Taconic Rehabilitation And Nursing At Hopewell
Inspection history, citations, penalties and survey trends for this long-term care facility in Fishkill, New York.
- Location
- 3 Summit Court, Fishkill, New York 12524
- CMS Provider Number
- 335789
- Inspections on file
- 17
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Taconic Rehabilitation And Nursing At Hopewell during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow its food storage policy requiring all opened items to be labeled and dated, identifying twelve food items across refrigerators, freezers, and dry/bulk storage that lacked identification labels and/or open dates. Unlabeled or undated items included milk, half & half, almond milk, chicken tenders, meatless chicken tenders, frozen pizza, hot dogs, cereal, breadcrumbs, elbow macaroni, rice, and flour. The Food Service Manager confirmed that these practices were not acceptable and that staff were expected to comply with the facility’s labeling and dating requirements.
A resident admitted for short-term rehab with intact cognition and a stated goal to return to the community was not invited to participate in a comprehensive, interdisciplinary care plan meeting, and there was no documented ongoing evaluation of discharge needs or options. Despite documentation that active discharge planning was occurring and that the resident wished to go home, no care plan meeting was held before Medicare coverage ended and the resident began paying privately. The resident did not recall any care plan meeting, and the Director of Social Work acknowledged that discharge planning beyond initial documentation had not occurred and that a meeting should have been scheduled sooner.
Two residents reported missing personal property, including a red flip phone, a gold-colored chain with a cross, and an iPhone case, and filed grievances that were documented as resolved after staff searches and offers of reimbursement. One resident was cognitively intact and another had moderately impaired cognition, and both had significant medical conditions such as heart failure, spinal stenosis, ESRD, and diabetes. Despite the grievances being marked resolved and reimbursement having been offered, there was no documentation of reimbursement amounts, no evidence that payments were made, and no recorded follow-up sufficient to finalize resolution, as confirmed by resident and staff interviews.
Surveyors found that the facility did not send required copies of transfer/discharge notices to the State LTC Ombudsman for two residents who were transferred to the hospital, one with a hip fracture and dementia and another with dementia and breast cancer experiencing uncontrolled pain and later hospice planning. Although transfer/discharge forms and bed-hold documents were completed and kept in a binder, the Director of Social Work acknowledged that no copies or monthly transfer/discharge lists had been sent to the Ombudsman for several months, and the Ombudsman confirmed not receiving notices or monthly lists during that period.
Two residents’ MDS assessments were inaccurately coded by an LPN, resulting in failure to reflect actual falls and pressure ulcer status. One resident with orthopedic and oncologic conditions had two documented falls, yet their quarterly and annual MDS assessments indicated no falls during the relevant look-back periods. Another resident with cancer, hypertension, and anemia developed a facility-acquired stage 3 pressure ulcer to the left ischium, but the subsequent quarterly MDS incorrectly coded the ulcer as present on admission, despite documentation and the LPN’s acknowledgment that it was not present on admission.
Surveyors found that the facility did not update comprehensive care plans to reflect two residents’ current medication regimens. One resident with atrial fibrillation was receiving Eliquis, as documented on the MDS and physician orders, but the cardiac care plan did not address atrial fibrillation or anticoagulant use, and the DON and a unit manager confirmed no such care plan existed. Another resident with dementia and anxiety was receiving olanzapine for major depressive disorder, but the psychosocial care plan only referenced non-psychotropic medications and did not include antipsychotic use or related interventions, which was confirmed by an LPN unit manager and the Director of Social Work.
Two residents at risk for pressure ulcers did not receive ordered and care-planned pressure-relief interventions. One resident with severe cognitive impairment, impaired mobility, and a stage IV pressure ulcer on admission had a care plan and CNA Kardex directing staff to float heels when in bed, yet surveyors repeatedly observed the heels resting on the mattress, and staff acknowledged they should have been offloaded. Another resident with epilepsy, diabetes, impaired mobility, and documented risk for pressure ulcers had physician orders and care plan interventions to offload heels in bed and use a pressure-reducing wheelchair cushion, but observations showed heels on the mattress and no cushion in the wheelchair. A CNA reported not knowing about the heel-offloading requirement because it was not on the Kardex and admitted not reporting the missing cushion, while nursing and rehab staff confirmed the existence of the orders and care plan interventions and that they had not been carried out or reported.
