The Grand Rehabilitation And Nursing At Rome
Inspection history, citations, penalties and survey trends for this long-term care facility in Rome, New York.
- Location
- 801 North James Street, Rome, New York 13440
- CMS Provider Number
- 335589
- Inspections on file
- 25
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at The Grand Rehabilitation And Nursing At Rome during CMS and state inspections, most recent first.
Surveyors found multiple failures in medication security and labeling on three of four medication carts. On one Wing Three cart, an LPN left the cart unlocked and unattended with two unlabeled cups of pre‑poured medications for residents who were not immediately available, and the nurse admitted not knowing what to do with pre‑poured meds when a resident could not be found. On another Wing Three cart, surveyors found an opened, unlabeled lidocaine vial, an undated fluticasone/salmeterol inhaler, expired insulin (Rezvoglar pen and Humulin R vial) still stored in the cart, and additional opened insulin (lispro vial and Lantus pen) that were undated, with the LPN confirming these should have been dated and removed when expired. On a Wing Four cart, opened artificial tears and latanoprost eye drops lacked open dates, and several opened inhalers were undated and unlabeled; the LPN stated they had not been trained that inhalers required dating and believed they did not expire, despite facility policy requiring opened multi‑dose medications to be dated and outdated drugs not to be used.
Surveyors identified multiple failures in food storage, sanitation, and meal service, including a main kitchen reach-in cooler operating above safe temperatures with improperly cooled eggs and other cold foods, and black residue on cooler door gaskets and a walk-in milk cooler ceiling crease in both the main kitchen and a unit pantry. There was no documented kitchen cleaning schedule, no record of gasket or ceiling cleaning, and staff gave conflicting accounts of who was responsible for cleaning refrigerators and gaskets. During meal service, a food service worker attempted to provide a resident with a tray taken from a cart containing dirty and uneaten trays, without a tray ticket, before acknowledging this should not be done and removing the tray.
The facility failed to follow care-planned ADL assistance for two residents who required substantial help with oral hygiene and toileting. One resident with dementia and Parkinson’s disease, care-planned for substantial/maximum assistance with oral care, was repeatedly observed with foul breath, reported that staff did not brush their teeth, and had oral care documented as completed by a CNA who later admitted they had not provided it and had charted anticipated care. Another resident with dementia, dependent for most ADLs and care-planned for regular toileting and brief checks every few hours, was observed sitting in the dining area for extended periods without being toileted or repositioned, was later found with a saturated brief or visibly wet clothing, and had toileting documented at times inconsistent with observations. CNAs and an LPN acknowledged expectations for toileting every 2–3 hours and for staff to brush teeth when substantial assistance was required, but these practices were not carried out or accurately documented.
Surveyors found that the facility failed to maintain accurate and secure controlled substance management on one unit. An LPN and another nurse did not complete required two‑nurse narcotic counts before exchanging keys, and several controlled drug records did not match the actual quantities on hand. For multiple residents receiving Vimpat, gabapentin, hydrocodone‑acetaminophen, and PRN lorazepam, doses were signed out on controlled substance logs with incorrect balances, one PRN lorazepam dose was signed out but not documented as given on the MAR, and a poured dose of liquid Vimpat was left in a cup inside the narcotic compartment instead of being administered or wasted. Staff interviews confirmed that counts were sometimes estimated, done by a single nurse, or pre‑signed, contrary to facility policy requiring real‑time documentation, two‑nurse reconciliation, and immediate wasting of unused controlled doses.
A resident with diabetes and diabetic wounds was discharged without proper education, supplies, or medication reconciliation, and without confirmation of safe housing or supportive services. The resident, lacking identification and a primary care provider, was sent to the Department of Social Services without prior coordination, resulting in denial of emergency housing and subsequent hospitalization for severe hyperglycemia.
A resident with a history of a brain hemorrhage and dependent on staff for care developed a Stage 2 pressure ulcer due to inadequate incontinence care. The facility's failure to provide consistent toileting hygiene and wound treatment led to the ulcer progressing to an unstageable state with necrotic tissue. Despite care plans and protocols, the resident's condition worsened, resulting in hospitalization.
The facility failed to maintain a safe, clean, and homelike environment across all units, with issues such as sticky floors, damaged walls, and unclean resident chairs. Drain flies were observed, and negative air pressure was lacking in soiled utility rooms. Staff interviews revealed systemic issues in maintenance and housekeeping, with no documented work orders for the deficiencies.
