Spring Creek Rehabilitation & Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, New York.
- Location
- 660 Louisiana Ave, Brooklyn, New York 11239
- CMS Provider Number
- 335125
- Inspections on file
- 14
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Spring Creek Rehabilitation & Nursing Care Center during CMS and state inspections, most recent first.
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 was not readmitted to the facility after hospitalization for severe dysphagia, despite the hospital's assessment that a feeding tube was unnecessary. The facility cited care needs exceeding capacity and failed to provide a written discharge notice with appeal rights or notify the Ombudsman. The facility's policies did not address this situation, leading to a deficiency.
The facility experienced significant staffing shortages on weekends, as revealed by a recertification survey. The staffing plan was not met, leading to excessive workloads for CNAs and delays in resident care. Interviews with residents and staff confirmed the issue, with CNAs often responsible for 14-15 residents each. The Director of Nursing cited high turnover and staff having other jobs as contributing factors. The administrator was unaware of the summer staffing shortfalls, which were worsened by vacations and holidays.
The facility did not maintain corridor doors to resist smoke passage, as transfer grilles were found on doors across multiple floors, violating safety standards.
The facility did not ensure adequate sprinkler system coverage, as observed during a life safety survey. On the 2nd floor, a sprinkler head was missing under ductwork in the air handling room, and light fixtures were obstructing sprinkler heads in several utility closets, potentially affecting their spray patterns.
The facility did not ensure fire hoses were inspected, tested, and maintained as per 2011 NFPA 25 standards. During a survey, it was found that hoses on stairwell E landings were last marked in March 2018, indicating a lapse in the required five-year inspection or replacement schedule. The Director of Maintenance acknowledged the issue.
A resident with severe cognitive impairment alleged being slapped by staff, but the facility delayed reporting the incident to the state agency beyond the required two-hour timeframe. The DON did not report the allegation promptly due to disbelief in the resident's account, violating the facility's abuse prevention policy.
A resident's representative was not properly invited to care plan meetings due to outdated contact information, resulting in their inability to participate in the resident's care planning. The facility failed to verify the representative's address and phone number, leading to a lack of communication and involvement in the care process.
A resident with medical conditions including Atrial Fibrillation and Diabetes Mellitus expressed a preference for daily showers but received only six showers over nearly three months, contrary to the facility's policy of twice-weekly showers. Staff interviews revealed inconsistent documentation and communication regarding the resident's shower schedule and preferences, leading to a deficiency in honoring the resident's right to make significant life choices.
A facility failed to provide a resident with quarterly financial statements as required by policy. Despite the resident having intact cognition, they did not receive written statements of their account balance. Interviews revealed a lack of communication and adherence to the policy, with staff unaware of the resident's unmet needs.
A resident with multiple diagnoses was left with unattended medications at their bedside, contrary to facility policy. An LPN failed to ensure the resident took their medications before documenting administration. The RN Supervisor and DON confirmed that medications should not be left at the bedside and residents must be assessed for self-administration.
A CNA failed to perform hand hygiene between assisting multiple residents with hand hygiene before meal service, as observed during a survey. The facility's policy requires hand hygiene between residents to prevent cross-contamination, but the CNA did not adhere to this, acknowledging the oversight. Interviews with staff confirmed the requirement for hand hygiene to prevent infection spread.
During a survey, a facility was found to have an unducted air return used as a ceiling plenum, violating NFPA standards. This setup, located on the second floor of the extension building, had multiple penetrations that could allow smoke to enter the lobby, impeding egress during a fire. The Director of Maintenance acknowledged the issue.
A facility failed to ensure an accurate MDS assessment for a resident's psychiatric status. The assessment inaccurately documented the resident's psychiatric condition without confirmation from the facility's medical provider, despite the facility's policy requiring comprehensive assessment through communication with the resident and review of medical records. This led to a deficiency citation.
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.