A resident with severe cognitive impairment, dysphagia, and a stage 4 sacral wound on enhanced barrier precautions received oxygen via nasal cannula at a higher flow rate than ordered, with the concentrator repeatedly observed at 3 L/min instead of the prescribed 2 L/min. An LPN acknowledged not verifying the exact oxygen order and failing to adjust the flow rate to match it. In addition, a CNA handled and reinserted the resident’s nasal cannula from the resident’s hair into the nostrils without performing hand hygiene or using required PPE (mask, gloves, gown), despite the resident being on enhanced barrier precautions.
A resident admitted with Hospice care did not have a comprehensive, patient-centered Hospice care plan developed or implemented, as required by facility policy. Despite receiving Hospice services, there were no Hospice orders, progress notes, or care plans in the medical record, and staff interviews revealed communication failures during the admissions process that led to the omission.
A resident receiving Hospice care from an outside agency did not have any orders, progress notes, or a comprehensive care plan addressing Hospice services in their medical record. Facility staff and the Hospice provider confirmed that while the resident received multiple Hospice visits, documentation and communication about these services were not integrated into the facility's records, and staff were unclear about the process for documenting and coordinating Hospice care.
A resident with limited mobility and a deep tissue injury did not have consistent documentation or evidence of being turned and positioned every two hours as required by their care plan. Staff interviews revealed confusion and lack of clarity regarding documentation procedures, with both CNAs and nursing staff unable to confirm when interventions were performed. Facility policies required close monitoring and documentation, but no reliable system was in place to ensure these interventions were carried out and recorded.
A resident admitted on Hospice care did not have any physician orders or progress notes entered to continue Hospice services, and the medical provider was unaware of the resident's Hospice status. The absence of required documentation and orders was confirmed by record review and staff interviews, revealing a lapse in the facility's process for coordinating Hospice care.
Multiple residents were found living in rooms with environmental deficiencies, including windows covered with duct tape or plastic, broken furniture, and unpainted spackled wall patches. Residents reported drafts, water leaks, and concerns about cleanliness and safety, while staff confirmed delays in repairs and a lack of a formal work order system.
Certified Nurse Aides failed to complete required annual abuse prevention training, with overdue assignments and significant gaps between trainings, despite reminders and notifications from facility staff. Interviews confirmed that multiple staff were out of compliance with mandatory in-service requirements, and the facility's policy did not specify training frequency.
A resident with multiple medical conditions, including dementia and recent fractures, did not receive a timely follow-up with an orthopedic surgeon as ordered in hospital discharge instructions. Facility staff discussed the need for the appointment and transportation issues with the family, but there was no documentation that the appointment was scheduled or completed, nor evidence of required follow-up communication. The absence of records and follow-through led to a failure to provide care according to professional standards.
Failure to Label and Date Multiple Food Items in Storage Areas
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards and its own policy requiring all opened items to be labeled, dated, and discarded after three days. During a recertification survey kitchen inspection, surveyors observed multiple food items in various storage areas without required identification labels or open dates. In the night prep refrigerator, there was a gallon container of milk and a quart container of half & half with no opened dates. In the walk-in refrigerator, one bag of chicken tenders and one bag of meatless chicken tenders lacked identification labels. In the freezer, a bag of frozen pizza and a container of hot dogs were stored without identification labels. Additional unlabeled or undated items were found in dry and bulk storage areas. In the dry storage area, surveyors observed a tray of Cheerio cereal in bowls with no identification label, a bag of breadcrumbs with no opened date and no identification label, and a bag of dry elbow macaroni with no opened date. In the bulk storage area, a container of rice and a container of flour had no identification labels. In the milk storage refrigerator, a quart container of almond milk had no opened date. During an interview, the Food Service Manager acknowledged that it was not acceptable for food to be unlabeled or undated and stated that staff were expected to follow the facility’s food storage policy.