A facility failed to provide adequate hygiene care for residents, including those with dementia and hemiplegia, resulting in untrimmed and soiled fingernails. Staff were unaware of residents' needs for glasses and nail care, and documentation inaccurately reflected care provided.
The facility failed to serve food and drinks at safe and appetizing temperatures, as observed during breakfast and lunch meals. Residents reported dissatisfaction with the food's taste and temperature, with items like scrambled eggs and pureed chicken served below the required 135°F. Cold items, such as diet cola and milk, were also served above the acceptable temperature range. The Food Service Director confirmed that such temperatures could lead to foodborne illnesses.
The facility failed to provide adequate dining facilities for residents on Units 100 and 400, resulting in residents being lined up in hallways during meals. Observations showed that dining areas did not accommodate residents' needs, with many eating in cramped conditions without social interaction. Staff interviews revealed that the main dining room had been closed due to staffing issues, contributing to the lack of space and dignified dining experiences.
Two residents with severe cognitive impairments were treated undignifiedly by staff, who referred to them as 'feeders' and assisted them with eating in a disrespectful manner. This violated the facility's dignity policy, which mandates respectful treatment and avoidance of labels based on care needs.
A facility failed to conduct a Level II PASARR for a resident newly diagnosed with schizoaffective disorder, as required by federal regulations. Despite the diagnosis, no documentation of a referral was found. Interviews revealed that the Director of Social Work did not initiate the screening process for new mental health diagnoses, and the Director of Nursing confirmed that such diagnoses were discussed in meetings but not followed by a new PASARR.
A resident with dysphagia and no teeth was served whole sandwiches instead of the prescribed chopped consistency diet, posing a choking risk. Despite facility policies requiring meal accuracy checks, staff failed to ensure the resident received food prepared to meet their individual needs.
A resident with Alzheimer's and chronic kidney disease did not receive the prescribed fluids and was not offered a suitable substitution when requesting a sandwich. Despite being on a pureed diet, the resident's care plan was not updated to reflect dietary changes, leading to inadequate food intake and dissatisfaction. Staff interviews revealed a lack of follow-through in providing requested food alternatives.
The facility violated CMS regulations by conducting an off-site nurse aide training program despite a prohibition. Observations revealed that nurse aide students were receiving clinical training at the facility, which was not allowed under the CMS letter dated February 2024. The facility's administration was unaware that the prohibition applied to off-site training, leading to the continuation of the program until the survey.
Improper Medication Cart Security and Failure to Label and Remove Outdated Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were securely stored and properly labeled in accordance with facility policy and accepted professional standards. On Wing Three, surveyors observed the front medication cart unlocked and unattended, with the first drawer containing two unlabeled cups of pre‑poured medications. Each cup contained multiple different pills, and the responsible LPN stated they had walked away from the cart to speak with a family member and acknowledged the cart should never be left unlocked and unattended. The LPN also stated that one resident was not available for medication administration and that they were waiting for another resident’s inhaler from the pharmacy, and admitted they were unsure what to do with pre‑poured medications when a resident was unavailable. Further observations on the Wing Three back cart revealed multiple issues with labeling and expiration of medications. Surveyors found an opened, unlabeled, and undated vial of lidocaine in the second drawer, which the assigned LPN stated came with ertapenem and had not been labeled or dated when opened; the LPN was unsure whether it needed to be dated. The third drawer contained an undated fluticasone/salmeterol inhaler, which the LPN acknowledged should probably have been labeled when opened but was not. Another drawer contained a Rezvoglar insulin pen and a Humulin R insulin vial with open dates indicating they were beyond the stated in‑use period; the LPN confirmed they were expired and should be discarded and reordered, and could not explain why expired insulin remained in the cart. The same drawer also contained an opened, undated insulin lispro vial and an opened, undated Lantus insulin pen, which the LPN stated were required to be dated when opened but could not determine when they had been opened or whether they were expired. On Wing Four, surveyors observed additional failures to date and label opened medications. In the first drawer of the back medication cart, artificial tears and latanoprost eye drops were found opened without open dates, despite the assigned LPN stating that eye drops were supposed to be labeled with an open date and an expiration date and that they expired 30 days after opening; the LPN was unsure why these eye drops lacked open dates. In the third drawer, opened, undated inhalers (including umeclidinium/vilanterol and albuterol) were found without labeling to indicate when they were opened. The LPN assigned to this cart stated they had never been trained that inhalers had to be labeled when opened, did not think inhalers expired, and believed they were good until the medication was finished, despite the unit manager later stating that inhalers and eye drops should be dated when opened and were typically good for 30 days. Facility policies in effect required medication storage compartments to be locked when unattended, prohibited use of outdated drugs, and required multi‑dose medications to be dated when opened.