Failure to Readmit Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return following hospitalization, which was evident for one of six residents. The resident was initially transferred to the hospital for severe dysphagia evaluation and possible feeding tube placement. Despite the hospital's assessment that a feeding tube was not necessary, the facility refused to readmit the resident, citing care needs exceeding their current capacity. The facility did not provide the resident or their representative with a written notice of discharge, including notification of appeal rights, nor did they notify the Long-term Care Ombudsman. The facility's policies on admissions and discharge planning did not address the protocol for residents transferred to the hospital but not accepted back. The resident, who was cognitively intact, had been admitted with a diagnosis that included dysphagia. The facility's interdisciplinary team, including a medical doctor, determined that the resident was at high risk for aspiration and recommended hospital transfer for further evaluation. However, the facility did not follow the required procedure for discharge notification, failing to issue a 30-day notice with appeal rights. Interviews with the resident's representative and facility staff revealed that the decision not to readmit the resident was based on the facility's assessment of the resident's care needs and risk for aspiration. The medical team, including the medical director, reviewed the hospital's patient review instrument and decided against the resident's return. Despite discussions with the resident's family about the risks and necessary precautions, the facility did not document or communicate the discharge decision appropriately, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 24, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action 1. Resident #1 was transferred to the hospital on [DATE] and did not return to the facility. 2. The Director of Social Service was given an educational counseling and a 1:1 inservice on discharge protocol emphasizing that the resident / resident representative and the Long-term Care Ombudsman is notified of the discharge in writing, including notification of appeal rights. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service compiled a list of residents in the last 30 days who have been discharged from the facility. The list was reviewed to ensure that each resident / resident representative in addition to the Long Term Care Ombudsman was notified of the discharge in writing, including notification of appeal rights. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS and Director of Social Service reviewed and revised the policy on “Discharge Planning: Discharge Notification to Resident / Family” to include a protocol for a resident who was transferred to the hospital from the facility but is not being accepted back into the facility. The protocol includes that the resident / resident representative in addition to the Long Term Care Ombudsman will be notified of the discharge in writing, including notification of appeal rights. 2. The Director of Social Service and the social workers will be in-serviced on the revised policy “Discharge Planning: Discharge Notification to Resident / Family” by the administrator / designee with emphasis on ensuring that each resident / resident representative in addition to the Long Term Care Ombudsman are notified of the discharge in writing, including notification of appeal rights. 3. The Administrator, Medical Director, DNS and Director of Social Service reviewed the policy on “Admission Process” including not being able to accept a resident if the facility cannot provide adequate or appropriate care for that resident and found it to be compliant. 4. The Director of Admissions, Director of Social Service and the social workers will be in-serviced on the policy by the administrator regarding “Admission Process” by the administrator / designee with emphasis on appropriate admissions to the facility depending on the resident’s level of care. 5. A copy of the Lesson Plan and Attendance is filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that the resident / resident representative as well as the Long Term Care Ombudsman is notified in writing regarding the discharge including the notification of appeal process. 2. Audits will be done by the Director of Social Service/Designee on 10 random discharges weekly x 4 weeks, 10 random discharges monthly x 3 months and 10 random discharges quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible to ensure correction of this deficiency by 4/7/2025.
Staffing Shortages on Weekends in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, particularly on weekends, as identified during a recertification survey. The facility's policy required adequate staffing to provide necessary care and services, but the Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 indicated excessively low staffing levels on weekends. The facility's staffing plan outlined specific numbers of licensed nurses and certified nursing assistants (CNAs) required per shift, but actual staffing schedules revealed frequent shortages of both nurses and CNAs across various units on weekends. Interviews with residents and staff corroborated the staffing deficiencies. Several residents reported that the facility was short-staffed on weekends, leading to situations where CNAs were responsible for 14-15 residents each, which is above the facility's standard. This resulted in delays in care, such as residents not being changed on time. Staff members, including CNAs and a Registered Nurse Supervisor, confirmed the high workload and frequent call-outs on weekends, which necessitated reassigning staff to cover shortages. The Director of Nursing acknowledged the staffing issues, attributing them to high turnover rates and staff having other jobs or being in school. The facility's administrator was unaware of the staffing shortfalls over the summer, which were exacerbated by increased absences due to vacations and holidays. The report highlights the facility's failure to maintain adequate staffing levels, impacting the quality of care provided to residents. Interviews with residents and their families indicated dissatisfaction with the care received, particularly on weekends when staffing was insufficient.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. The monthly staffing patterns as of (MONTH) 2025 will be reviewed by the DNS, ADNS and the Staffing Coordinator to ensure that there is sufficient nursing staff provided to meet the needs of the residents on all shifts. 2. Facility will actively continue to enhance staffing by contacting more agencies, advertise for hiring more staff, pay overtime when needed, offer incentives to work extra shifts, increase orientation classes with sign-on bonuses and offer opportunities to join the union when appropriate. 3. Resident # 34 met with the DNS, ADNS and Social Worker who reinforced the facility’s commitment to staffing and the importance of their safety as well as maintaining their highest physical, mental and psychosocial well-being as determined by their assessments and person-centered plan of care. II. Identification of others 1. The facility is aware that they must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. 2. The DNS/ADNS/RNS will review all staffing patterns prior to the schedule being posted to ensure that sufficient nursing staff is consistently provided to meet the needs of residents on all shifts. 3. An audit tool was developed by the DNS to review staffing to ensure that there is sufficient nursing staff provided to meet the needs of the residents on all shifts. This audit will be done for one week from 3/16/2025 to 3/22/2025 by the DNS / designee. All issues identified will be immediately corrected. III. System changes 1. The Administrator and DNS reviewed and revised the policy on “Staffing.” 2. ADNS, Staffing Coordinator, Licensed Nurses and Certified Nursing Assistants will be re-educated by the staff educator / designee on the above policy with emphasis on ensuring resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and person-centered care plans. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance 1. The DNS developed an audit tool to ensure that there is sufficient staffing every day on all three shifts. 2. Audits will be done by the ADNS / designee daily x 4 weeks, 3 days a week monthly for 3 months, 3 days a week quarterly thereafter. 3. Any issues identified will have immediate corrective action taken by the DNS & reported to the Administrator. 4. The outcome of this audit will be quantified & reported to the QA committee by the DNS. V. The Director of Nursing will be responsible to ensure correction of this deficiency by 4/7/2025.