Failure to Involve Resident in Person-Centered Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was included in person-centered care planning and ongoing discharge planning. The resident was admitted for short-term rehabilitation with diagnoses including repeated falls, chronic kidney disease, and benign prostatic hyperplasia. A social work note documented that the resident was alert and oriented in all spheres, able to make needs known, and that the overall goal was to discharge to the community. The five-day MDS documented intact cognition, resident participation in assessment and goal setting, a goal to discharge to the community, and that active discharge planning was occurring. The care plan for discharge planning documented maintaining the resident’s customary routine/treatment and evaluating preferences and needs for possible transition to the community. However, there was no documented evidence that the resident or their representative was invited to participate in a comprehensive care plan meeting. The record further showed that the resident signed a Notice of Medicare Non-Coverage indicating Medicare coverage would end on 01/23/2026, and an appeal of this non-coverage was later denied. Despite these events, there was no documented evidence of an interdisciplinary care plan meeting to address discharge planning prior to the end of Medicare coverage or the start of private pay. In interviews, the resident did not recall having a care plan meeting and stated they planned to go home. The Director of Social Work stated that discharge plans start at admission and that they were aware the resident wanted to return home, but acknowledged that no care plan meeting had been held since admission and that there had been no further discharge planning until 02/12/2026. The Director of Social Work stated they should have planned a meeting sooner and could not explain why it was missed.
Failure to Timely Resolve Grievances for Missing Personal Property
Penalty
Summary
The facility failed to ensure grievances related to missing personal property were resolved in a timely manner for two residents. One resident with heart failure and depression, who was cognitively intact per a quarterly MDS assessment, reported via a grievance form that a red flip phone had been missing for four days. The grievance form, dated in late November, indicated the family had replaced the phone and the facility would reimburse the cost upon receipt of documentation from the family, and the form was signed as resolved in early December. However, there was no documented evidence of the reimbursement amount or that a check was provided, and the resident later stated in an interview that the phone was never found and no reimbursement had been received. Another resident with spinal stenosis, end stage renal disease, and diabetes, and with moderately impaired cognition per a quarterly MDS assessment, reported through a grievance form that a gold-colored chain with a medal cross and an iPhone case were missing. The grievance form documented that housekeeping and dietary staff were notified, a room search was completed, and reimbursement was offered while the facility awaited an estimate from the family; the grievance was also signed as resolved in early December. Despite this, there was no documentation of the reimbursement cost or that payment was made. In interviews, the Director of Social Work and two administrators acknowledged that reimbursement had been offered and that they preferred to resolve grievances within 24 hours, but they had no explanation for why reimbursement had not been provided or why there was no documentation of follow-up efforts or final resolution, even though the items had been reported missing months earlier.
Failure to Notify State Ombudsman of Resident Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide required copies of transfer or discharge notices to the State Long Term Care Ombudsman for residents who were hospitalized. Facility policy titled “Discharge Notice,” last revised 06/2025, states that when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, and that copies of notices for emergency transfers must also be sent to the Ombudsman, which may be done when practicable, such as in a monthly list. For Resident #14, who had diagnoses including fracture of the right femur, essential hypertension, and dementia, nursing progress notes documented admission to the hospital on 11/16/2025 with a right hip fracture. A transfer/discharge notice dated 11/16/2025 showed the resident representative’s signature dated 11/17/2025, and a bed-hold policy form dated 11/18/2025 also had the representative’s signature. However, there was no documented evidence that the New York State Ombudsman office was notified of this transfer. For Resident #153, who had diagnoses including unspecified dementia and malignant neoplasm of the left breast, a nursing progress note dated 11/13/2025 documented that the resident was sent to the hospital due to uncontrolled pain. A transfer/discharge notice dated 11/15/2025 documented that the resident representative was verbally notified on 11/13/2025, and a nursing progress note dated 11/14/2025 recorded that the emergency room nurse reported the designated representative was at the bedside requesting transfer to hospice for end-of-life care. Despite this documentation of the transfer and representative notification, there was no documented evidence that the New York State Ombudsman office was notified of the 11/13/2025 transfer. During interview, the Director of Social Work stated they kept a binder with a monthly transfer/discharge list, completed transfer/discharge forms, and bed-hold forms available for Ombudsman review, but acknowledged that they had not sent or emailed copies of completed transfer/discharge notification forms or a monthly transfer/discharge list to the Ombudsman office during the last six months. The Ombudsman confirmed they had not received copies of the transfer/discharge notifications for these residents and had not received a monthly list of discharged/transferred residents since April 2025.