Improper Food Storage, Sanitation, and Meal Tray Handling
Penalty
Summary
The deficiency involves failure to store, clean, and handle food in accordance with professional standards in the main kitchen and a unit pantry. Surveyors observed that the main kitchen cold production reach-in cooler had an internal temperature of 50°F, with stored items including hard‑boiled eggs, cheese slices, poultry cold cuts, liquid supplements, and poured juices; the hard‑boiled eggs measured 43.2°F, above the facility policy requirement that cold food be stored below 41°F. A black substance was observed on the door gasket of this reach‑in cooler, along the ceiling crease of the main kitchen walk‑in milk cooler, and on the door gasket of the Unit 2 snack refrigerator. There was no documented main kitchen cleaning schedule, and the food service maintenance communication log from September 2025 through April 2026 contained no entries for gasket or walk‑in cooler ceiling crease cleaning. Staff interviews revealed conflicting understandings of responsibility for cleaning refrigerators and gaskets, with food service leadership stating maintenance was responsible for gaskets, while maintenance leadership stated kitchen staff were responsible, and nursing staff reporting they cleaned unit refrigerators without a set schedule and did not clean gaskets. The deficiency also includes improper meal service practices. During a lunch observation, a resident who had initially declined lunch later requested it after the food cart had left the wing with dirty and uneaten trays mixed throughout the cart. A food service worker went to the dirty cart in the hallway, pulled several trays out before selecting one they felt looked acceptable, and brought it to the unit without a tray ticket, handing it to a CNA. The worker then acknowledged that trays removed from a dirty food cart should not be served and removed the tray, stating they would obtain a fresh one. The food service director later stated that uneaten meal trays mixed with dirty trays should not be served for infection control reasons and that staff should obtain a new tray from the kitchen.
Failure to Provide Planned Oral Care and Toileting Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically oral hygiene and toileting, as required by residents’ care plans and facility policy. Facility policy stated that residents needing ADL assistance would receive adequate toileting every two to four hours and staff would assist with oral hygiene, with refusals reported to a supervisor. Resident #1, with dementia, anxiety, and Parkinson’s disease, had a care plan and care instructions requiring substantial/maximum assistance with personal hygiene and oral care, meaning staff were to apply toothpaste and brush the resident’s teeth. The Minimum Data Set (MDS) documented moderately impaired cognition, substantial/maximum assistance needed for hygiene and toileting, partial/moderate assistance for oral care, and no rejection of care. Resident #1 was observed on two separate dates with foul breath. Documentation showed that a CNA recorded oral care as completed during the overnight shift, but that CNA later stated they did not perform oral care for the resident and had documented anticipated care at the start of the shift rather than after completion. Another CNA assigned to the resident on day shift stated they did not brush the resident’s teeth because they believed night shift had already done so, and confirmed the resident had never refused care. The resident reported that staff did not brush their teeth and that they liked having their teeth brushed. An LPN and the unit manager both described that substantial/maximum assistance for oral care required staff to brush the resident’s teeth and that refusals should be documented, but the LPN incorrectly stated that the resident was independent with brushing their teeth, contrary to the care plan and MDS. Resident #2, with dementia and dependence for most ADLs, had a care plan documenting dependence on toileting hygiene, supervision or touching assistance for toilet transfers, and interventions including checking and changing briefs every three to four hours and as needed. Continuous observations on two separate days showed the resident seated in the dining area for over four hours each day without being repositioned, taken to the bathroom, or offered toileting, until staff eventually walked the resident to the bathroom or room. On one day, the resident’s brief was observed to be saturated when removed; on the other day, a large wet area was visible on the resident’s pants. Documentation indicated the resident was toileted during the day shift on both days at times inconsistent with the observed lack of toileting. The CNA caring for the resident stated residents were to be toileted or repositioned every two to three hours and that refusals should be reported to a nurse, but admitted that although the resident declined offers to be changed, these declinations were not reported and the resident was not re-approached. An LPN stated residents should be repositioned and toileted every two hours and that the assigned aide was responsible for doing so while the nurse ensured it occurred, and confirmed the resident should not have been sitting for over four hours.
