Sands Point Center For Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Port Washington, New York.
- Location
- 1440 Port Washington Blvd, Port Washington, New York 11050
- CMS Provider Number
- 335022
- Inspections on file
- 14
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Sands Point Center For Health And Rehabilitation during CMS and state inspections, most recent first.
Insufficient weekend nursing staffing was identified across multiple units after PBJ data showed excessively low weekend staffing for several quarters. The facility assessment required specific RN/LPN and CNA coverage on each shift, plus an RN supervisor on weekends, but staffing schedules showed repeated shifts with fewer CNAs than required and at least one shift with no nurse on a unit. The Staffing Coordinator, DON, and Administrator all acknowledged ongoing weekend staffing shortages, frequent call-outs, retention problems, and use of the RN supervisor or reassignments to cover gaps.
Infection control program deficiencies were cited because the facility did not document testing of all portions of the potable water system for Legionella and other waterborne pathogens. The water management plan and related engineering policy lacked a full description of the water distribution systems, flow diagrams, and identified Legionella sampling points, and staff stated the cold-water potable system had not been tested.
Two residents with cognitive impairment and behavioral risk factors were involved in an altercation after one became visibly annoyed when another entered the dining area. A CNA escorted the second resident back to their room but did not inform nursing staff or arrange for monitoring, allowing the resident to wheel themself back to the dining room and re-approach the first resident. While the CNA was occupied on the other side of the room, the first resident became angrier and struck the second resident on the head with an empty meal tray, resulting in an incident that facility leadership later acknowledged could have been prevented with closer supervision and communication.
A resident with gastrostomy, esophageal cancer, and dysphagia had a PEG tube and received tube feeding during the assessment period, but the admission MDS did not indicate the feeding tube in Section K. The Dietician said the omission was an error, the MDS nurse said signing Section Z only verified completion, and the DON stated the assessment should have accurately reflected the resident’s feeding tube status.
Significant medication error involving crushing of extended-release metoprolol. An LPN crushed multiple medications for a resident with HTN, HF, and DM, including an extended-release metoprolol succinate tablet labeled to swallow whole and not crush. The resident had no current order to crush medications, and the DON, physician, and pharmacist all confirmed the extended-release tablet should not have been crushed.
Unlabeled tube feeding and IV solution bags were observed for two residents. A resident receiving continuous enteral feeding had a feeding bottle without the required resident and administration details, and an RN acknowledged the label was forgotten. Another resident receiving IV hydration had an IV bag without resident identification or start date/time on two observations, and staff stated the label should have included the resident’s name, room number, medication information, and start time.
Incomplete documentation of PRN oxygen administration. A resident with COPD, CVA, seizure disorder, and severe cognitive impairment had an order for oxygen at 2 L/min via NC as needed to keep O2 saturation above 90%. Surveyors observed the resident receiving oxygen on multiple occasions, but the MAR/TAR had no nursing signatures showing the PRN oxygen was administered. Staff stated the oxygen was applied when the resident became short of breath and desaturated, but it was not documented as required.
The facility failed to maintain adequate staffing levels, as outlined in their assessment, leading to a 1-star staffing rating and resident complaints. CNAs were often responsible for more residents than the facility's plan allowed, resulting in missed showers and delayed meals. Staff and administration acknowledged the staffing shortages, citing high turnover and callouts as contributing factors.
A resident at risk for pressure ulcers was not provided with a comprehensive care plan, as they were observed without physician-ordered heel boots. The CNA was unaware of the requirement, and the resident had not worn the boots for months due to discomfort. The refusal was not documented or reported, and alternative measures were not explored until after the deficiency was identified.
Two residents with pressure ulcers in an LTC facility were found to have their alternating pressure relief air mattresses set inaccurately according to their weights, contrary to physician's orders. Despite the facility's policy requiring nurses to monitor and adjust the settings every shift, staff failed to do so, leading to inadequate care. Interviews revealed a lack of awareness among nursing staff about the importance of correct weight settings.
The facility failed to maintain a safe environment for three residents. A resident with impaired cognition had a Symbicort inhaler at their bedside without proper assessment for self-administration. Another resident had unauthorized cleaning supplies in their room, and a third resident with severe cognitive impairment had an unsecured oxygen tank next to their bed. These incidents highlight a lack of adherence to facility policies and supervision, posing potential risks to resident safety.