Inaccurate MDS Coding for Falls and Pressure Ulcer Status
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments for two residents, contrary to facility policy requiring that the MDS accurately reflect resident status. One resident with diagnoses including orthopedic conditions, cancer, and osteoarthritis of the knee experienced a documented fall on 08/09/2025, when they were observed on the floor in front of their wheelchair, and another documented fall on 10/21/2025, when they were observed on the floor of their room. Despite these incidents, the 09/26/2025 quarterly MDS assessment documented no falls anytime in the last month prior to admission and no falls in the last 2 to 6 months, and the 12/12/2025 annual MDS assessment documented no falls since admission/entry or reentry or the prior assessment. During interview and record review, the MDS LPN acknowledged that these falls were not documented on the respective MDS assessments, stated they had entered "no falls" in error, and reported they had overlooked the resident’s falls and were not aware of the correct process to identify falls at the time of the assessments. A second resident, with diagnoses including cancer, hypertension, and anemia, had a wound care note dated 12/04/2025 documenting an initial evaluation of a stage three pressure ulcer to the left ischium, indicating it was facility-acquired. However, the 01/23/2026 quarterly MDS documented that this resident had a stage three pressure ulcer that was present on admission. In interview, the MDS LPN stated they entered the wound information on the MDS based on evaluations, progress notes, and wound care notes in the electronic medical record, confirmed that the resident did not have a pressure ulcer on admission, and stated they should have coded the pressure ulcer as not present on admission when completing the 01/23/2026 MDS assessment.
Failure to Update Care Plans for Anticoagulant and Antipsychotic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure comprehensive care plans were reviewed and revised with each assessment and as needed to reflect residents’ changing needs, as required by facility policy and regulation. For one resident with diagnoses including peripheral vascular disease and atrial fibrillation, a quarterly MDS documented moderate cognitive impairment and receipt of anticoagulants, and a physician order specified Eliquis 5 mg by mouth twice daily. However, there was no documented evidence in the resident’s cardiac care plan addressing the diagnosis of atrial fibrillation or the use of anticoagulants. During interview, the DON confirmed they could not locate a care plan addressing anticoagulant use for this resident and acknowledged that interventions to monitor and report signs and symptoms of bleeding or bruising should have been in place. The LPN Unit Manager stated they were aware of the anticoagulant order and that an RN could add an anticoagulant care plan, and identified that updating care plan interventions was a unit manager role. For another resident with diagnoses including dementia with anxiety and unspecified pain, a quarterly MDS documented moderate cognitive impairment and receipt of antipsychotic medication. A physician order documented olanzapine 5 mg by mouth at bedtime for major depressive disorder. The psychosocial care plan in place documented administration of non-psychotropic medication per physician order, but there was no care plan with interventions specifically addressing the use of antipsychotic medications. The LPN Unit Manager confirmed the resident received antipsychotic medication and could not locate a care plan addressing antipsychotic use, stating that such interventions could have been added under the psychosocial care plan and that the Social Work Department updated psychosocial care plans. The Director of Social Work stated that antipsychotic medication use was to be documented under psychosocial care plans, could not locate this on the resident’s care plan, and acknowledged responsibility for updating the care plan to address antipsychotic use, including interventions such as documenting antipsychotic use, psychology/psychiatry consults as needed, and monitoring and reporting changes in behavior.