Failure to Accurately Reconcile and Securely Manage Controlled Substances
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate records and secure handling of controlled substances on Unit 1, contrary to its own Controlled Substance/Narcotic Management Protocol. Policy required that with each administration, nurses document date, time, prior and post‑administration counts, and sign the controlled substance log; that any dose removed but not given be destroyed in the presence of another nurse; that all narcotics be counted and reconciled at the beginning of every shift by both oncoming and outgoing nurses with both signing; and that discrepancies be reported immediately. On the dates reviewed, the narcotic count sheets, individual controlled substance records, and actual on‑hand quantities did not match, and required two‑nurse shift counts were not consistently performed before narcotic keys were exchanged. For one resident receiving Vimpat (lacosamide) twice daily, the narcotic count record showed 940 mL remaining, while direct observation found only 850 mL on hand (one opened bottle at the 50 mL mark and two unopened 400 mL bottles). The LPN who signed the 8:00 AM administration documented using 20 mL and a remaining balance of 940 mL, and the MAR reflected that the dose was given, but the nurse later stated there were only 850 mL and could not explain why 940 mL was recorded. For another resident on Vimpat 10 mL twice daily, the LPN signed out 10 mL on the controlled substance record, leaving a documented balance of 120 mL, but also documented on the MAR that the morning dose was “poured but not given” because the resident did not wake up. A clear liquid in a 30 mL cup was found spilled in the locked narcotic compartment; the LPN identified it as that resident’s Vimpat, stated they had placed it there when the resident was not awake, and admitted they forgot it and did not discard it as required. For a resident with an as‑needed order for lorazepam 0.5 mg every six hours for anxiety, a blister pack with 26 tablets was observed, while the lorazepam administration record showed that one tablet had been signed out at 8:00 AM with a balance of 25 tablets. The MAR, however, contained no documentation that the resident actually received lorazepam that day. The LPN stated they signed out the lorazepam intending to administer it but did not give it because the resident was not having behaviors, and acknowledged they should not have signed it out on the count sheet. For a resident receiving scheduled gabapentin 300 mg twice daily, there were 55 tablets physically present (a full card of 30 in the medication room and a card of 25 in the cart), but the narcotic count record and controlled substance record documented a balance of 56 tablets after one tablet was signed out at 8:00 AM; the LPN stated they must have counted wrong when documenting the balance. For another resident prescribed hydrocodone‑acetaminophen 5‑325 mg three times daily, there were 66 tablets on hand (two full 30‑tablet cards and one card with six tablets), while the narcotic count record documented a 7:00 AM balance of 68 tablets. The controlled substance administration record showed the LPN signed out one tablet leaving a balance of 66 tablets, which did not reconcile with the earlier count sheet. The LPN reported that narcotics were supposed to be counted by two nurses and that the numbers on the count sheets should match the pills on hand, but stated that when they arrived that morning, the other LPN had already filled out and signed the narcotic count sheet and they then counted alone and co‑signed. The outgoing LPN confirmed that counts were supposed to be done by two nurses at shift change, admitted they had roughly estimated the Vimpat volume without glasses, acknowledged the count sheet should not have shown 940 mL when only about 850 mL were present, and stated they handed over the narcotic keys before completing a joint count because they were busy with a tube feeding. The unit manager and DON both stated that counts should be done by two nurses with both sheets and medications present, keys should not be exchanged until counts are verified, medications should be wasted if not immediately administered, and narcotics should be signed out at the time of actual administration, which did not occur in these instances.
Failure to Ensure Safe Discharge and Continuity of Care for Resident with Diabetes
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident with diabetes and diabetic wounds, resulting in Immediate Jeopardy. The resident, who was homeless and had no identification, was discharged to the Department of Social Services via family transportation without prior consultation with the Department to confirm the availability of housing or supportive services. The discharge planning process did not include verification that the resident's health and safety needs or preferences were met, and there was no evidence that the resident or their representative received or signed discharge instructions. The resident was discharged without proper education or supplies to manage their diabetes and diabetic wounds. Documentation was lacking regarding the provision of insulin, a glucometer, or wound care supplies, and there was no record of medication reconciliation or teaching for diabetes management. Interviews with facility staff revealed confusion about responsibilities for discharge education and supply provision, and it was confirmed that the resident did not have a primary care provider established at the time of discharge, which prevented the setup of home health or wound care services. After discharge, the resident was denied emergency housing at the Department of Social Services due to a previous unpaid stay and had to rely on their sibling for temporary accommodation and basic needs such as food. The resident subsequently presented to the emergency department with dangerously high blood sugar, having been discharged from the facility without insulin or medications sent to a pharmacy. Interviews with staff and the resident's family confirmed that the resident was not adequately prepared or equipped for self-care post-discharge, and that the facility's discharge process failed to ensure continuity of care or resident safety.