A resident with moderately impaired cognition was found with a Symbicort inhaler at their bedside, contrary to facility policy and physician's orders requiring medications to be stored in locked compartments and administered by nursing staff. Observations and staff interviews confirmed the inhaler should have been stored in the medication cart, highlighting a failure in medication storage protocols.
A deficiency in infection control was identified when a nurse failed to perform hand hygiene and allowed a cleansed wound to contact a dirty surface during wound care for a resident with a heel ulcer. The nurse did not seek assistance to hold the resident's leg, leading to improper wound care practices, as confirmed by the infection preventionist and DON.
The facility's assessment failed to document the necessary nursing staff resources for competent resident care. The staffing plan lacked details on the number of LPNs and RNs per shift and incorrectly calculated CNA numbers based on fewer beds than the facility's capacity. The Administrator acknowledged these omissions during an interview.
Insufficient Weekend Nursing Staffing
Penalty
Summary
The facility did not ensure sufficient nursing staff were available to provide nursing and related services to meet resident needs and maintain resident safety. The deficiency was identified on all five units reviewed for the Sufficient Nursing Staffing Task: Unit 1 Center, Unit 1 North, Unit 1 West, Unit 2 Center, and Unit 2 West. The Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report showed the facility triggered for excessively low weekend staffing for Fiscal Year 2025 Quarter 1 through Quarter 4 and Fiscal Year 2026 Quarter 1. The facility assessment last reviewed on 12/04/2025 documented a bed capacity of 180 and an average daily census of 138.4. For weekend staffing, the assessment required specific RN or LPN and CNA coverage on each unit for day, evening, and night shifts, and also required an additional RN Supervisor on each weekend shift. However, a review of staffing schedules from 10/05/2024 through 12/28/2025 showed multiple shifts where units were staffed below the assessed CNA requirements, including instances where only two CNAs were assigned on units that required three to four CNAs, and instances where only one CNA was assigned on night shift units that required two CNAs. The report also noted one occasion where the RN Supervisor covered Unit 1 Center and there was no nurse on Unit 2 West. During interviews, the Staffing Coordinator stated the facility had low weekend staffing over the past year, especially with CNAs, and that they tried to staff four CNAs per unit but at least three should be assigned if there were staffing problems. The DON stated staff called out frequently, retention had been a concern, and when weekend staffing was short the RN Supervisor sometimes covered unit nursing needs, including an instance where a nurse was moved from Unit 1 North to Unit 2 West, leaving Unit 1 North with only one RN even though it was a subacute unit requiring two nurses each shift. The Administrator stated the facility had longstanding nurse staffing shortages and weekend coverage concerns related to transportation access and staffing availability.
Infection Control Program Lacked Complete Water Management Documentation
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and help prevent the development and transmission of communicable diseases and infections. During the Infection Control Task, surveyors found that the facility did not provide documented evidence of testing all portions of the potable water system for Legionnaires' and other waterborne pathogens, and it also did not provide documents describing the building's water distribution systems to identify Legionella sampling points. The facility's undated Engineering & Facilities policy titled Section: Engineering Management Subject: Legionella Tessing did not document a description of the water distribution systems in the building, did not include a flow diagram of the water distribution systems, and did not identify Legionella water sampling points. The Laboratory Certificate of Analysis showed water samples were collected from four hot water sinks and reported no Legionella isolates, but there was no documented evidence that the facility identified other areas with a high probability of opportunistic pathogens in the building's water distribution systems. During interviews, the Director of Plant Operations and Environmental Services stated they were not aware of testing the cold-water potable water distribution system and that the water management plan would be amended to identify additional sampling points and include a description and flow diagrams of the water distribution systems. The Administrator also stated the current Water Management Plan would be reviewed and revised to include a full description of the water distribution systems with flow diagrams and additional Legionella sampling points.
