Silver Lake Specialized Rehab And Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Staten Island, New York.
- Location
- 275 Castleton Avenue, Staten Island, New York 10301
- CMS Provider Number
- 335196
- Inspections on file
- 15
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Silver Lake Specialized Rehab And Care Center during CMS and state inspections, most recent first.
A resident with dementia, syncope, gait abnormalities, severe cognitive impairment, and a history of multiple falls, who required substantial/maximal assistance for transfers, was placed in a wheelchair in a hallway and left without direct supervision while staff provided morning care to others. The resident’s fall care plan, initiated years earlier and later updated only to add a chair tab alarm, was not revised with new interventions despite repeated falls, and there was no documented fall risk assessment or monitoring schedule in place. Staff interviews showed reliance on the chair alarm for supervision and lack of awareness among CNAs of the resident’s fall history or specific fall-prevention measures. The resident was later found on the floor after staff heard an alarm or loud thump, and facility video review showed the resident leaning forward from the wheelchair to reach for something on the floor before falling, resulting in a head laceration and cervical fracture.
Two residents’ comprehensive care plans were not reviewed and revised as required following assessments and clinical events. One resident with COPD and dementia continued to receive O2 therapy under a respiratory care plan that had not been updated after a quarterly MDS, despite facility policy requiring at least 90‑day evaluations. Another resident with dementia, syncope, gait abnormalities, severe cognitive impairment, and a history of falls and fracture had a falls care plan with generic interventions that were not modified after multiple documented falls, including a hallway fall with a laceration from a wheelchair. Staff interviews confirmed that nurse managers, LPNs, and RNs were responsible for quarterly and significant-change updates, yet no new interventions were added and the plans were not revised in line with residents’ changing needs.
A resident with dementia, syncope, and gait abnormalities, assessed as severely cognitively impaired, was found on the hallway floor after staff heard an alarm, with an unwitnessed fall from a wheelchair and a laceration above the right eyebrow. Hospital records confirmed an acute C2 (odontoid) fracture and recommended neurosurgery follow-up, indicating a major injury of unknown origin. The facility’s incident report described the event as unwitnessed, with the resident confused and unable to follow instructions, while nursing staff were occupied in the med room and providing care to other residents. The facility’s abuse investigation policy addressed investigation of injuries of unknown source but lacked protocols for reporting them to the State Survey Agency, and leadership interviews revealed uncertainty and misunderstanding about the requirement to report such major injuries, resulting in the incident not being reported to the state health department.
A ventilator-dependent resident with multiple comorbidities had a clearly documented allergy to Vancomycin in the care plan, physician orders, and EMR, and wore a red allergy bracelet. Despite this, a provider ordered IV Vancomycin for pneumonia, and an RN administered the dose without reconciling the order against the documented allergy. After administration, staff noted wheezing, increased work of breathing, facial and lip swelling, and abnormal lung sounds, and a medication error report later identified failure to check the allergy as the cause.
A resident with multiple chronic conditions and a documented allergy to Vancomycin received IV Vancomycin after a new order was written and processed. The allergy had been added to the care plan and physician orders, and the pharmacy profile reflected the allergy, but the pharmacy’s dispensing system was not updated to flag it, and the RN who administered the dose failed to check the allergy information. The resident subsequently developed increased work of breathing and facial and lip swelling while receiving the infusion, and a medication error report cited failure to check allergies as the cause.
A resident with dementia and moderate cognitive impairment was physically abused by a CNA, who struck the resident on the head and arm following a verbal altercation in the dayroom. Surveillance footage confirmed the incident, and the CNA admitted to the actions, which violated the facility's abuse prevention policy.
A CNA was observed on surveillance footage striking a resident with dementia on the head and upper arm. Although the incident was reported to the Department of Health, it was not reported to local law enforcement as required by federal law and facility policy, resulting in a deficiency for failure to report suspected abuse within mandated timeframes.
The facility did not ensure a clean, comfortable, and homelike environment across all resident floors. Observations revealed stained walls, missing paint, torn wallpaper, and dirty AC units on the 1st Floor; rusty and mismatched tables on the 2nd Floor; missing baseboards and exposed wires on the 3rd Floor; and mismatched tables on the 4th Floor. Staff interviews indicated a lack of awareness and reporting of these issues.
The facility was found to have expired food items, including cottage cheese and thickened juices, in its kitchen and pantry refrigerators. Staff interviews revealed inconsistent procedures for checking and discarding expired items, with responsibilities shared between dietary and nursing staff. The Registered Dietitian and Food Service Director were aware of the issue but had not identified the expired items during their checks.