Corridor Doors Not Smoke-Resistant
Penalty
Summary
The facility failed to ensure that all corridor doors were maintained to resist the passage of smoke, as required by safety regulations. During a life safety survey conducted on February 10, 2025, it was observed that transfer grilles were present on corridor doors across multiple floors, specifically on floors 1 through 4. These grilles were found on the doors to janitor's closets near rooms 4C25 and 4D08 on the 4th floor, near rooms 3A08, 3D08, and 3B25 on the 3rd floor, near rooms C25 and D08 on the 2nd floor, and on the utility room door near the activities room on the 1st floor. The presence of these grilles violates the requirement that corridor doors must be constructed to resist the passage of smoke, as outlined in the 2012 NFPA 101 and 2011 NFPA 25 standards, as well as 10 NYCRR 711.2 (a).
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action The transfer grilles which were found on corridor doors in the following locations were closed off with metal plates: 1) On the doors to the janitor's closets near rooms 4C25 and 4 DO8 on the 4th floor. 2) On the 3rd floor janitor's closets near rooms 3A08, 3D08 and 3B25. 3) On the 2nd floor near rooms 2C25 and 2D08. 4) On the 1st floor on the utility room near the activities room. II. Identification of Other Residents a. An audit has been conducted of all corridor doors throughout the facility to make sure all doors close and latch as required with proper sealing to prevent the transfer of smoke. b. No additional doors were found noncompliant. c. No residents' additional residents were found to be affected upon completion of this review. III. Systemic Changes 1. The facility has reviewed the Preventive Maintenance Plan and door inspection policy and revised the same to include directives for ventilation grilles, as well as inspection observations. 2. All Maintenance staff will be educated by the maintenance director on the Preventive Maintenance Plan and requirement for appropriate Door operation. 3. The Lesson Plan will concentrate on the following: > Overview of requirements for K363 > Preventive Maintenance plan for performing observational inspections of the doors > Responsibility for providing appropriate door closures. 4. A copy of the Lesson Plan and attendance will be filed for reference and validation. a. The facility reviewed and revised its policy regarding corridor doors. b. All maintenance staff were in service on the updated corridor door policies. IV. QA monitoring a. An audit tool was created to monitor the facility’s corridor doors. b. Monitoring of the facility’s doors shall be performed monthly for the first 3 months and then quarterly thereafter for 9 months. c. Any negative findings from inspections shall be reported to the administrator for further evaluation and will be addressed. d. All reports shall be brought to the Quality Assurance meeting to review with the team to ensure that repairs are being performed in a timely manner for 12 months. V. Title Responsible Director of maintenance
Inadequate Sprinkler System Coverage
Penalty
Summary
The facility failed to ensure that all areas of the building were adequately protected by the automatic sprinkler system, as required by the 2012 NFPA 101 and 2010 NFPA 13 standards. During a life safety survey, it was observed that in the 2nd floor air handling room on the A unit, there was only one sprinkler head located on the door side of the room, with no sprinkler head under the wide ductwork suspended from the ceiling. Additionally, in the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station, and the 1st floor utility closet by the activities room, light fixtures were positioned directly under the upright sprinkler heads, potentially affecting the spray pattern of the sprinkler heads. These deficiencies were noted during the survey conducted on the 1st and 2nd floors of the facility.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action 1. The facility Director of Maintenance contacted the Fire Sprinkle Company upon Discovery to install the required missing fire sprinklers in the 2nd floor air handling room on the A unit, there was under the wide ductwork that is suspended from the ceiling. 2. In the 2nd floor electrical closet, the 2nd floor utility closet by the nurses' station and the 1st floor utility closet by the activities room, the light fixture which was located directly under the upright sprinkler heads has been relocated to provide proper clearance to not affect the spray pattern of the sprinkler heads and was provided with Appropriate coverage. II. Identification of Other Residents The Facility respectfully states that no residents were involved in this deficiency, however all residents were directly affected. The Director of Maintenance reviewed sprinkler coverage throughout, and no additional areas were affected. III. Systemic Changes 1. The Administrator, in conjunction with the Director of Maintenance, reviewed and revised the facility construction/renovation policies and procedures and incorporated the requirements of sprinkler coverage as per NFPA 13 and NFPA 99 into the policies for any Renovation Plan. 2. Any plans which are implemented shall include a review of fire sprinkler coverage by an approved licensed individual. IV. QA Monitoring 1. The Administrator, in conjunction with the Director of Maintenance, will conduct monthly reviews and inspections of sprinkler reports for the next 3 months, then upon completion of work thereafter. Documentation will be maintained in logbook for reference and validation. 2. The Director of Maintenance will review the findings and report to QA Committee on a quarterly basis, for evaluation by the QA Committee. V. Title Responsible Director of Maintenance
Failure to Maintain Fire Hose Inspection Compliance
Penalty
Summary