Removal Plan
- The pending discharge was reviewed for verification of post-discharge services, receiving locations, and physician notification.
- Social Services, the Nursing Management team involved in discharges, Director and Assistant Director of Rehabilitation, and the Recreation Director were educated on discharge planning process to include verification of safety and discharge medication.
- A new discharge form was instituted that required medication listed with quantities, medical equipment provided, teaching provided, and discharge location that required both resident/resident representative signature in addition to discharging nurse.
- All discharges in the last 30 days were reviewed for safety and called to ensure they had the necessary services in place.
- All staff identified for education received education, with the exception of staff members who were not available. The individuals who did not receive education will complete education upon their return, prior to the start of their shift.
- Interviews were completed to determine compliance with staff training and education including the Director of Social Services, the Recreation Director, the Assistant Director of Rehabilitation, one Unit Manager, and the Director of Nursing.
Inadequate Pressure Ulcer Care Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and progression of pressure ulcers for a resident at risk. The resident, who had a history of a non-traumatic subarachnoid hemorrhage and was dependent on staff for all activities of daily living, developed a Stage 2 pressure ulcer on the right buttock due to inadequate incontinence care. The facility's policy required daily skin inspections and timely incontinence care, but documentation revealed that the resident was not consistently provided with toileting hygiene, leading to moisture-associated skin damage and the development of a pressure ulcer. The resident's care plan included interventions such as applying zinc ointment with each incontinence episode, repositioning every 2-3 hours, and using pressure-relieving devices. However, the treatment administration records showed multiple instances where the prescribed treatments were not documented as completed. Interviews with staff indicated that the resident was often found with soaked incontinence briefs and dried feces, suggesting a lack of adherence to the care plan. The wound progressed to an unstageable pressure ulcer with necrotic tissue, indicating a failure to follow physician orders and provide consistent wound care. Despite the facility's protocols and care plans, the resident's condition worsened, leading to hospitalization. Staff interviews revealed inconsistencies in care documentation and a lack of awareness regarding the resident's condition. The facility's failure to provide routine incontinence care and consistent wound treatment contributed to the deterioration of the resident's skin integrity, resulting in a significant deficiency in care.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment across all four units reviewed during the recertification survey. Observations revealed multiple deficiencies, including sticky floors, damaged walls, and unclean resident chairs on Units 100, 200, 300, and 400. Additionally, drain flies were found in the Unit 200 shower room, and there was a lack of negative air pressure in the soiled utility rooms of Units 200, 300, and 400. Specific issues included a call bell out of reach for a resident, a strong odor of urine in a resident's room, and damaged wheelchairs. The facility's housekeeping policy, which mandates routine cleaning and maintenance, was not effectively implemented, as evidenced by the absence of documented work orders for the identified issues. Interviews with facility staff highlighted systemic issues in maintenance and housekeeping responsibilities. Housekeeper #4 noted difficulties in maintaining clean floors due to resident incontinence, while LPN Unit Manager #3 acknowledged that the maintenance department was responsible for painting and repairs, but work orders were not consistently submitted or completed. The Maintenance Director confirmed that work orders could be submitted via computers or a phone application, but there was no evidence of such orders for the observed deficiencies. The facility's goal to maintain a homelike environment was not met, as evidenced by the numerous environmental issues and lack of timely maintenance.