The facility failed to maintain infection control practices, with a resident's Foley catheter tubing found on the floor and inadequate hand hygiene observed in the Main Dining Room. Despite policies requiring catheter care and hand hygiene, staff interviews revealed lapses in monitoring and coordination, leading to these deficiencies.
A resident with a Foley catheter was observed with their drainage bag exposed and visible from the hallway, contrary to the facility's policy requiring dignity bag covers. Despite staff awareness of the policy, the resident's bag was not covered, and the tubing was on the floor. Interviews with a CNA, an LPN, and the ADON revealed a lack of adherence to the policy, with no explanation provided for the oversight.
A resident with anemia and paraplegia was not invited to participate in their Comprehensive Care Plan (CCP) meetings, despite being cognitively intact. Facility policy required resident participation in various CCP meetings, but staff interviews revealed that residents were not invited to quarterly meetings. The Director of Social Worker, Assistant Director of Nursing, and Director of Nursing were unaware of the need to include residents in all scheduled meetings, leading to the resident's exclusion from their care planning process.
A facility failed to accurately document a resident's use of bilateral hand mittens as a restraint in the MDS assessment. Despite physician orders and documentation indicating the use of mittens to prevent the resident from pulling at tubes, the MDS assessment did not reflect this. Observations confirmed the use of mittens, and the MDS Assessor admitted the omission was an oversight.
Unwitnessed Hallway Fall of High-Risk Resident Left Without Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment to prevent accidents for a resident with severe cognitive impairment and a history of multiple falls. The resident had diagnoses including dementia, syncope, and gait and mobility abnormalities, and required substantial/maximal assistance for sit-to-stand and transfers per the MDS. Despite this, the facility could not provide documentation of a fall risk assessment prior to the resident’s fall, and the existing fall/injury care plan, initiated in 2022 and updated in 2024 to include a wheelchair tab alarm, was not revised with new interventions after multiple documented falls in 2022, 2023, and early 2024. On the date of the incident, staff transferred the resident out of bed to a wheelchair in the early morning and left the resident sitting in the hallway. The resident was not on any documented monitoring or supervision schedule at that time. Staff interviews revealed that the CNA assigned to the resident placed the resident in the hallway and then went to other rooms to provide morning care, and the LPN on duty stated the resident was left in the hallway and that they relied on the chair alarm for supervision. The CNA assigned to the resident reported not being aware of the resident’s prior falls or any specific fall-prevention interventions beyond the alarm, and another CNA on the unit stated the resident was not on any supervision or monitoring schedule and that they were unaware if the resident had a wheelchair or bed alarm. At approximately 5:50 AM, staff heard an alarm and/or a loud thump and found the resident on the floor in the hallway with a laceration above the right eyebrow and active bleeding. The fall was unwitnessed, and the resident, who was confused and had impaired judgment and inability to follow instructions, was unable to explain how the incident occurred. Facility investigation and review of surveillance footage by nursing leadership showed the resident in a wheelchair in the hallway, leaning forward to reach for something on the floor and then falling forward. The resident was transported to the hospital, where imaging confirmed an acute fracture of the odontoid process of the second cervical vertebra, and the facility documented that the resident sustained a cervical fracture as a result of the fall.
Failure to Review and Revise Comprehensive Care Plans for Respiratory Care and Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment and in response to changes in residents’ needs, as required by facility policy and regulation. The facility’s policy on comprehensive care plans, last reviewed in January 2026, states that individualized care plans with measurable objectives and timetables must be evaluated in response to significant changes in a resident’s status or at least every 90 days. Surveyors found that this process was not followed for residents receiving respiratory care and for a resident with a history of falls. For one resident with diagnoses including Chronic Obstructive Pulmonary Disease and non-Alzheimer’s dementia, a quarterly Minimum Data Set (MDS) assessment documented that the resident was receiving oxygen therapy. The resident’s Respiratory Conditions Comprehensive Care Plan, initiated in June 2023, included a goal to remain free from signs and symptoms of respiratory distress for 90 days, with interventions such as administering oxygen as needed and elevating the head of the bed due to shortness of breath when lying flat. This care plan was last updated in December 2025 and was not revised following the resident’s quarterly MDS assessment in March 2026. Interviews with the unit manager LPN, the Assistant Director of Nursing, and the Director of Nursing confirmed that nurse managers and supervisors were responsible for quarterly updates and that they were unaware or unable to explain why the respiratory care plan had not been updated. For another resident with dementia, syncope and collapse, and gait and mobility abnormalities, the MDS documented severe cognitive impairment, a history of falls, and a fracture related to a fall. A falls/injury comprehensive care plan was initiated in January 2022 for physical performance limitations, with interventions such as anticipating needs, monitoring activities, and monitoring risk factors. The care plan notes documented multiple prior falls over 2022–2024, but the interventions were not updated in response to these incidents. In June 2025, the resident sustained another fall in the hallway, resulting in a visible laceration above the right eyebrow, and the care plan documented that the resident had been leaning forward and fell from a wheelchair; however, there was no evidence that fall-prevention interventions were reviewed or revised after this event. The CNA assignment sheet from April 2025 showed the resident required extensive assistance of two staff for transfers and only listed a tab alarm on chair and bed for fall prevention. Interviews with nursing staff and leadership indicated that care plans were expected to be updated quarterly, annually, with significant changes, and as needed, but confirmed that no new fall-prevention interventions were added and that responsibility for updating care plans rested with unit managers, LPNs, and RNs.