Failure to Adequately Supervise Residents Leading to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevention of accident hazards during an interaction between two residents in the dining/dayroom. One resident with Alzheimer’s disease, major depressive disorder, anxiety disorder, severely impaired cognition (BIMS score of 7), and a history of agitation and verbal outbursts entered the dining room where another resident was present. The second resident had a traumatic brain injury, seizures, hemiplegia of the left dominant side, moderately impaired cognition (BIMS score of 12), and was care planned as being at risk of being abused or mistreated by others and having the potential to abuse or mistreat others, with interventions including monitoring mood and providing early intervention on changes observed. Both residents used wheelchairs for locomotion. On the day of the incident, CNA #3 was monitoring the dining/dayroom shortly before 5:45 PM when the resident with traumatic brain injury appeared annoyed or upset upon the entry of the resident with Alzheimer’s disease. In response, CNA #3 escorted the resident with Alzheimer’s disease back to their room and then immediately returned to the dining room. CNA #3 did not notify the nurse or another CNA that the resident with traumatic brain injury was upset with the other resident, nor did they arrange for monitoring of the resident who had been redirected to their room to ensure they did not return to the dining room. Shortly afterward, the resident with Alzheimer’s disease wheeled themself back to the dining/dayroom and approached the table of the resident with traumatic brain injury. At that point, the resident with traumatic brain injury became angrier, picked up an empty meal tray, and struck the other resident on the head. CNA #3 was present in the dining room but was on the other side of the room assisting another resident and was unable to intervene in time to prevent the altercation. The resident who was struck was assessed and had no visible injuries, and the physician was notified. The other resident was sent to the hospital for evaluation and returned the next day with no recommendations. Facility leadership stated that the incident could have been prevented if the resident who had been redirected had been closely supervised or if staff had been informed of the potential for an altercation between the two residents.
MDS Did Not Accurately Reflect Feeding Tube Status
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to complete an admission MDS that accurately reflected a resident’s status. Resident #1 was admitted with diagnoses including gastrostomy, malignant neoplasm of the esophagus, and dysphagia, and had a PEG tube placed prior to the admission assessment period. The admission MDS documented a BIMS score of 8, indicating moderate cognitive impairment, but did not indicate that the resident had a feeding tube while in the facility. The record showed the resident had a PEG tube and received tube feeding during the assessment period, including physician’s orders for Jevity 1.5 via PEG tube with water flushes. A hospital and community patient review instrument documented the PEG tube placement, and care plans referenced the gastrostomy tube and tube feeding. During interviews, the Dietician stated Section K of the admission MDS should have indicated the feeding tube because the resident had one during the assessment period, and the omission in K0502 was an error. The MDS Assessment Nurse stated they signed Section Z only to verify completion, not the accuracy of each section, and the DON stated each staff member completing MDS sections is responsible for accuracy and the assessment should have reflected the feeding tube.
Significant Medication Error Involving Crushing of Extended-Release Metoprolol
Penalty
Summary
Resident #15, who had diagnoses including hypertension, heart failure, and diabetes mellitus, was observed during medication administration with a BIMS score of 11 and no documented swallowing disorder on the MDS. The resident had an order for a regular diet with thin liquids and no current physician’s order to crush medications. During the medication pass, an LPN prepared aspirin, Januvia, Lasix, metoprolol succinate extended-release, and potassium chloride extended-release for the resident. The LPN stated the resident had trouble swallowing and diluted the potassium chloride tablet in water, then crushed the other tablets together in a plastic bag with a pill crusher, including the extended-release metoprolol succinate tablet, despite the blister pack directions stating to swallow whole and not chew or crush. The crushed medications were placed in applesauce and administered to the resident, and the diluted potassium chloride was given in water. The record review confirmed there was no physician’s order in place to crush medications at the time of administration. During interviews, the LPN acknowledged the metoprolol succinate label said not to crush it, the DON stated there should have been a physician’s order and that the extended-release metoprolol succinate should not be crushed, and the physician stated the order to crush medications should have been in place before crushing occurred. The pharmacist stated crushing the extended-release metoprolol succinate changes its mechanism of action and causes the medication to be released at once.
Unlabeled tube feeding and IV solution bags
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles for two residents receiving tube feeding and intravenous hydration. The report identified that a resident with diagnoses including cerebrovascular accident, seizure disorder, and dysphagia, and with severe cognitive impairment, was receiving continuous Osmolite 1.5 tube feeding when the feeding bottle was observed without the resident’s name, room number, start time, flow rate, or the name of the nurse who started it. The facility policy for ready-to-hang feedings required complete labeling information, including resident name, room, date, start time, and rate. During observation, the tube feeding pump showed a flow rate of 55 milliliters per hour and formula remained in the bottle, but the bottle itself had no resident label. The unit manager stated the bottle should have been labeled with the resident’s identifying information and feeding details, and the medication nurse acknowledged forgetting to place the label on the bottle after starting the feeding. The Director of Nursing Services stated the nurse must place a resident label on the tube feeding bottle to ensure the right resident receives the right formula, rate, and volume. A second resident with diagnoses including anemia, adult failure to thrive, and heart failure, and with severe cognitive impairment, had an order for Dextrose 5% and 0.45% sodium chloride intravenous solution at 30 cc per hour. On two separate observations, the IV bag was infusing through a midline catheter but had no label showing resident information or the date and time the solution was initiated. The nurse stated the bag should have been labeled with the resident’s name and room number and acknowledged that the start date and time were not always indicated, while the unit manager and DON stated the IV label must include the resident’s name, room number, medication information, and start date and time.