Deficiency in Resident Hygiene and Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #127, who had diagnoses including cerebral infarction and dementia, was observed multiple times with long, untrimmed fingernails and without wearing their glasses, despite being dependent on staff for personal hygiene and requiring corrective lenses. The facility's documentation inaccurately reflected that the resident was wearing glasses, and staff interviews revealed a lack of awareness regarding the resident's need for glasses and nail care. Resident #80, who had right hemiplegia and was dependent on staff for personal hygiene, was observed with long fingernails containing brown debris on several occasions. Despite the resident expressing discomfort and a desire for their nails to be cut, the facility failed to provide the necessary nail care. Interviews with staff indicated a lack of adherence to the facility's nail care policy and a failure to document any refusals of care by the resident. Resident #90, diagnosed with dementia and requiring assistance with personal care, was also observed with long fingernails and brown debris underneath. The resident's care plan indicated dependence on staff for personal hygiene, yet the facility did not ensure proper nail care was provided. Staff interviews highlighted a lack of communication and documentation regarding the resident's hygiene needs, resulting in undignified conditions for the resident.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, attractive, and at safe and appetizing temperatures during the recertification and abbreviated surveys conducted. Specifically, during the breakfast and lunch meals on June 26, 2024, food items were served at temperatures outside the acceptable range. The facility's policy required hot foods to be served at a minimum of 135 degrees Fahrenheit and cold foods to be below 41 degrees Fahrenheit. However, observations revealed that the temperatures of several food items, including cheesy scrambled eggs, pureed barbecue chicken, and pureed macaroni and cheese, were below the required 135 degrees Fahrenheit. Additionally, cold items such as diet cola and honey thickened milk were served at temperatures above the acceptable range. Interviews with residents and the Food Service Director highlighted dissatisfaction with the food's palatability and temperature. Residents reported that the food was bland, lacked taste, and was often served at incorrect temperatures. The Food Service Director acknowledged that food items served at temperatures outside the acceptable range could lead to foodborne illnesses. Despite the facility's policy to test food palatability for two test trays per week, the deficiency in maintaining appropriate food temperatures persisted, affecting the quality of meals served to residents.
Inadequate Dining Facilities for Residents
Penalty
Summary
The facility failed to provide adequately furnished and spacious dining rooms for resident dining and activities on Units 100 and 400. Observations revealed that the dining rooms on these units did not accommodate the social and physical needs of the residents. On Unit 100, the dining area had six square tables, with some tables pushed together, and residents were observed sitting in wheelchairs, reclining chairs, or with assistive devices, leaving no room for ambulatory residents. Many residents were lined up in the hallway during meals, seated with bedside tables, and appeared cramped, with no music or conversation to enhance the dining experience. On Unit 400, there was no designated dining area, and residents were observed eating in the hallway or in their rooms. Interviews with staff revealed that the main dining room had been closed for several months due to staffing issues and had not been used for two years. The CNA stated that residents requiring supervision were lined up in the hallway, while the LPN Supervisor suggested that opening the main dining room could reduce congestion. The Director of Nursing acknowledged that the main dining room had been closed since the COVID-19 outbreak and recognized that dining in the hallway was not a dignified experience for residents. The lack of adequate dining facilities led to residents being lined up in hallways, which did not provide a comfortable or social dining environment.
Failure to Ensure Dignified Care for Residents
Penalty
Summary
The facility failed to ensure a dignified existence for two residents during the recertification and abbreviated surveys. Resident #28, who had severe cognitive impairment and required extensive assistance for eating, was referred to as a 'feeder' by staff. During an observation, a Licensed Practical Nurse (LPN) was assisting Resident #28 with eating when a Certified Nurse Aide Instructor inquired if a student could assist. The LPN responded negatively, labeling the resident as a 'difficult feeder,' a conversation that was audible to others nearby. This labeling was contrary to the facility's policy on dignity, which emphasized treating residents with respect and avoiding labels based on care needs. Similarly, Resident #44, who also had severe cognitive impairment and was dependent on staff for eating, was observed being fed by a Certified Nurse Aide who stood over them, an action acknowledged by the aide as undignified. The aide also referred to the resident as a 'feeder,' indicating a lack of adherence to the facility's dignity policy. Both instances highlight the facility's failure to uphold the residents' rights to dignity and respect, as outlined in their own policies and regulatory requirements.