The facility failed to ensure that all fire hoses were inspected, tested, and maintained in accordance with the 2011 NFPA 25 standards. During a life safety survey, it was observed that the fire hoses located on landings 1-4 of stairwell E were marked with a date of March 2018, indicating that they had not been inspected or replaced within the required five-year period. This deficiency was identified through both observation and staff interviews, where the Director of Maintenance acknowledged the oversight and indicated that a vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrective Action 1. The Director of Maintenance engaged our Service Company to replace the identified standpipe hoses with new hoses in all locations more than five years old. 2. The Director of Maintenance engaged our Service Company to inspect the buildings standpipe system to determine hose testing years and complete NFPA required testing if necessary. II. Identification of Other Residents All Residents have the potential to be affected by this practice. The Director of Maintenance had the company check all hose stations and for similar issues. No other deficiencies were found. No other standpipe, hose or water-based fire prevention issues were found. III. Systemic Changes 1. The Administrator policy on Environmental Rounds was reviewed and revised by Administration to include the auditing and monitoring of standpipe hose system. 2. The existing rounds inspection form has added the monthly standpipe audit tool. 3. All environment of care staff were educated on the revision of this policy by the Director of Maintenance. Non-compliant hose systems shall be replaced with appropriate type and reported to the Administrator and Director of Maintenance for scheduled correction. 4. This has been added to the facility preventive Engineering program. 5. Staff involved in the sprinkler system were educated by the Director of Maintenance that any issues with standpipe system identified during rounds will be corrected asap and interim safety measures put in place as needed until repairs are complete. IV. QA Monitoring An audit tool was created by the Director of Maintenance to monitor compliance with required inspections of sprinkler systems. This audit includes inspection of hose racks. Any identified issues will be scheduled for correction asap. All of the facilities plenum will be audited monthly by the Director of Maintenance for the first 3 months and then quarterly for 9 months. Audit results shall be reported to QAPI Committee quarterly to review with the team to ensure that repairs are being performed. Frequency of ongoing audits will be determined by the Committee based on audit results once 100% compliance is achieved. V. Title Responsible Director of Maintenance
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required timeframe. On January 12, 2024, a resident with severe cognitive impairment and diagnosed with unspecified dementia, vascular dementia, and cerebrovascular disease, alleged that a staff member slapped them in the face. The incident was reported to a Certified Nursing Assistant (CNA) during the morning shift, who then informed a Licensed Practical Nurse (LPN). The LPN subsequently reported the allegation to a Registered Nurse (RN), who then informed the Director of Nursing (DON). Despite the facility's policy requiring immediate reporting of abuse allegations to the State Survey Agency within two hours, the DON delayed reporting the incident to the New York State Department of Health until 7:03 PM, citing disbelief in the allegation due to lack of injury and inconsistencies in the resident's account. The delay in reporting the alleged abuse was a violation of the facility's abuse prevention policy, which mandates that all alleged abuse violations be reported immediately, but not later than two hours after the allegation is made. The DON's decision to delay the report was based on their personal assessment of the situation rather than adhering to the policy requirements. This failure to comply with the reporting protocol was identified during the Recertification and Complaint Survey, highlighting a deficiency in the facility's handling of abuse allegations.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 97 was assessed by the DNP on 1/12/2025 and there were no visible signs of injury. There were no complaints of pain. 2. Resident # 97 was assessed by the RN Supervisor on 1/12/2025 and there were no visible signs of injury. There were no complaints of pain. 3. The Administrator received an Educational Counseling by the Medical Director with emphasis on ensuring that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency and Law Enforcement. 4. The Director of Nursing received an Educational Counseling by the Medical Director with emphasis on ensuring that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency and Law Enforcement. II. Identification of Others 1. The facility respectfully acknowledges that all residents who have accidents/incidents have the potential to be affected by this deficiency. 2. The DNS / designee reviewed Accident/Incident reports for the past 30 days to ensure that any residents with alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property, were reported no later than 2 hours if the event results in bodily injury or no later than 24 hours if the events that cause the allegation do not involve serious bodily injury. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the policy related to residents' right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This policy was found to be compliant. This policy includes: Abuse Prevention with emphasis on ensuring residents remain free from abuse and neglect, and the immediate removal from the facility of any individual alleged to have been involved in the abuse / neglect until completion of the investigation. All alleged abuse or serious bodily injury must be reported to the Department of Health and law enforcement within 2 hours. It also emphasizes reporting guidelines to submit the outcome of investigations within 5 days. 2. All staff will be in-serviced by the DNS/Designee on the above policy with emphasis on the importance of ensuring all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency and law enforcement. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. An audit tool was developed by the Administrator and DNS to ensure that any residents with alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources and misappropriation of resident property, were reported no later than 2 hours if the event results in bodily injury or no later than 24 hours if the events that cause the allegation do not involve serious bodily injury. 2. Audits will be done by the DNS / Designee on 10 accident / incident reports weekly x 4 weeks, 10 accident / incident reports monthly x 3 months and 10 accident / incident quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA committee quarterly by the DNS / designee for monitoring of performance and recommendations and follow-up. V. The Director of Nursing will be responsible to ensure correction of this deficiency by 4/7/2025.