Incomplete Documentation of PRN Oxygen Administration
Penalty
Summary
Medical records were not maintained in accordance with professional standards because the facility did not document administration of as-needed oxygen for one resident. The resident had diagnoses including cerebrovascular accident, seizure disorder, and chronic obstructive pulmonary disease, and the quarterly MDS documented severe cognitive impairment with a BIMS score of 5. The resident also had shortness of breath when lying flat and received oxygen therapy while in the facility. A physician’s order dated 01/22/2026 directed oxygen at 2 liters per minute via nasal cannula as needed, with oxygen saturation to remain greater than 90%. During observations on 03/09/2026, 03/10/2026, and 03/11/2026, the resident was seen receiving oxygen via nasal cannula, and the concentrator was set at 2 liters per minute during at least two of those observations. Review of the March 2026 Treatment Administration Record showed no nursing signatures documenting that the as-needed oxygen had been administered for that month. During interviews, the unit manager stated oxygen had been applied that morning because the resident became agitated, short of breath, and had an oxygen saturation of 88%, but there was no chance to document it. Staff Development and the DON stated nurses should sign off in the treatment administration record and document when oxygen therapy is administered.
Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by a 1-star staffing rating and numerous complaints from residents about short staffing. The facility's staffing plan outlined specific ratios for Certified Nurse Aides (CNAs) during different shifts, but these ratios were not consistently maintained. For instance, during the night shift, the facility assessment required a ratio of one CNA to 13 residents, but records showed instances where one CNA was responsible for up to 36 residents. Similarly, during the day and evening shifts, the required ratio of one CNA to eight residents was often exceeded, with CNAs sometimes caring for up to 17.5 residents. Interviews with staff and residents further highlighted the impact of short staffing. Residents reported missing showers and receiving bed baths instead, and meals were delayed, resulting in cold food. CNAs described being overworked and unable to provide timely care due to the high number of residents assigned to them. The facility's staffing coordinator and Director of Nursing Services acknowledged the staffing shortages, attributing them to high staff turnover and frequent callouts, which left the facility unable to maintain the staffing levels outlined in their assessment. The facility's administration, including the Administrator and Director of Nursing Services, recognized the ongoing staffing challenges. They noted that the facility struggled with recruiting and retaining staff, which contributed to the inability to meet the required staffing ratios. Despite efforts to manage the situation, such as the Director of Nursing Services stepping in to assist with care, the facility continued to operate with insufficient staff, compromising the quality of care provided to residents.
Failure to Implement Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was implemented for a resident at risk for developing pressure ulcers. Resident #86, who had a history of Diabetes Mellitus, Cerebrovascular Accident, and Hemiplegia, was assessed to be at risk for pressure ulcers and had physician orders to wear protective heel boots while in bed. However, the resident was observed multiple times without the heel boots, and the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of the requirement. The resident stated they were not informed about the heel boots and had not worn them for months, citing discomfort as the reason for refusal. The CNA did not report the resident's refusal to wear the heel boots to the Registered Nurse (RN) or document the refusal in the resident's medical record. Consequently, the care plan was not updated to reflect the resident's needs or preferences, and alternative measures for offloading the heels were not explored until after the deficiency was identified. The Director of Nursing Services acknowledged that staff should have consulted with the physician and rehabilitation department for alternative solutions when the resident expressed discomfort with the heel boots.
