The Paramount At Somers Rehab And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Somers, New York.
- Location
- Route 100, Somers, New York 10589
- CMS Provider Number
- 335261
- Inspections on file
- 21
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Paramount At Somers Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of constipation was repeatedly flagged for not having bowel movements, but the facility failed to initiate its bowel protocol or document interventions as required. Despite ongoing alerts and care plan directives, staff did not consistently follow up or record the effectiveness of administered treatments, leading to the resident's hospital admission for severe constipation and related complications.
A resident's representative reported missing personal items to facility staff, but the grievance was not documented or followed up according to policy. Communication breakdowns and lack of staff awareness of the grievance process resulted in the resident's concern not being properly addressed.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
A resident with a documented diagnosis of constipation did not have a care plan addressing this issue initiated in a timely manner. Despite repeated documentation of constipation and related symptoms, the facility delayed implementing its bowel protocol and did not consistently administer or monitor prescribed interventions. Staff interviews confirmed that care plan initiation and review processes were not followed as required, resulting in the resident being discharged to the hospital with severe complications related to constipation.
A resident with a history of stroke and Parkinson's disease experienced a sudden onset of slurred speech, which was reported by nursing staff to an NP. The NP initially ordered rest and IV fluids, suspecting dehydration, and only arranged for hospital transfer after continued symptoms and at the request of the resident's representative. The resident was later diagnosed with bilateral scattered infarcts. Facility staff and the medical director did not immediately recognize or act on the potential for acute stroke, resulting in delayed hospital evaluation.
Surveyors found that two residents did not have physician-ordered follow-up orthopedic consultations properly documented or scheduled after initial consults for hip fractures. Staff interviews revealed that orders for follow-up visits were not consistently entered into the electronic medical record, and communication about these appointments was often verbal rather than documented. As a result, both residents were discharged without the recommended follow-up care being arranged or recorded.
A nurse crushed and administered an extended-release Morphine tablet, clearly labeled 'do not crush,' to a resident with chronic pain and respiratory conditions. The resident became lethargic and exhibited opioid overdose symptoms, requiring Naloxone to reverse the effects. Facility policy requiring label checks and adherence to administration instructions was not followed, resulting in actual harm.
Two residents experienced falls, but their care plans were not updated to reflect the incidents as required. One resident with severe cognitive impairment fell from a Hoyer lift, and another with muscle weakness and ambulatory dysfunction had an unwitnessed fall resulting in injury. Staff interviews revealed inconsistent understanding of the need to revise care plans after such events.
A resident with severe cognitive impairment and total dependence for transfers fell from a mechanical lift during a transfer by two CNAs. The fall occurred when a strap on the Hoyer pad slipped or detached, causing the resident to strike their head on the lift. Staff interviews revealed inconsistencies in the transfer process, and the facility's investigation found that the equipment was intact but may not have been properly secured or monitored during the lift.
Two residents in an LTC facility were exposed to accident hazards due to inadequate supervision and safety protocol failures. One resident, with a pureed diet order, consumed inappropriate food and required suctioning after aspirating, while another had an uninspected electric air mattress overlay brought in by a private aide. Staff were unaware of supervision responsibilities and safety checks for personal equipment, leading to these deficiencies.
A resident's privacy was compromised due to a broken window shade and torn screen in their room, which faced the staff parking lot. Despite the resident's complaints and the facility's policy to maintain windows, the issue persisted for over a week. Staff were aware but did not report the problem, and the Director of Maintenance was only informed days later. The deficiency was noted during a recertification survey.
A resident with severe cognitive impairment did not receive necessary ADL care from facility staff, as a private duty aide, against facility policy, provided all care. The aide's involvement was not reported by staff, leading to a lack of documented evidence of care. The facility failed to ensure adherence to care plans and proper documentation.
A facility failed to maintain an adequate stock of prescribed gastrostomy tubes, leading to complications in the care of a resident with a feeding tube. The resident required an 18-gauge gastrostomy tube, but the facility ran out of stock, resulting in the use of an incorrect size and a temporary Foley catheter. The inventory management system was inadequate, and the purchasing process was delayed, contributing to the deficiency.