Failure to Report Unwitnessed Fall With Major Injury to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged violation involving an injury of unknown source that resulted in serious bodily injury to the State Survey Agency, as required. A cognitively impaired resident with diagnoses including dementia, syncope and collapse, and gait and mobility abnormalities, and assessed as having severe cognitive impairment, was found on the floor in the hallway after staff heard an alarm. Nursing documentation shows that an LPN heard the alarm while in the medication room, found the resident on the floor, and called the nursing supervisor. An RN documented that the resident had an unwitnessed fall from a wheelchair with a visible laceration above the right eyebrow, and the resident was unable to state how the incident occurred. Hospital records and the transfer form documented that the resident sustained an acute fracture of the odontoid process (C2 cervical vertebra) and that neurosurgery follow-up was recommended, confirming a major injury. The facility’s Accident/Incident Report, completed several days later, described the event as unwitnessed, with the resident confused, having impaired judgment, and unable to understand and follow instructions, and noted that the floor nurse was in the medication room and CNAs were providing care to other residents at the time. There was no documented evidence that this unwitnessed fall with a major injury and unknown cause was reported to the New York State Department of Health. The facility’s abuse investigation policy required prompt investigation of injuries of unknown source but did not include protocols for reporting such injuries to the State Survey Agency, and interviews with the Assistant DON and DON showed uncertainty and misunderstanding about the requirement to report major injuries of unknown origin.
Failure to Prevent Administration of Medication Despite Documented Allergy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and documented medication allergies. The facility’s medication administration policy required nurses to verify allergies prior to giving medications. Resident #191 had multiple diagnoses including heart failure, seizure disorder, respiratory failure, and ventilator dependence, and wore a red allergy bracelet. The resident’s comprehensive care plan initially listed an allergy to mucomyst and was later updated to include an allergy to Vancomycin, with interventions such as monitoring for allergic reactions and use of a red charm bracelet. A physician’s order also documented the resident’s allergy to Vancomycin. Despite the documented allergy, a subsequent physician’s order was entered for Vancomycin 1 gram IV every 12 hours for 10 days, and the medication was administered by a registered nurse. The Medication Administration Record showed that Vancomycin was given on 06/30/2025 at 9:00 AM. At that time, the resident was ventilator-dependent and severely cognitively impaired, and the allergy information was available in the electronic medical record and indicated by the allergy bracelet. The failure to reconcile the new Vancomycin order with the existing allergy documentation and to verify allergies before administration led to the resident receiving a medication to which they were known to be allergic. Following the administration, clinical staff observed changes in the resident’s condition. A respiratory therapist documented scattered rhonchi, wheezing, and an oxygen saturation of 96%, and noted that the resident required suctioning for large amounts of thick yellowish secretions and received albuterol. An LPN later observed increased work of breathing, facial and lip swelling, and noted that the resident was receiving IV Vancomycin at that time. A medication error report documented that the error was due to failure to check the resident’s allergy, and interviews with nursing and respiratory staff confirmed that the resident had been given Vancomycin despite a known documented allergy and visible allergy alerts.