Failure to Implement Heel Offloading and Pressure-Relief Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with professional standards and residents’ care plans for two residents identified as being at risk for pressure ulcers. One resident had diagnoses including bipolar disorder, unspecified dementia without behavior disturbance, and dysphagia, and was care planned under Skin Integrity as being at risk for impaired skin integrity related to impaired mobility, with an intervention to float/offload heels when in bed. The resident’s quarterly MDS documented severe cognitive impairment, dependence on staff for bed mobility, risk for pressure ulcers, and the presence of a stage IV pressure ulcer on admission. The CNA Kardex also directed staff to float the resident’s heels when in bed, reposition every two to four hours, and use a pressure relief mattress. Despite these documented interventions, surveyor observations on multiple dates showed the resident’s bilateral heels resting directly on the mattress, not offloaded or floated. During interviews conducted concurrently with observations, a CNA acknowledged that the resident’s heels were resting on the mattress and confirmed they should have been offloaded/floated, stating that the heels should have been checked after the resident was hand-fed lunch. An LPN similarly confirmed that the resident’s heels were not offloaded/floated, acknowledged the care plan intervention for heel offloading when in bed, and stated that all nursing staff, including CNAs, were responsible for ensuring the heels were offloaded, with nurses responsible for ensuring CNA tasks were completed. The LPN Unit Manager also confirmed the care plan intervention for heel offloading and stated that staff should have used pillows or a wedge device to offload the heels. The second resident had diagnoses including unspecified epilepsy non-intractable with status epilepticus, history of transient ischemic attack and cerebral infarction without residual deficits, and bipolar disorder. A physician order directed staff to offload the resident’s heels on a pillow in bed every shift as tolerated, and the Skin Integrity care plan documented the resident was at risk for impaired skin integrity related to type 1 diabetes and impaired mobility, with interventions including offloading/floating heels while in bed, turning and repositioning every two to four hours as needed, and use of a pressure reduction device when out of bed. The Transfer care plan also specified a pressure reduction device for out-of-bed use. The quarterly MDS documented moderate cognitive impairment, substantial/maximal assistance needed for bed mobility, and risk for pressure ulcers, with no current pressure ulcer. However, repeated observations showed the resident in bed with heels resting on the mattress, not offloaded, and in a wheelchair without a pressure-relieving cushion. A CNA confirmed the absence of a pressure-relieving cushion, stated they had last seen it weeks earlier when the resident used a Geri chair, admitted they had not reported the missing cushion, and stated they were unaware of the heel offloading order and care plan intervention because it was not on the CNA Kardex. The LPN Unit Manager confirmed the existence of the physician order and care plan interventions for heel offloading and wheelchair pressure reduction device, acknowledged the tasks were not completed, and stated that no staff had reported the missing cushion. The acting Director of Rehabilitation confirmed that a pressure reduction device for the wheelchair had been added to the care plan and that staff were expected to report missing cushions, but no such report had been received.
Failure to Follow Oxygen Orders and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failure to provide respiratory care consistent with professional standards and the resident’s care plan for one resident receiving oxygen therapy. The resident had diagnoses including bipolar disorder, unspecified dementia without behavior disturbance, dysphagia, and a stage 4 sacral wound requiring enhanced barrier precautions. The care plan directed staff to administer oxygen per physician order, and the physician order specified continuous oxygen via nasal cannula at 2 liters per minute. However, on multiple observations, the resident was receiving oxygen at 3 liters per minute. An LPN reported checking the oxygen concentrator earlier in the shift and confirmed it was set at 3 liters per minute, and also stated they were not initially aware of the exact physician order. After reviewing the order, the LPN acknowledged the order was for 2 liters per minute and that they should have verified the order and adjusted the flow rate accordingly. The deficiency also includes failure to follow enhanced barrier precautions and infection control practices when handling the resident’s nasal cannula. The resident was on enhanced barrier precautions due to a stage 4 sacral wound. During observation, the nasal cannula was resting in the resident’s hair/scalp, and a CNA removed the cannula from the hair and inserted the prongs into the resident’s nostrils without performing hand hygiene, donning gloves, or wearing a gown. The CNA later stated they should have applied appropriate PPE and performed hand hygiene before handling and placing the nasal cannula. The LPN unit manager stated that nursing staff were required to check oxygen flow rates during medication administration and each shift to ensure they matched the physician order, and that staff should mask, glove, and gown when providing care to residents on enhanced barrier precautions, with nurses responsible for supervising CNAs to ensure PPE use.
