’s transfer to the emergency department, and there was no documented evidence that the medical director was made aware of the resident’s experience. The DON stated that, in the event of a fall, they would expect a thorough investigation, completion of an incident report, documentation in the electronic health record, and family notification, and that such events should be reviewed in morning report. The administrator acknowledged there were issues with documentation and staff understanding of processes for adverse events and reporting, underscoring the facility’s failure to ensure the resident was free from neglect.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain mechanical and patient care-related equipment in safe operating condition when the self-closing device on the walk-in freezer door was not functioning as intended. During an observation conducted on 2/17/2026 at 11:00 AM, surveyors noted that the self-closing mechanism on the main entry door of the walk-in freezer was inoperable and did not pull the door closed to ensure a tight seal. In a subsequent interview on 2/17/2026 at 2:00 PM, the Food Service Director stated that an outside company had been at the facility several days earlier and had left several items, including this mechanism, in disrepair, and acknowledged the need to contact them to have the issue addressed. This deficiency was cited under 10 New York Codes, Rules, and Regulations 415.5(e)(1)(2), which requires that all mechanical, electrical, and patient care equipment be maintained in safe operating condition.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that nurse aides received at least 12 hours of annual in‑service training, including dementia care and abuse prevention, as required by regulation and the facility’s own assessment. Record review showed that 11 of 14 CNAs did not complete the minimum required hours or topics. The facility assessment dated 1/2026 specified that nurse aide in‑service training must be no less than 12 hours per year and include dementia management and resident abuse prevention, as well as topics such as communication, resident rights, emergency planning, person‑centered care, behavioral management, substance abuse identification, trauma‑informed care, body mechanics, infection control, and culture change. It also stated that training should address areas of weakness identified in performance reviews and the facility assessment. Education records and in‑service sign‑in sheets demonstrated that multiple CNAs fell short of these requirements. One CNA hired in 2013 completed 7 of 11 required electronic topics totaling 4 of 7.5 hours and attended 5 in‑service trainings in 2025, while another hired in 2017 completed only 3 of 11 topics totaling 2.5 of 7.5 hours and attended 1 in‑service. Other CNAs hired between 1984 and 2024 showed similar shortfalls, such as completing only 3–6 of 8–14 required electronic topics and accumulating between 2.5 and 6 hours of electronic education, with 0–2 in‑service sessions attended in 2025. Several CNAs had no in‑service attendance documented for the year. The facility was unable to provide evidence that these CNAs had received the full 12 hours of mandatory annual training, including dementia and abuse content. Interviews with administrative and nursing staff revealed inconsistent responsibility and follow‑through for the education program, contributing to the deficiency. The assistant administrator stated that the nurse educator role typically belonged to the ADON, and that RN staff had been “filling in,” with on‑the‑spot education occurring as needed. Staff reported that online education was done through an electronic system, but that education had stopped for a period during management changes, and that reminders were not consistently generated or posted. One LPN stated they did not know how to access the computer‑based education, and another acknowledged having overdue electronic education. The acting DON stated they did not do education, and the new DON and administrator both acknowledged that the education process lacked structure, that responsibilities had shifted with staff turnover, and that they were unclear or mistaken about the exact annual hour requirements for CNAs. These actions and inactions resulted in the facility’s failure to ensure sufficient, documented annual in‑service training for the affected CNAs.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure Resident #52 and/or the resident’s designated representative received timely notice of the termination of Medicare Part A skilled services and the required information about appeal rights and potential financial liability. The record showed the resident’s current skilled services were to end on 9/06/2025, but the Notice of Medicare Non-Coverage and the Advance Beneficiary Notice of Non-Coverage were not signed by the resident or representative at that time. Instead, both forms were signed by Acting Director of Nursing #1 on 9/15/2025, and the forms contained handwritten notes that the Acting DON spoke with the resident’s family member/spouse and provided the business office contact information. Facility policy required the NOMNC to be delivered at least two calendar days before the last covered day of skilled services and the ABN to be issued before providing non-covered services, with signatures documenting receipt or refusal. During interview, Acting Director of Nursing #1 stated the forms are typically completed two days before the resident’s last covered day and acknowledged there was no documentation showing the spouse was spoken to before 9/15/2025 regarding these forms. The Acting DON stated the spouse should have been notified about signing the forms by 09/04/2025, but the record did not show that this occurred.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #43 did not receive respiratory care according to the facility’s documented orders and policy for continuous positive airway pressure (CPAP) use. The resident was admitted with obstructive sleep apnea, diabetes mellitus type 2 with hyperglycemia, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The Minimum Data Set dated 10/01/2025 documented that the resident could usually be understood and usually understood others with intact cognition. The physician’s orders dated 10/18/2025 directed staff to clean the CPAP tubing every morning, empty and air dry the water chamber every morning, fill the chamber with distilled water before turning on the machine, clean the mask daily, and apply the CPAP at bedtime with a setting of 12-20 cm water. Survey observations found the resident’s CPAP machine on the nightstand on multiple dates with the tubing and mask attached, dry, and not covered with a protective bag. Review of the electronic Treatment Administration Record showed no documented evidence that the CPAP water chamber was filled on 01/11/2026, 01/12/2026, or 01/23/2026, and no documented evidence that the CPAP device was placed on the resident at bedtime on those dates. The record also showed no documented evidence of cleaning the CPAP mask on 02/01/2026 or 02/06/2026, and no documented evidence of cleaning the CPAP tubing on 02/01/2026 or 02/06/2026. The comprehensive care plan reviewed 01/15/2026 contained no documented respiratory care plan, and there was no documented provider order for daily removal of the CPAP machine, oxygenation monitoring, or staff education or training for CPAP use.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that complete and accurate direct care staffing information was electronically submitted to CMS based on payroll and other verifiable and auditable data. During the recertification survey, payroll data submitted to CMS for Fiscal Quarter 4 (July 2025 through September 2025) showed less than eight consecutive hours of RN coverage on multiple dates, and no RN hours were documented on several dates. Review of timecards and internal facility reports showed that the submitted data did not capture hours worked by the DON. During interviews, the Human Resources Director stated they began in August 2025, did not submit the data to CMS, and verified staff punch cards before sending them to the Director of Payroll. The Human Resources Director later compared timecard punches with the Job Title Report and found that the dates with less than eight hours were missing hours by the DON. The Director of Payroll stated the payroll data was submitted through the portal in a zip file and accepted, but they did not review the timecards and could not explain why the DON's hours were not captured. The Administrator stated the issue with the Job Title Report must have been on CMS's side and did not believe there was a problem with the submission.

Penalty

Fine: $118,415

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that Resident #25 was offered pneumococcal and influenza immunizations or that the resident or resident representative received education about the benefits and potential side effects of those vaccines. Record review showed no documented evidence that the resident was offered, declined, or educated regarding the pneumococcal or influenza immunizations, either before or after admission. The resident was admitted with diagnoses including periprosthetic fracture around an internal prosthetic hip joint, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and unspecified fall. The [NAME] Data Set dated 1/27/2026 documented that Resident #25 was usually able to understand others and be understood, but was significantly cognitively impaired. The immunization record showed the resident received dose #1 of the Mantoux tuberculin skin test on 10/23/2025 with a negative result, and dose #2 on 11/01/2025 with results pending. The facility admission policy required the nurse to record immunization history, required immunizations, and tuberculosis testing in the resident record. During interviews, the Administrator stated immunizations were tracked through an electronic report, that refusal should be documented, and that education about the risks of refusal should be in the medical record, but no documentation for the pneumococcal or influenza vaccines was found for this resident.