Failure to Prevent Administration of Medication Despite Documented Allergy
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe medication dispensing and administration in accordance with professional standards, specifically related to a resident with a documented allergy to Vancomycin. The resident had multiple diagnoses including heart failure, seizure disorder, respiratory failure, and ventilator dependence, and was severely cognitively impaired and dependent for activities of daily living. A comprehensive care plan for medication allergies was initiated and later updated to include Vancomycin, and a physician’s order also documented the Vancomycin allergy. Despite this, a subsequent physician’s order was entered for IV Vancomycin, and the medication was dispensed by the pharmacy and administered by a registered nurse, who did not identify the documented allergy prior to administration. The facility was unable to provide a policy related to pharmacy services. Following administration of Vancomycin, the resident was observed by an LPN to have increased work of breathing, facial and lip swelling, and was noted to be receiving IV Vancomycin at that time. A medication error report documented that the error was due to failure to check the resident’s allergy. Interviews revealed that the prescribing physician stated the incident could have been prevented if staff at either the nursing home or the pharmacy had recognized the allergy. The pharmacy’s general manager reported that the resident’s medical profile showed a Vancomycin allergy and that the allergy was listed on the electronic physician order received by the pharmacy, but the pharmacy’s dispensing system did not prevent dispensing because the new allergy had not been updated in that system and therefore did not generate a flag. The Assistant Director of Nursing/Infection Preventionist confirmed that the resident received Vancomycin despite the known allergy.
Resident Physically Abused by CNA in Dayroom
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident in the facility's dayroom. Surveillance footage captured the CNA approaching the resident, pulling a table away from the resident's wheelchair, and then striking the resident on the back of the head with an open hand, causing the resident's head to fall forward. Shortly after, the CNA pushed the resident's wheelchair to the dayroom exit and, following a verbal exchange and the resident throwing a cup of liquid at the CNA, the CNA struck the resident's upper arm twice with a paper plate. The incident was observed while reviewing surveillance footage for another matter. The resident involved had a history of dementia, restlessness, agitation, major depressive disorder, and obsessive-compulsive disorder, with documented moderate cognitive impairment. The resident's care plan included interventions to ensure safety and to remove the resident from the area of any aggressor. Despite these interventions, the CNA engaged in physical abuse following a verbal altercation, during which the resident used offensive language toward the CNA. The CNA admitted to slapping the resident on the head and stated awareness of the wrongdoing. Interviews with other residents assigned to the CNA revealed no similar complaints or witnessed abuse. Documentation showed that the CNA had received in-service training on abuse prevention. The facility's abuse prevention policy clearly stated residents' rights to be free from abuse, neglect, and corporal punishment, and required prompt reporting of any suspected abuse. However, the actions of the CNA violated these policies and resulted in the resident not being protected from abuse.
Failure to Timely Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to all required authorities within the mandated timeframes. Surveillance footage showed a Certified Nursing Assistant (CNA) approaching a resident in the dayroom, pulling a table away from the resident's wheelchair, and then striking the resident on the back of the head with an open hand. Later, the CNA was observed taking items from the resident's wheelchair and, after the resident threw a cup of liquid at the CNA, the CNA struck the resident's upper arm twice with a paper plate. The incident was discovered while reviewing surveillance footage for another matter. The resident involved had diagnoses including dementia, restlessness and agitation, major depressive disorder, and obsessive-compulsive disorder, with documentation of moderately impaired cognition. Although the CNA was immediately removed from the unit and the resident was evaluated with no injuries noted, the facility did not report the incident to local law enforcement as required by federal law and facility policy. The Administrator reported the incident to the Department of Health but did not believe it was necessary to notify law enforcement, resulting in a failure to meet reporting requirements for suspected abuse.
Facility Fails to Maintain Homelike Environment Across All Floors
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across all four resident floors, as observed during the recertification survey. On the 1st Floor, issues included stained walls and curtains, missing and mismatched paint, missing baseboards, torn wallpaper, and a dirty air conditioning unit. Specific rooms had additional problems such as missing sink handles, cracked tiles, brown water stains on drapes, peeling paint, exposed wall outlets, and unpainted drywall patches. The pantry also had unpainted patches and missing veneer under the sink. On the 2nd Floor, the dining room had a rusty overbed table and several tables with mismatched and missing paint. The 3rd Floor had missing baseboards, mismatched and unpainted areas in the hallway, and cracked and missing veneer on pantry shelves. The ceiling light in the pantry was missing a cover, exposing wires and a light bulb. The dining room had tables with missing and mismatched paint. On the 4th Floor, rooms had overbed and bedside tables with mismatched and missing paint. Interviews with staff revealed a lack of awareness and reporting of these issues, with maintenance staff acknowledging the poor condition of the tables but being unable to address them due to other priorities.
Expired Food Items Found in Facility
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, it was observed that a 5-pound container of expired cottage cheese was found in the kitchen refrigerator. Additionally, the 3rd floor pantry contained expired honey-thickened juices, and the 4th floor pantry had an expired quart of milk. These findings indicate a lapse in the facility's adherence to its policy on food supply storage and receiving, which mandates proper stock rotation and the provision of fresh food for residents. Interviews with staff revealed a lack of consistent procedures for checking and discarding expired food items. A dietary aide responsible for stocking the kitchen refrigerator did not notice the expired cottage cheese. A CNA on the 3rd floor, who was responsible for checking the dates on thickened beverages, did not include the pantry refrigerator in their routine checks. An LPN stated that the night shift was responsible for clearing expired items but admitted to not having time to do so. The Registered Dietitian and Food Service Director acknowledged that both nursing and dietary staff should collaborate on this task, but neither had identified the expired items during their checks.