Failure to Ensure Resident Representative Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's representative was able to participate in the development and implementation of the resident's person-centered care plan. The resident, who had diagnoses including Dementia, Alzheimer's Disease, and Major Depressive Disorder, was severely impaired in cognition and unable to meaningfully participate in care plan meetings. Despite this, the facility did not ensure that the resident's representative was properly invited to these meetings. The representative, who lived out of state, did not receive any invitation letters or calls from the facility, as the facility had been using an outdated address and phone number for the representative. The facility's Social Services Director assumed that invitations were delivered if they were not returned and did not follow up to confirm receipt or participation. The facility's records lacked evidence that care plan meeting invitations were mailed to the correct address or that the representative's contact information was verified. This oversight resulted in the representative being unaware of and unable to participate in the care plan meetings, contrary to the facility's policy and federal and state requirements.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediately Corrective Action 1. Resident #36 representative was contacted and new information was obtained in order to ensure that the care plan meeting invitations were mailed and received by Resident #36’s representative by the Director of Social Service. 2. The Director of Social Service received a 1:1 inservice on the importance of ensuring that the resident and/or the resident’s representative participated in the development, review, and revision of the person-centered comprehensive care plan. This includes ensuring that the address the letter is mailed to is the most current contact information. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Service and the MDS Coordinator compiled a list of residents in the last 30 days who have had a comprehensive care plan meeting to ensure a care plan meeting invitation was mailed and received by the resident’s representative. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director, DNS, and Director of Social Service reviewed and revised the policy & procedure for the Comprehensive Care Plan. 2. All Social Workers will be in-serviced by the Administrator/Designee on the revised policy and procedure. The lesson plan will focus on the Care Plan Meeting Invitation to the resident and the resident’s representative, the response to the letter, and accurate documentation. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and Director of Social Service created an audit tool to ensure that Care Plan Meeting Invitations are mailed to the resident’s representative, a response is received or follow-up is initiated and documented accordingly. 2. Audits will be done by the Director of Social Service/Designee on 10 random Care Plan Meeting Invitations for follow-up weekly x 4 weeks, 10 Care Plan Meeting Invitations monthly x 3 months, and 10 Care Plan Meeting Invitations quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the Director of Social Service and reported to the Administrator for review & follow-up. 4. Audit findings will be presented to the QA Committee quarterly by the Director of Social Service. V. The Administrator will be responsible for overseeing this corrective action plan by 4/7/2025.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to ensure that a resident's right to make choices about significant aspects of their life was honored, specifically regarding their preference for showering. Resident #7, who was admitted with diagnoses including Atrial Fibrillation, Heart Failure, and Diabetes Mellitus, expressed a desire to shower daily but was willing to accept the facility's offer of twice-weekly showers. However, the resident reported not receiving showers consistently since admission, instead receiving regular bed baths. The facility's policy required residents to be showered at least twice a week, with refusals documented and reported to a nurse. The documentation revealed that Resident #7 received only six showers over a period of nearly three months, despite the facility's policy and the resident's preferences. Interviews with staff, including CNAs and nurses, indicated a lack of consistent communication and documentation regarding the resident's shower schedule and preferences. CNA #11, who occasionally assisted Resident #7, stated they had never provided a shower to the resident and noted that sometimes the resident was already in bed when they realized a shower was due. CNA #5 mentioned that the resident could be difficult and sometimes refused showers, but this was not consistently documented. The Director of Nursing acknowledged that showers are mandatory at least twice a week and that residents can request more frequent showers. However, there was no documentation of Resident #7's preferences being discussed or recorded upon admission. The Director of Nursing also stated that supervisors should check accountability sheets to ensure tasks are completed, but this was not consistently done. The lack of proper documentation and communication led to the resident not receiving showers according to their preference, highlighting a deficiency in honoring resident choice and self-determination.