The facility experienced significant staffing shortages, particularly on night shifts and weekends, affecting resident care. Residents reported falls and delayed response times to call bells, while staff confirmed the lack of sufficient aides impacted care quality. Despite efforts to address the issue, including using agencies and offering incentives, the facility remained understaffed on multiple occasions.
The facility failed to maintain proper labeling and expiration management of medications. Unlabeled Ascor was found in a refrigerator on the [NAME] Unit, and expired Nexium was found in a medication cart on the Westminister Unit. Staff interviews revealed a lack of clarity on medication discontinuation and removal processes.
The facility's main kitchen failed to store food properly due to faulty insulation door seals on the walk-in freezer, leading to ice accumulation. The facility's policy required regular maintenance checks, but the seals were not functioning properly, causing a gap and ice formation. The Food Services Director acknowledged the issue and had requested repairs.
A resident with severe cognitive impairment and a history of aggression was physically abused by a CNA in a long-term care facility. The incident, captured on surveillance video, showed the CNA hitting the resident, resulting in an abrasion. The CNA had a prior disciplinary record and was the only aide on duty at the time. The facility's investigation found reasonable cause for abuse, leading to the CNA's termination.
A resident's Designated Representative was not informed about the risks and benefits of a newly prescribed medication, Depakote, or alternative treatment options before administration. The resident, who was severely cognitively impaired and had a history of aggression, began receiving Depakote following a recommendation from a Psychiatry NP. Despite the facility's policy requiring family notification for medication changes, there was no documented evidence of such communication. The Medical Doctor claimed to have discussed the medication regimen with the Designated Representative but did not document the conversation.
A facility failed to maintain a clean and homelike environment in a dementia unit, where a strong urine odor was pervasive. The unit lacked a night housekeeper, leaving nursing staff to manage accidents until morning. Carpets were cleaned weekly, but the odor persisted due to residents' incontinence and humid weather, highlighting a deficiency in environmental maintenance.
A resident with severe cognitive impairment and multiple diagnoses experienced a fall, but the facility failed to update the Comprehensive Care Plan (CCP) as required. The care plan, which included interventions for fall prevention, was not revised after the incident, despite protocols stating that care plans must be reviewed post-fall. Interviews revealed confusion over responsibilities for updating care plans, contributing to the deficiency.
A resident with dementia in an LTC facility exhibited increasing aggression and wandering behaviors, but their care plan was not updated to address these issues. Despite staff awareness and training, the care plan remained unchanged, and the medical doctor was not informed of escalating behaviors. Staffing challenges were noted by the DON.
The facility did not conduct a comprehensive assessment to determine necessary resources for the [NAME] Unit, a specialized dementia care area. The assessment failed to identify the unit's specific needs and appropriate staffing levels. Observations revealed insufficient night shift staffing, with only 2 CNAs and 1 LPN for 40 residents, some requiring two-person assistance. Despite staff concerns, no staffing changes were made.
Failure to Initiate and Document Bowel Protocol for Resident with Constipation
Penalty
Summary
A resident with moderate cognitive impairment and a history of constipation was admitted to the facility with diagnoses including constipation and sepsis. The resident was frequently incontinent of bowel and bladder, and a care plan was in place to monitor and manage bowel movements, including initiating a bowel protocol if no bowel movement occurred in two days. Despite this, the resident was repeatedly flagged on the facility's bowel list report in June, July, and August for not having bowel movements, but the facility's bowel protocol was not initiated as required by facility guidelines. The resident's medication orders for constipation were inconsistently managed. Senna was ordered and then discontinued after the resident declined it, and Colace was started later. There was no documentation that the bowel protocol was initiated during multiple periods when the resident had no bowel movements, as indicated by clinical alerts. When the resident finally received a dose of Milk of Magnesia, there was no documented evidence of its effectiveness. The lack of follow-up and documentation persisted despite the resident being seen by nurse practitioners and other staff, and despite ongoing alerts indicating the absence of bowel movements. After discharge, the resident was admitted to the hospital with severe sepsis and was found to have large amounts of stool in the rectum and rectal mural thickening on imaging, consistent with severe constipation. Interviews with staff revealed inconsistent practices regarding monitoring, documentation, and initiation of the bowel protocol. Staff acknowledged that alerts were available and discussed, but there was no evidence that appropriate interventions were consistently implemented or documented for this resident.