Failure to Develop and Implement Hospice Care Plan Upon Admission
Penalty
Summary
A deficiency was identified when a resident admitted from a hospital with Hospice care in place did not have a comprehensive, patient-centered Hospice care plan developed or implemented upon admission. The facility's policies require the interdisciplinary team to create and regularly update a care plan that includes collaboration with Hospice, the resident, and family. However, review of the resident's electronic medical record revealed no Hospice orders, no progress notes from medical providers indicating collaboration with Hospice, and no care plans addressing Hospice services. Despite documentation from the hospital and Hospice provider confirming the resident was receiving Hospice care, this information was not reflected in the facility's care planning documentation. Interviews with facility staff and the Hospice provider confirmed that Hospice services were being provided, including nursing, aide, and social work visits. However, communication breakdowns were evident, as the admissions process failed to relay the Hospice status to the care team, and staff were unaware or unable to document the resident's Hospice care in the system. The Director of Social Work stated they could not update the care plan without being informed of the resident's Hospice status, and the Nurse Liaison acknowledged that the information was not communicated as required. This lack of coordination and documentation resulted in the absence of a comprehensive Hospice care plan for the resident.
Failure to Document and Coordinate Hospice Care Services
Penalty
Summary
The facility failed to provide services in accordance with professional standards of care for a resident receiving Hospice care from an outside agency. The resident's medical record lacked documentation, including orders for Hospice, progress notes from medical providers, and a comprehensive care plan addressing Hospice services. Despite the facility's policy requiring nursing coordination and ongoing collaboration with Hospice, as well as the development and regular review of a resident-centered care plan by the interdisciplinary team, these requirements were not met. The electronic medical record did not contain any evidence of Hospice involvement, and communication about the resident's Hospice status was not documented or relayed to relevant staff. Interviews with facility staff and the Hospice provider revealed that while the resident did receive multiple visits from Hospice nurses, aides, and a social worker, the documentation of these services was not integrated into the facility's records. Staff were unclear about the process for documenting Hospice care, with some believing that notes were kept in a binder on the unit, while others, including the Medical Director, were unaware of such a system. The lack of communication and documentation resulted in the facility not having an order for Hospice or a care plan reflecting the resident's Hospice status, and the information about the resident's enrollment in Hospice was not properly conveyed to the admissions or care team.
Failure to Document and Implement Pressure Injury Prevention Interventions
Penalty
Summary
The facility failed to provide consistent evidence that care plan interventions for pressure injury prevention were carried out for a resident admitted with a deep tissue injury. The resident, who had multiple diagnoses including a femur fracture, hypotension, and was receiving palliative care, had a care plan intervention requiring turning and positioning every two hours. However, documentation from the period reviewed showed only 14 notes suggesting the resident may have been moved, with just five notes specifically indicating that turning and positioning occurred. Most documentation did not clearly state that the intervention was performed as required by the care plan. Facility policies required close monitoring and documentation of pressure ulcers and chronic wounds, as well as adherence to care plan interventions for activities of daily living, including turning and positioning. Interviews with staff revealed a lack of clarity and consistency in documenting these interventions. Certified Nurse Aides reported that they were not instructed to document turning and positioning, and that communication about these interventions was informal and not reliably recorded. Attempts to demonstrate electronic documentation were unsuccessful, and staff were unable to confirm when the resident was last turned or positioned. Nursing staff, including LPNs and the Assistant Director of Nursing, confirmed that there was no systematic documentation of turning and positioning, either on paper or electronically. They expressed uncertainty about when interventions were performed and acknowledged that there was no tracking system in place. This lack of documentation and inconsistent communication among staff led to the deficiency in ensuring that the resident's care plan interventions for pressure injury prevention were consistently implemented and recorded.