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 7 was spoken to by the RN Supervisor regarding her shower schedule which is twice a week and as requested. Resident # 7 was also asked for her preference, but is agreeable to the shower schedule that is already in place. 2. The CNAAR for Resident # 7 was reviewed to ensure that the shower schedule was correctly documented and activated in the resident’s EMR. 3. CNA # 11 was given a 1:1 inservice on ADL care. This inservice included the importance of the resident receiving a shower twice a week and more often if requested. If the resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. 4. CNA # 5 was given a 1:1 inservice on residents refusing showers. If the resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The DNS / ADNS developed an audit tool to ensure that the resident’s CNAAR reflects residents preference for shower schedules with proper documentation. The DNS / designee developed a list of 10 random residents on each unit in order to audit the showering schedule and documentation on each resident. 3. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the policy & procedure for the Activities of Daily Living and found the policy to be compliant. 2. RN, LPN and CNA will be in-serviced by the DNS/Designee on this policy with emphasis on the importance of the resident receiving showers twice a week as to their preference. If a resident refuses the shower then the charge nurse will be notified and the event will be documented accordingly. 3. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that the resident’s CNAAR is accurate for the showering schedule with proper documentation. 2. Audits will be done by the DNS/Designee on 10 random residents weekly x 4 weeks, 10 random residents monthly x 3 months and 10 random residents quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/2025.
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide quarterly financial statements to a resident, as required by their policy and procedure. The policy mandates that residents or their legal representatives receive a statement showing the account balance, including funds deposited, withdrawn, and interest accrued, at least quarterly. However, during the recertification survey, it was found that a resident with intact cognition did not receive their account statements in writing within 30 days after the end of the quarter. The resident confirmed they had not been receiving copies of their account statements, despite having an account with the facility. Interviews with facility staff revealed a lack of communication and adherence to the policy. The Social Service Director claimed that statements were distributed to alert and oriented residents and mailed to families of those who were not. However, the Financial Controller and the Administrator were unaware that the resident had not been receiving their statements. The Social Worker reportedly informed the Administrator that the resident did not want a copy of the statement, which was contrary to the resident's statement. This discrepancy indicates a failure in the facility's process for managing and distributing resident financial information.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. On 1/28/2025, Resident #142 was provided with an account statement for October, (MONTH) and (MONTH) by the Director of Social Service. II. Identification of Others 1. The Facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. The Director of Social Work reviewed all other residents' accounts. The residents who have funds were provided with a quarterly account statement and/or a copy is sent to the resident representative. 3. No other issues were identified. III. Systemic Changes 1. The Administrator, Medical Director, Director of Social Service, and the Controller reviewed the policy on “Resident Funds Accounts” and found it to be compliant. 2. Social Workers and the Controller will be inserviced on the above policy with emphasis on the resident’s and residents' representative receiving quarterly account statements. 3. A copy of the Lesson Plan and Attendance will be filed for reference and validation. IV. Quarterly Assurance 1. The Director of Social Service developed an Audit tool to ensure compliance with residents and residents' representatives receiving quarterly statements. 2. Audits will be done by the Director of Social Service / Designee on 10 random residents weekly x 4 weeks, 10 random residents monthly x 3 months, and 10 random residents quarterly thereafter. 3. Audits with negative findings will have immediate corrective action taken by the Director of Social Service & reported to the Administrator for review and follow-up. 4. Audit results will be presented to the QA committee by the Director of Social Service quarterly for evaluation and follow-up. V. The Director of Social Service will be responsible for overseeing this corrective action plan by 4/7/2025.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. During the recertification survey, it was observed that medications were left unattended at a resident's bedside. The Licensed Practical Nurse (LPN) responsible for administering the medications did not verify that the resident had taken them before leaving the room and documenting the administration in the Medication Administration Record. The facility's policy requires that the nurse observe the resident taking the medication and document any held or refused medications, which was not adhered to in this instance. The resident involved was cognitively intact and had multiple diagnoses, including anemia, coronary artery disease, renal insufficiency, diabetes mellitus, and malnutrition. The medications left unattended included Ferrous Sulfate, Eliquis, Aspirin, Famotidine, and Vitamin B2. The LPN admitted to placing the medications in the resident's hand and leaving the room without ensuring they were taken. The Registered Nurse Supervisor and Director of Nursing confirmed that medications should not be left at the bedside and that residents must be assessed for self-administration before being allowed to take their own medications.