Failure to Document and Address Resident Grievance Regarding Missing Property
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to voice grievances and to make prompt efforts to resolve them, as required by policy. The representative of a resident with moderate cognitive impairment and multiple care needs reported several missing items, including a fleece blanket and a nail manicure kit, to the Patient Relations Concierge. Despite this report, there was no documented evidence that a grievance was filed or that any follow-up was provided to the resident's representative regarding the missing items. The facility's grievance policy requires that grievances be documented and addressed promptly, but this process was not followed in this instance. Interviews revealed that the Patient Relations Concierge received the complaint and attempted to notify the Assistant Administrator and Director of Social Services via WhatsApp, but did not receive a response and was unaware of the official grievance process. The Director of Social Services, who is designated as the grievance officer, stated they were not informed of the issue until much later and confirmed that no grievance documentation existed in the resident's chart. The Administrator acknowledged that the grievance should have been documented and processed according to policy, but this did not occur. Communication breakdowns and lack of staff awareness of the grievance process contributed to the failure to address the resident's grievance appropriately.
Failure to Provide Complete Discharge Information Delays Home Care Services
Penalty
Summary
The facility failed to ensure that all necessary resident information was conveyed to the home care agency at the time of discharge, resulting in a delay in the initiation of home care services for one resident. The resident, who had a history of right femur fracture, depression, muscle weakness, moderate cognitive impairment, and required significant assistance with activities of daily living, was scheduled for discharge with home care services. The discharge planning documentation indicated that arrangements should be made with community resources to support the resident's independence post-discharge. However, the home care agency did not receive all required documentation, including the resident's demographics and orders specifying needed disciplines, which prevented timely initiation of services. Interviews revealed that the facility typically sends discharge referrals two to three weeks before discharge, but the documentation is not maintained in the electronic medical record and is instead kept in paper form. The home care agency representative confirmed that only clinical information was received, and the absence of demographic and insurance information delayed the start of home care services. As a result, the resident's home care services were not initiated until several days after discharge, contrary to the usual practice of starting services within 48 hours.
Failure to Develop and Implement Timely Care Plan for Constipation
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address constipation for one resident. The resident was admitted with multiple diagnoses, including a documented diagnosis of constipation, but no care plan addressing constipation was in place until more than two weeks after admission. Despite the facility's policy requiring timely care plan development and the presence of a bowel protocol, the resident experienced multiple episodes without a bowel movement, as documented in the facility's bowel alert lists and medication administration records. The bowel protocol was not initiated until much later, and there was no evidence that interventions were consistently implemented or monitored for effectiveness. The resident's medical records showed repeated documentation of constipation, complaints of discomfort, and requests for stool softeners. Orders for medications such as Senna and Colace were made, but there was inconsistency in their administration and follow-up. The medication administration records did not reflect refusals or consistent use of prescribed laxatives, and there was a lack of documentation regarding the effectiveness of interventions when they were eventually provided. Nursing and medical progress notes indicated ongoing issues with constipation, but the facility did not initiate the bowel protocol in a timely manner, nor did they update the resident's diagnosis list to reflect active constipation. Interviews with facility staff, including LPNs and the DON, revealed that care plans are expected to be initiated at admission and reviewed by registered nurses and the interdisciplinary team. However, in this case, the care plan for constipation was delayed, and the diagnosis was not properly carried over or updated in the resident's records. The resident was eventually discharged and admitted to the hospital with severe sepsis, where imaging revealed significant stool retention and colitis. The deficiency was attributed to the facility's failure to ensure timely and effective care planning and intervention for constipation as required by policy and regulation.