Inaccurate Air Mattress Settings for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for two residents who were using alternating pressure relief air mattresses as per physician's orders. For Resident #126, the air mattress was not set accurately according to the resident's weight, which was 157 pounds, but the mattress was set at 305 pounds. This discrepancy was observed on multiple occasions, and the responsible nurses did not verify the weight setting, merely signing off on the electronic medical record without proper checks. Resident #124, who had an unstageable right hip pressure ulcer, also experienced similar issues with the air mattress settings. The resident's weight was recorded as 166 pounds, yet the air mattress was set at 325 pounds. Nurses documented that the mattress was functioning properly without ensuring the weight setting was correct. Interviews with nursing staff revealed a lack of awareness and understanding of the importance of setting the air mattress according to the resident's weight. The facility's policy required nurses to monitor the air mattress every shift and ensure it was set correctly according to the resident's weight. However, interviews with the Director of Nursing Services and other staff indicated that this was not being done, leading to the deficiency. The failure to adhere to the policy and physician's orders resulted in inadequate pressure ulcer care for the residents involved.
Failure to Maintain a Safe Environment Free from Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. Resident #140, who had moderately impaired cognition and was receiving oxygen therapy, was found with a Symbicort inhaler at their bedside. The resident was not assessed or care planned to self-administer medications, and the inhaler was supposed to be stored in the medication cart and administered by nursing staff. Despite this, the resident self-administered the inhaler and informed the nurse afterward, indicating a lack of supervision and adherence to the facility's medication policy. Resident #58, who was cognitively intact, was observed with an air freshener spray and a multi-surface disinfectant cleaner spray at their bedside. These items were brought in by a family member, contrary to the facility's policy prohibiting outside chemicals. Despite staff awareness and previous discussions with the resident and family, the cleaning supplies remained in the room, indicating a failure to enforce the policy and remove potential hazards. Resident #91, with severe cognitive impairment, had an unsecured oxygen E-Cylinder tank next to their bed. The tank was not in a rolling safety stand as required by the facility's policy, posing a risk of falling and potential injury. The resident no longer had an order for oxygen use, and the tank should have been removed. Staff oversight and lack of adherence to the oxygen storage policy contributed to this deficiency.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by state and federal regulations. This deficiency was identified during a recertification survey when a resident was observed with a Symbicort inhaler stored at their bedside without staff supervision. The facility's policy mandates that medications be stored in locked areas and accessed only by authorized personnel. However, the resident, who had moderately impaired cognition and was receiving oxygen therapy, was found self-administering the inhaler, contrary to the physician's orders that required nursing staff to administer the medication and store it in the medication cart. The incident was confirmed through observations and interviews with facility staff, including the LPN responsible for administering medications and the Charge Nurse. Both acknowledged that the inhaler should not have been left at the resident's bedside and should have been stored securely in the medication cart. The Director of Nursing Services also confirmed that the inhaler should not have been accessible to the resident, as it posed a risk of unsupervised self-administration. This oversight highlights a failure to adhere to medication storage protocols, potentially compromising resident safety.
Infection Control Deficiency in Wound Care
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's infection prevention and control program. The deficiency involved improper wound care for a resident with a left heel ulcer. The resident, who had a history of diabetes mellitus, peripheral vascular disease, and a non-pressure chronic ulcer of the heel, was observed receiving wound care from a registered nurse. The nurse failed to perform hand hygiene after cleaning the wound and allowed the cleansed wound to come into contact with a dirty bed sheet. This was contrary to the facility's policy and competency requirements, which mandate hand hygiene and the use of clean gloves after wound cleaning. The incident was observed by a surveyor, who noted that the nurse did not have assistance to hold the resident's leg, resulting in the wound resting on the mattress. The nurse admitted to being nervous and acknowledged the mistake of not sanitizing their hands. Interviews with the infection preventionist and the director of nursing services confirmed that the nurse should have sought assistance and maintained proper hand hygiene. The failure to follow proper procedures was a clear breach of the facility's infection control protocols.
Inadequate Staffing Assessment in Facility
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately documented the necessary resources to care for residents competently during day-to-day operations. Specifically, the assessment did not include the overall number of qualified nursing staff required to meet each resident's needs. The staffing plan outlined in the assessment lacked specific details regarding the number of Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) assigned to each shift, including day, evening, and night shifts. This omission indicates a significant gap in the facility's ability to plan and allocate appropriate nursing resources. During an interview, the Administrator acknowledged that the facility assessment was reviewed but failed to notice the missing details about the number of licensed nurses per shift. Additionally, the Administrator admitted that the staffing plan for Certified Nurse Aides (CNAs) was incorrect, as it was based on a lower number of beds than the facility's actual capacity of 180 certified beds. This discrepancy resulted in an inadequate number of CNAs to maintain the required ratio of one CNA to eight residents, further highlighting the deficiency in the facility's staffing assessment.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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