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 101 was immediately given the morning medications with no adverse reactions. 2. The DNP assessed the resident since his medication was left at his bedside. There were no ill effects noted. 3. LPN # 4 was given educational counseling, a 1:1 in-service, and written warning on medication administration with proper medication administration techniques and not leaving medication unattended. 4. A medication administration observation was completed with LPN # 4 by the DNS II. II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by this deficiency. 2. On 2/5/2025, the RN Supervisor checked all resident’s rooms on unit 2 AB and no other medications were left unattended at the bedside. 3. On 2/25/2025, the RN Supervisor checked all resident’s MAR indicated [REDACTED]. 4. No other issues were identified. III. Systematic Changes 1. The Administrator, Medical Director and DNS reviewed the Medication Administration policy and found it to be compliant. 2. All RNs and LPNs will be in-serviced by the DNS/Designee on the above policy with emphasis on administering a full dose of medication to the resident via correct route, offers the resident a drink and observes the resident to ensure medication consumption. Medication should never be left unattended. 3. Lesson plan and attendance sheets will be kept on record for validation. IV. Quality Assurance 1. The Administrator and DNS created an audit tool to ensure that medication was being administered to the resident and not left at the bedside. 2. Audits will be done by the RN Supervisor / Designee on 10 random resident’s room / bedside for medication weekly x 4 weeks, 10 random resident’s room / bedside for medication monthly x 3 months and 10 random resident’s room / bedside for medication quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS will be responsible for overseeing this corrective action plan by 4/7/2025.
Infection Control Deficiency During Dining Task
Penalty
Summary
The facility failed to maintain proper infection control practices during a dining task, as observed during a recertification survey. Certified Nursing Assistant #7 did not perform hand hygiene between assisting multiple residents with hand hygiene before meal service. This was observed with 11 out of 24 sampled residents. The facility's policy requires staff to perform hand hygiene in accordance with CDC guidelines and to clean their hands between providing direct care to different residents. However, the CNA was seen picking up used hand wipes with bare hands and then using clean wipes to assist residents without cleaning their hands in between. Interviews conducted during the survey revealed that the CNA acknowledged the failure to perform hand hygiene, stating they were not thinking at the time. A Registered Nurse and the Assistant Director of Nursing both confirmed that hand hygiene is required between residents to prevent cross-contamination. The deficiency was noted under the regulation 10 NYCRR 415.19 (b)(4), highlighting the facility's failure to adhere to its own infection control policies and procedures.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 I. Immediate Corrective Action 1. Resident # 1 had no ill effects from the CNA who did not conduct proper hand hygiene. 2. Resident # 8 had no ill effects from the CNA who did not conduct proper hand hygiene. 3. Resident # 26 had no ill effects from the CNA who did not conduct proper hand hygiene. 4. Resident # 31 had no ill effects from the CNA who did not conduct proper hand hygiene. 5. Resident # 39 had no ill effects from the CNA who did not conduct proper hand hygiene. 6. Resident # 44 had no ill effects from the CNA who did not conduct proper hand hygiene. 7. Resident # 54 had no ill effects from the CNA who did not conduct proper hand hygiene. 8. Resident # 82 had no ill effects from the CNA who did not conduct proper hand hygiene. 9. Resident # 102 had no ill effects from the CNA who did not conduct proper hand hygiene. 10. Resident # 145 had no ill effects from the CNA who did not conduct proper hand hygiene. 11. Resident # 157 had no ill effects from the CNA who did not conduct proper hand hygiene. 12. CNA # 7 was given Educational Counseling and 1:1 Inservice on Handwashing and Hygiene with emphasis on cleaning her hands in between residents while assisting multiple residents with hand hygiene before meal service. II. Identification of Others 1. The facility respectfully acknowledges that all residents have the potential to be affected by these deficient practices. 2. The RN supervisors conducted a meal observation on each unit for lunch on 2/6/2025 to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. No further issues were identified. III. System Changes 1. The Administrator, Medical Director and DNS reviewed the policy on “Handwashing and Hygiene” and found it to be compliant. 2. The Administrator, Medical Director and DNS reviewed and revised the policy on “Dining Meal Service” to include the CNA performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 3. RN, LPN and CNA will be inserviced on the “Handwashing and Hygiene” policy and the policy on “Dining Rooms Meal Service” with emphasis on performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 4. A copy of the Lesson Plan and Attendance filed for reference and validation. IV. Quality Assurance 1. The DNS / ADNS developed an audit tool to ensure that the CNAs were performing proper hand hygiene in between residents while assisting multiple residents with hand hygiene before meal service. 2. Audits will be done by the RN Supervisor / Designee on 10 meals weekly x 4 weeks, 10 meals monthly x 3 months and 10 meals quarterly thereafter. 3. Audits with negative findings will have an immediate corrective action taken by the DNS and reported to the Administrator for review & follow up. 4. Audit findings will be presented to the QA Committee quarterly by the DNS. V. The DNS is responsible for overseeing this plan of correction by 4/7/2025.