Failure to Provide Timely Hospital Transfer for Resident with Acute Neurological Changes
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services provided met professional standards of quality for a resident with a history of stroke, peripheral vascular disease, and Parkinson's disease. The resident, who had moderate cognitive impairment and required significant assistance with activities of daily living, experienced a sudden onset of slurred speech. This change was first noted by an LPN, who notified the nursing supervisor and a nurse practitioner (NP). The NP instructed staff to place the resident in bed for rest. Despite continued slurred speech, the NP initially ordered intravenous fluids and lab work, suspecting dehydration, and later requested a speech evaluation. The resident's symptoms persisted into the following day, with ongoing slurred speech and general weakness. The NP was again notified and, after further discussion and at the request of the resident's representative, ordered the resident to be transferred to the hospital to rule out a stroke. The resident was subsequently admitted to the hospital with a diagnosis of bilateral scattered infarcts. Documentation and interviews revealed that the NP and medical director did not immediately suspect a stroke and opted to treat in place, attributing symptoms to possible dehydration or other non-stroke causes. The medical director indicated that unless symptoms worsened or failed to improve, the standard practice was to continue treatment in the facility rather than transfer to the hospital. Interviews with facility staff and the resident's representative highlighted delays in recognizing the severity of the resident's symptoms and in transferring the resident for appropriate evaluation and treatment. The NP did not consult the medical director regarding the case, and the medical director did not question the NP's decisions. The facility's approach did not align with timely intervention for potential stroke symptoms, as required by professional standards of care.
Failure to Document and Schedule Physician-Ordered Follow-Up Consultations
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians reviewed residents' total programs of care and documented progress notes and orders at each required visit for two out of three residents reviewed for follow-up consultation visits. Specifically, one resident admitted after a right hip fracture had an orthopedic consultation recommending a follow-up visit and x-ray in six weeks. However, there was no documented evidence that a physician's order for the follow-up was entered, nor was the appointment scheduled before the resident was discharged home. The resident's discharge instructions included a recommendation to follow up with orthopedics post-discharge, but the required in-facility follow-up was not arranged or documented. Another resident, admitted after a left hip fracture, was also scheduled for an orthopedic follow-up consultation. The consultation report specified a follow-up appointment, but there was no documented physician's order for this visit. The resident was discharged without having the follow-up orthopedic appointment completed. Review of the medical record and staff interviews confirmed the absence of documentation regarding the follow-up consultation, and it was noted that the resident would sometimes cancel appointments, but this was not consistently documented in the medical record. Interviews with facility staff, including the unit clerk, LPN, nurse practitioner, and medical director, revealed inconsistent practices regarding the scheduling and documentation of follow-up consultations. The nurse practitioner stated that recommendations from consultations were verbally communicated to nursing staff, but orders were not entered into the electronic medical record. The medical director acknowledged that orders and progress notes for consultations should be documented and that the current process allowed for lapses in scheduling and documentation, leading to missed appointments.
Crushed Extended-Release Morphine Administered, Resulting in Harm
Penalty
Summary
A deficiency occurred when a nurse administered a crushed extended-release Morphine Sulfate tablet to a resident, despite the medication being clearly labeled as 'do not crush.' The nurse, who was responsible for medication administration, stated that the resident was known to spit out medications and could become verbally disruptive if pain medication was not given on time. In an effort to ensure the resident received their pain medication, the nurse crushed all of the resident's medications, including the extended-release Morphine, and administered them together. The facility's policy required nurses to check pharmacy labels and follow all instructions, including not crushing medications labeled as such, but this protocol was not followed in this instance. Following administration, the resident was found lethargic in bed by a speech language pathologist, who alerted nursing staff. The resident exhibited decreased responsiveness, decreased respirations, wheezing, and pinpoint pupils. Initial assessments by nursing staff and the physician led to the administration of Solumedrol and Lasix for respiratory symptoms, as the resident had a history of chronic obstructive pulmonary disease and pulmonary hypertension. It was only after further inquiry that the nurse disclosed the error of crushing the extended-release Morphine, prompting the administration of Naloxone to reverse the effects of the opioid overdose. The resident returned to baseline shortly after receiving Naloxone, and the incident was reported to the physician and the resident's representative. Interviews with staff confirmed that the nurse was aware of the 'do not crush' instruction but proceeded due to being in a rush and wanting to address the resident's pain. The facility's policy on narcotic handling and administration was not adhered to, resulting in actual harm to the resident.
Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised following actual falls for two out of four residents reviewed for falls. For one resident with severe cognitive impairment, dementia, and total dependence for mobility and transfers, the care plan was not updated to reflect a fall from a Hoyer lift during a transfer by two CNAs. Although the care plan was later updated with staff education and a physical therapy evaluation, there was no documented evidence that the actual fall event was incorporated into the fall risk care plan as required by facility policy. Another resident, who was cognitively intact but had muscle weakness, ambulatory dysfunction, and required assistance with mobility, experienced an unwitnessed fall in their room resulting in a laceration and skin tears. The care plan for this resident, which identified fall risk due to their physical limitations, was not updated to include the details of the fall incident. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the requirement to update care plans immediately after a fall, with some staff relying on progress notes rather than revising the care plan itself.
Resident Fall During Mechanical Lift Transfer Due to Improper Supervision and Equipment Attachment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and total dependence for transfers fell from a mechanical lift during a transfer. The resident, who was bedridden and required assistance for all activities of daily living, was being transferred by two Certified Nurse Aides (CNAs) using a Hoyer lift. The facility's fall prevention policy required a comprehensive approach to safety, including environmental adjustments and individualized interventions for residents at risk of falls. During the transfer, one CNA was preparing the resident's chair while the other CNA attached the Hoyer pad to the lift. As the resident was being lifted, they fell out of the Hoyer pad and struck their head on the leg of the lift. Upon investigation, it was found that one of the straps on the Hoyer pad had slipped or become detached during the lifting process, resulting in the resident's fall. Interviews with staff revealed inconsistencies in the sequence of actions, with one CNA stating they were not in position when the transfer began and the other indicating they had attached all the necessary clips. Further interviews with nursing staff and administration indicated that the Hoyer pad and equipment were intact, but the incident may have been caused by improper attachment or shifting of the resident during the transfer. The facility's investigation concluded that the strap may have come off due to the resident's movement or contact with the bed rail, but both CNAs believed they had followed proper procedures. The event demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided during the transfer process.
Lack of Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. Resident #631, who had a physician order for a pureed diet with nectar thick liquids due to dysphagia, was able to consume thin liquids and a cookie while in a supervised area. This led to the resident requiring oral suctioning to clear their throat after aspirating. The incident occurred when the resident was left unsupervised in the common area, despite the care plan indicating the need for close supervision during meals. Staff members were unaware of who was responsible for supervising the area, leading to the resident's exposure to inappropriate food and drink. Resident #226 was found to have an electric air mattress overlay on their bed, which had not been inspected by the maintenance department for safety. The air mattress overlay was brought in by the resident's private duty aide without the facility's knowledge. The Director of Nursing and other staff members were unaware that the air mattress overlay was not provided by the facility and had not been checked for safety. The maintenance department was only informed of the equipment after the survey had begun, highlighting a lapse in the facility's protocol for inspecting electrical equipment brought in by visitors. Both incidents demonstrate a lack of adequate supervision and adherence to safety protocols within the facility. The failure to supervise Resident #631 in the common area and the oversight in inspecting Resident #226's air mattress overlay contributed to the deficiencies identified during the survey. These lapses in care and safety protocols put the residents at risk and indicate a need for improved communication and adherence to established procedures within the facility.