Failure to Conduct Level II PASARR for Newly Diagnosed Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a newly diagnosed serious mental disorder was referred for a Level II Pre-admission Screening and Resident Review (PASARR), as required by federal regulations. The resident, admitted with diagnoses of anxiety and depression, was later diagnosed with schizoaffective disorder. Despite this new diagnosis, there was no documentation of a Level II PASARR referral, which is necessary to identify the specialized services required by the resident. The New York State Department of Health Instruction Manual mandates that a new SCREEN and Level II referral must be completed within 14 calendar days of a new mental illness diagnosis. Interviews with facility staff revealed a lack of understanding and adherence to the PASARR process. The Director of Social Work admitted to not reviewing PASARRs until after admission and did not initiate a new screening process for newly diagnosed serious mental health conditions. The Director of Nursing confirmed that new mental health diagnoses were discussed in team meetings, but there was no evidence of a new PASARR being conducted. This oversight indicates a gap in the facility's procedures for ensuring appropriate placement and care for residents with serious mental illnesses.
Failure to Provide Appropriate Food Consistency for Resident
Penalty
Summary
The facility failed to ensure that Resident #111 received food prepared in a form designed to meet their individual needs, as required by their physician's order. Resident #111, who had diagnoses including Alzheimer's disease, gastro-esophageal reflux disease, and dysphagia, was ordered a regular diet with chopped consistency due to being edentulous and at risk for malnutrition. However, during a lunch meal observation, the resident was served a whole meatball hoagie and a whole grilled cheese sandwich, which were not chopped as required by their dietary needs. Interviews with various staff members, including a Certified Nurse Aide, Resident Assistant, LPN Unit Manager, Registered Dietitian, Speech Language Pathologist, Food Service Director, and Director of Nursing, revealed a lack of adherence to the facility's policy on food consistencies and definitions. The staff acknowledged that a chopped consistency diet should involve cutting food into smaller pieces, and serving whole sandwiches posed a choking risk for the resident. Despite the facility's policy requiring meals to be checked for accuracy by both the Food and Nutrition staff and service staff, the resident received inappropriate food consistency. The deficiency was further highlighted by the fact that the facility's policy on the accuracy and quality of tray lines was not followed. The Food Service Director admitted that meal tickets should have been checked before trays left the kitchen and upon delivery to the units. The staff's failure to adhere to the prescribed diet consistency for Resident #111, who had no teeth and required chopped food, demonstrated a significant oversight in ensuring the resident's safety and dietary needs were met.
Failure to Accommodate Resident's Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food that accommodated the dietary needs and preferences of a resident, identified as Resident #59, during a recertification survey. Resident #59, who had diagnoses including Alzheimer's Disease and chronic kidney disease, was on a regular diet with pureed texture and thin liquid consistency due to mild oral phase dysphagia. Despite these dietary requirements, the resident did not receive the ordered fluids on their meal tray and was not offered a suitable substitution when they requested a sandwich. Observations revealed that during a meal, the resident's tray lacked the prescribed Boost and water, and when the resident requested water and a sandwich, they were not provided with appropriate alternatives. The resident expressed dissatisfaction with the food served, stating it left a bad taste in their mouth and that they were often hungry. Interviews with staff indicated a lack of follow-through in providing the resident with requested food alternatives, such as a pureed sandwich, which was within the resident's dietary allowances. The facility's staff, including a Licensed Practical Nurse and a Registered Dietitian, acknowledged the importance of offering alternatives to ensure adequate nourishment. However, there was a failure to update the resident's care plan to reflect changes in dietary needs as recommended by the speech language pathologist. This oversight contributed to the resident's inadequate food intake and dissatisfaction with meal options, highlighting a deficiency in meeting the resident's dietary preferences and needs.
Violation of Nurse Aide Training Prohibition
Penalty
Summary
The facility was found to be in violation of regulations during a recertification survey due to conducting an off-site nurse aide training program despite a prohibition from the Centers for Medicare and Medicaid Services (CMS). The facility had received a letter from CMS dated February 9, 2024, which prohibited the provision of a Nurse Aide Training and Competency Evaluation Program, conducting onsite nurse aide competency exams, or utilizing onsite clinical training by an off-site nurse aide training program, effective through October 2025. However, observations during the survey revealed that the facility was collaborating with a local community college to provide clinical training for nurse aide students within the facility. The facility had a contract with the community college to provide in-agency learning experiences for nurse aide students, which included the college providing the curriculum and instructors, while the facility provided the necessary environment and support. During the survey, it was observed that nurse aide students were present in the facility for training, and the Nurse Aide Instructor confirmed that the students had been training at the facility since January 2024. The facility's Administrator and Corporate Nurse were unaware that the prohibition applied to off-site training programs as well, and upon reviewing the CMS letter, they acknowledged the mistake and stated that the training program would cease immediately.
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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