Infection Control Deficiencies in Catheter Care and Dining Room Hygiene
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by two specific incidents. First, Resident #238, who has a history of myocardial infarction and heart failure and is moderately cognitively impaired, was observed multiple times with their Foley catheter tubing touching the floor. This is contrary to the facility's policy, which mandates that catheter tubing and drainage bags be kept off the floor. Despite the care plan and physician's orders requiring monitoring and care of the catheter every shift, the tubing was found on the floor during several observations. Interviews with the CNA, LPN, and DON confirmed that the tubing should not have been on the floor, but no explanation was provided for the oversight. The second incident involved a lack of hand hygiene practices in the Main Dining Room (MDR) during lunch service. Residents were not offered hand hygiene before being served beverages, and one resident was observed distributing bibs to others after licking their hand. Interviews with staff, including a CNA, DA, RN, and the ADON/IP, revealed a lack of coordination and responsibility for ensuring hand hygiene. The CNA responsible for assisting with meal service was on break when service began, and the DA, who served beverages, did not ensure residents' hands were clean. The ADON/IP acknowledged the oversight and noted that they did not observe the meal service on the day of the incident.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to maintain the dignity of a resident with a urinary catheter, as observed during a recertification survey. Resident #238, who had a Foley catheter due to diagnoses of myocardial infarction and heart failure, was found with their catheter drainage bag exposed and visible from the hallway on multiple occasions. The facility's policy required that catheter bags be kept inside a dignity bag cover at all times, except during care, to maintain resident dignity. However, the resident's drainage bag was not contained in a dignity bag, and the tubing was observed on the floor. Interviews with staff revealed a lack of adherence to the facility's policy. A CNA confirmed that catheter care was provided every shift and that all residents with catheters should have their drainage bags covered with dignity bags. However, the CNA could not explain why the resident's bag was not covered. An LPN stated that they perform frequent rounds and that catheter bags should be contained in dignity bags, but they had not observed the resident's exposed bag. The ADON/Infection Control Preventionist acknowledged that staff were aware of the requirement to keep catheter bags in dignity bags and that supervisors were responsible for ensuring compliance.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility failed to ensure a resident's right to participate in the development and implementation of their person-centered plan of care. This deficiency was identified during a recertification survey, where it was found that a resident with diagnoses of anemia and paraplegia, who was cognitively intact, was not invited to attend their Comprehensive Care Plan (CCP) meetings since their admission. The facility's policy stated that residents and their health care agents or family members should be invited to participate in various CCP meetings, including admission, annual, significant change, and discharge meetings. However, it was noted that residents were not invited to quarterly CCP meetings. Interviews with facility staff, including the Director of Social Worker (DSW), Assistant Director of Nursing (ADON), and Director of Nursing (DON), revealed a lack of awareness and adherence to the policy regarding resident participation in CCP meetings. The DSW confirmed that residents were invited to certain meetings but not to quarterly ones. The ADON and DON were unaware that residents should be invited to all scheduled meetings, indicating a gap in communication and understanding of the policy requirements. This oversight resulted in the resident not being involved in their care planning process, as required by regulations.
Inaccurate MDS Assessment of Resident's Restraint Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected the status of a resident, specifically regarding the use of physical restraints. This deficiency was identified during a recertification survey conducted from December 6, 2023, to December 13, 2023. The issue was observed in one resident who had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The MDS assessment dated November 30, 2023, did not document the resident's use of bilateral hand mittens, which were used as a restraint to prevent the resident from pulling at tubes. Despite the physician's order and documentation in the Certified Nursing Assistant (CNA) Accountability Record and Comprehensive Care Plan (CCP) indicating the use of hand mittens, the MDS assessment failed to capture this information. Observations made on December 6 and December 13, 2023, confirmed that the resident was wearing bilateral hand mittens. Interviews with a CNA and the MDS Assessor revealed that the mittens were used to prevent the resident from pulling at their gastrostomy and trach tubes. The MDS Assessor acknowledged that the omission of the hand mittens in the MDS assessment was an oversight, as the resident did not use the mittens at the time the assessment was completed. This oversight led to the inaccurate reflection of the resident's status in the MDS assessment, violating the regulatory requirement for accurate resident assessments.
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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