Failure to Maintain Resident Privacy Due to Broken Window Shade
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #66, by not maintaining the window in their room in a functional state. The window, which faced the staff parking lot, had a broken shade that could not be pulled down, and a torn insect screen. This situation persisted for over a week, during which Resident #66 expressed dissatisfaction and a desire for privacy. The resident's roommate also confirmed the issue, stating that the broken shade allowed light to shine through the room continuously, necessitating the use of a curtain between the beds for some privacy. Despite the facility's policy requiring windows to be maintained in a safe and functional order, the broken shade and screen were not addressed promptly. Certified Nurse Aide #21 acknowledged awareness of the issue but failed to report it for repair. The Director of Maintenance was unaware of the problem until several days later, at which point the shade was repaired. The Director of Nursing confirmed that residents should be provided privacy upon request, including having window shades closed during care. The deficiency was identified during a recertification survey, highlighting a failure to uphold the resident's right to a dignified existence and privacy.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. The resident, who had severe cognitive impairment and required total assistance with eating, toileting, and personal hygiene, did not receive the required ADL care on multiple shifts as documented in the October 2024 Certified Nurse Aide documentation. A private duty aide, who was not permitted to provide care according to facility guidelines, stated they provided all care for the resident during their 8-hour daily shifts. Observations and interviews revealed that the private duty aide was performing tasks such as feeding, bathing, and applying protective cream, which were supposed to be done by the facility staff. Certified Nurse Aide #27 admitted that they documented care as provided even when it was not done by them, and they did not report the private duty aide's involvement to the nurses. The Director of Nursing and Licensed Practical Nurse Manager #22 confirmed that private duty aides were not allowed to provide care and that staff should have reported any non-compliance. The facility's failure to ensure proper documentation and adherence to care plans resulted in the resident not receiving the necessary care from the facility staff. The private duty aide's involvement, despite being against facility policy, was not adequately addressed by the staff, leading to a lack of documented evidence of care being provided by the certified nurse aides. This deficiency highlights a breakdown in communication and adherence to facility policies regarding the provision of care by private duty aides.
Failure to Maintain Adequate Stock of Prescribed Gastrostomy Tubes
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not have the physician-prescribed gastrostomy tube size available for Resident #182, who was admitted with diagnoses including aphasia, respiratory failure, and gastrostomy status. The resident's care plan required a specific size of gastrostomy tube, but the facility ran out of the necessary 18-gauge gastrostomy tubes, leading to complications in the resident's care. On July 20, 2024, the resident's g-tube balloon broke, and the g-tube came out. The facility did not have the prescribed 18-gauge gastrostomy tube available, and attempts to use a 20-gauge tube were unsuccessful. As a temporary measure, an 18 French Foley catheter was inserted, and the resident was sent to the hospital for a new tube. On July 22, 2024, a 14-gauge gastrostomy tube was inserted because the facility still did not have the correct size in stock, which may have caused the resident's abdominal opening to become smaller. Interviews with facility staff revealed that the inventory management system was inadequate, as the Director of Housekeeping and Central Supply did not maintain records of inventory levels, leading to a shortage of the necessary gastrostomy tubes. The staff was unaware of how long the stock had been depleted, and the facility's purchasing process was delayed, contributing to the deficiency in care for Resident #182.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Multiple residents and staff members reported that the facility was short-staffed, particularly on night shifts and weekends. The facility's staffing sheets from October 1 to October 31, 2024, revealed that the facility was understaffed on 19 out of 31 days, with only one Certified Nurse Aide scheduled on various units during night shifts. This staffing shortage led to delayed response times to call bells, with residents experiencing falls and other care issues as a result. Interviews with residents and staff highlighted the impact of the staffing shortages. One resident reported experiencing falls due to lengthy response times to call bells, while another resident noted that staff seemed rushed and took about 15 minutes to respond. Staff members, including Certified Nurse Aides and a Licensed Practical Nurse, confirmed the staffing issues, stating that the lack of sufficient aides affected the quality of care, resulting in skin issues and longer wait times for residents. The facility attempted to address the staffing challenges by utilizing agencies, offering incentives, and running a Certified Nurse Aide Training Program, but continued to struggle with maintaining adequate staffing levels.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were maintained in accordance with accepted professional standards, specifically regarding labeling and expiration dates. During an observation of the medication storage room refrigerator on the [NAME] Unit, two boxes of Ascor were found in a plastic bag without a resident name or pharmacy label, while another bag containing three boxes of Ascor was properly labeled. A Licensed Practical Charge Nurse confirmed that all Ascor was ordered for the same resident and should have been in the labeled bag. Additionally, on the Westminister Unit, a blister pack containing 27 capsules of Nexium DR 40 mg was found in a medication cart. The blister pack was labeled for a resident who was no longer receiving the medication, and it had an expiration date of 6/6/24, with a handwritten date of 10/28/24. A Registered Nurse stated that the medication had been discontinued, but they were unsure when. They explained that discontinued or expired medications should be removed from the cart, scanned by the Director of Nursing, and returned to the pharmacy. The Director of Nursing confirmed that the Pharmacy Consultant checks medication carts monthly, and Unit Managers and Charge Nurses conduct weekly checks.