Non-compliance with NFPA Standards in HVAC System
Penalty
Summary
The facility was found to have a deficiency related to the heating and ventilation system during a Life Safety Code portion of the recertification survey. Specifically, on the second floor of the extension building, an unducted air return was being used as a ceiling plenum in the office suite located on the lobby level. This setup was not in compliance with the 2012 NFPA 101 and 2012 NFPA 90A standards, which require that air-conditioning, heating, and ventilating systems be installed according to specific safety standards to prevent the spread of smoke and fire. During the survey, it was observed that there were multiple penetrations above the ceiling between the lobby, which serves as a means of egress, and the adjacent offices. This arrangement posed a risk as it could allow smoke to enter the lobby area, potentially impeding egress in the event of a fire in the adjacent spaces. The deficiency was identified through both observation and staff interviews, highlighting a lapse in maintaining the integrity of the fire and smoke stopping measures required by the relevant NFPA standards. At the time of the survey, the Director of Maintenance acknowledged the deficiency and indicated that it would be corrected. However, the report does not provide details on any corrective actions taken or planned to address the issue. The focus of the deficiency was on the non-compliance with the NFPA standards, which are critical for ensuring the safety and proper functioning of the facility's heating and ventilation systems.
Plan Of Correction
Plan of Correction: Approved February 24, 2025 I. Immediate Corrections: 1. The facility conducted a review of the lobby and office area plenum for compliance with NFPA 90A 4.3.11.2.1 through 4.3.11.2.7. The integrity of the fire and smoke stopping for penetrations shall be maintained. 2. The facility maintenance department has sealed with appropriate material all openings that were found throughout the above ceiling to adjoining rooms to prevent the transfer of smoke. II. Identification of Other Residents: 1. The Facility respectfully states that all residents were potentially affected but no residents were involved in this deficiency. 2. There were no additional issues identified from this environment review, as all egress doors functioned appropriately. III. Systemic Changes: 1. The Director of Maintenance has reviewed and implemented a Preventive Maintenance Program whereby the above ceilings are checked in accordance with 2012 NFPA 90A: 4.3.11.2.1 through 4.3.11.2.7 and documented on the inspection log with any corrective actions required or completed. 2. If repairs cannot be completed in house, then the items shall be logged on master work log and appropriate service company called with completion noted on master work log. 3. Staff performing the required inspections shall be in-serviced on the requirements set forth above. IV. QA-Monitoring 1. The Director of Maintenance will audit the completed inspection and testing log for completeness and completed repairs. 2. The audit will be completed weekly by the Maintenance staff/designee as assigned and reviewed by the Director of Maintenance. 3. Any quality issues identified will be communicated to the Administrator and repaired for compliance as identified. 4. Audit findings from the monthly tool will be presented to the Quarterly QA Committee by the Director of Maintenance for evaluation and follow-up as indicated. The review will continue for 6 months and then semiannual if there are no deficiencies found. Responsible Person: V. Title Responsible: Director of Maintenance
Inaccurate MDS Assessment of Psychiatric Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's psychiatric/mood disorder status. This deficiency was identified during a recertification survey, where it was found that the MDS assessment for a resident inaccurately documented their psychiatric condition. The facility's policy requires interdisciplinary team members to communicate with the resident and their family and review the resident's medical record to perform an accurate assessment. However, the MDS assessment inaccurately indicated that the resident was severely impaired in cognition, had no behavior symptoms, and had an active psychiatric diagnosis, despite the lack of confirmation from the facility's medical provider. The resident's medical history included a diagnosis of a psychiatric condition, as documented in a hospital Patient Review Instruction and a Trauma/Medical Condition Screening. However, the facility's medical provider had not diagnosed the resident with this condition, and the resident's representative was unaware of such a diagnosis. The MDS Coordinator, who conducted the assessment, acknowledged the error in coding the psychiatric diagnosis without confirmation from the facility's medical provider. This discrepancy highlights a failure in the facility's assessment process, as the MDS did not accurately reflect the resident's psychiatric status, leading to a deficiency citation under 10 NYCRR 415.11(b).
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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