Failure to Document and Order Hospice Care for Admitted Resident
Penalty
Summary
A deficiency was identified when a resident admitted to the facility, who was already receiving Hospice care at their prior facility, did not have any physician orders or progress notes entered to continue Hospice care upon admission. Record review showed that from the time of admission until discharge, there were no documented orders for Hospice services, nor any physician notes indicating awareness of the resident's Hospice status. The facility's policy requires a collaborative effort with Hospice providers and mandates a written agreement and documentation for residents with life-limiting illnesses, but this was not followed in this case. During interviews, the Medical Director confirmed that it is standard practice to write an order for Hospice care and acknowledged that there were no such orders or notes for this resident. The Medical Director stated they were unaware of the resident's Hospice status and had not seen any documentation or binders related to Hospice for this individual. The lack of physician documentation and orders for Hospice care was attributed to an oversight that went unnoticed by facility staff.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for residents, as required by regulation. Observations revealed that multiple resident rooms on the Roosevelt unit had significant environmental deficiencies, including windows covered with duct tape or plastic, window screens with holes, broken furniture, and numerous unpainted spackled patches on the walls. In several cases, residents were newly admitted and found their rooms in these conditions upon arrival, with some expressing dissatisfaction and concern about the state of their living environment. Residents reported ongoing issues such as drafts and water leaks from windows, with temporary fixes like duct tape and plastic coverings being used instead of permanent repairs. One resident noted that the plastic covering on their window had been in place for over a month, and water would accumulate and leak during rain. Another resident expressed concern about spackle dust from unpainted wall patches, which had been left after the removal of equipment from the walls. Residents also reported broken dressers that prevented them from storing their clothing properly. Interviews with facility staff, including the Maintenance Director and Administrator, confirmed that there was no formal work order system in place, and that maintenance rounds sometimes missed needed repairs. The Maintenance Director acknowledged that the Roosevelt unit had not been painted in several years, and that sanding and painting of spackled areas had been delayed due to workload. Staff also confirmed that temporary measures, such as plastic window coverings, were not appropriate for extended use, and that some windows and furniture were overdue for repair or replacement.
Failure to Ensure Timely Completion of Abuse Prevention Training by CNAs
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) maintained the required competencies and completed annual abuse prevention training as mandated by facility policy and regulatory requirements. Record review revealed that three CNAs involved in separate allegations of abuse had not completed their required annual abuse training on time. Specifically, each CNA had significant gaps between their last completed abuse training and the date of the incident or the most recent training, with overdue assignments not completed until several months after they were due. The facility's abuse prevention policy did not specify the frequency of required training, and staff were found to be out of compliance with annual training requirements. Interviews with facility staff, including the Staffing Educator, Regional DON, Interim Administrator, and DON, confirmed that multiple staff members had not completed mandatory in-service trainings on time. The Staffing Educator reported that notifications and reminders were sent to staff and administration regarding overdue trainings, but these measures were not effective in ensuring compliance. One CNA stated they did not recall their last abuse training and had not received disciplinary action for missing required trainings. The deficiency was identified through record review and staff interviews, with documentation showing that the required abuse prevention training was not completed annually as required.
Failure to Ensure Timely Orthopedic Follow-Up After Resident Fracture
Penalty
Summary
Resident #4, who had diagnoses including dementia, multiple fractures, nontraumatic intracerebral hemorrhage, and repeated falls, experienced an unwitnessed fall resulting in pelvic and iliac crest fractures. Following hospitalization, the discharge instructions specified that the resident should remain non-weight bearing on the right lower extremity and have a follow-up appointment with an orthopedic surgeon within 2-4 weeks. The facility's policy required assistance in scheduling outside appointments per provider recommendations. However, there was no documented evidence that the required orthopedic follow-up appointment was scheduled or completed as directed by the hospital discharge instructions. Interviews with facility staff revealed that discussions about the follow-up appointment and transportation occurred, but no documentation was provided to confirm these discussions or any follow-up actions. The Director of Therapy mentioned attempting to arrange a telehealth consultation with an orthopedic surgeon but could not provide documentation or a date for this action. The Director of Nursing confirmed that the unit manager and unit clerk were responsible for reviewing discharge paperwork and scheduling follow-up appointments, but no records of an orthopedic consult or appointment were available. The lack of documentation and follow-through resulted in the resident not receiving care in accordance with professional standards and the hospital's discharge instructions.
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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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