Improper Food Storage Due to Faulty Freezer Seals
Penalty
Summary
The facility failed to ensure proper storage of food in accordance with professional standards for food service safety in the main kitchen. During a recertification survey, it was observed that the walk-in freezer had ice accumulation on the inside door surface, the freezer's floor, and the inner plastic curtain. The facility's policy, dated 8/21/20, required daily maintenance tasks, including door seal inspections to ensure proper functioning, and monthly insulation inspections. However, the freezer's insulation door seals were not attaching properly, leaving a gap between the door and the door's frame, which led to the formation of ice inside the freezer. The Food Services Director confirmed the issue and stated that a request had been placed with a contractor to fix the door seals.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as evidenced by an incident captured on surveillance video. On the night of the incident, a Certified Nursing Assistant (CNA) was observed approaching a resident from behind and subsequently hitting the resident on the shoulder, which led to a physical altercation between the two. The CNA continued to hit the resident with a closed fist, causing the resident to fall to the floor and sustain an abrasion to the nose. This incident resulted in actual harm to the resident, although it was not deemed immediate jeopardy. The resident involved in the incident was admitted to the facility with diagnoses of Lyme disease and unspecified dementia without behavioral disturbance. The resident was assessed as severely cognitively impaired and had a history of physical aggression towards others. The facility had a comprehensive care plan in place for the resident, which included interventions for managing physical aggression and wandering behavior. However, on the night of the incident, the resident was agitated and wandering into other residents' rooms, requiring constant redirection. The CNA involved in the incident had a previous disciplinary record for not appropriately handling a resident-to-resident altercation. On the night of the incident, the CNA was the only aide on the floor, as the other CNA was on break. The Licensed Practical Nurse (LPN) on duty had informed the Nursing Supervisor about the resident's escalating behavior but did not receive a timely response. The LPN later activated a code to request assistance, but by that time, the altercation had already occurred. The facility's investigation concluded that there was reasonable cause to believe that abuse had occurred, leading to the termination of the CNA involved.
Failure to Inform Designated Representative of Medication Changes
Penalty
Summary
The facility failed to ensure that a resident's Designated Representative was informed in advance about the risks and benefits of a newly prescribed medication, Depakote, and alternative treatment options. This deficiency was identified during a survey conducted from July 23, 2024, to July 24, 2024. The resident, who was severely cognitively impaired and had a history of physical aggression, was administered Depakote without the Designated Representative being notified. The facility's policy required family notification regarding changes in medication, but there was no documented evidence that this occurred prior to the administration of Depakote. The Designated Representative had previously expressed concerns about medication changes and had refused an antidepressant due to inadequate explanation from the Psychiatrist. Despite this, the resident began receiving Depakote on July 13, 2024, following a recommendation from a Psychiatry Nurse Practitioner. The Medical Doctor involved stated they discussed the medication regimen with the Designated Representative but did not document the conversation or recall the exact date. The Assistant Director of Nursing indicated that both the Medical Doctor and the unit nurse should notify the Designated Representative of medication changes, but this did not happen in this case.
Deficiency in Maintaining a Clean Environment in Dementia Unit
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents in the [NAME] Unit, as evidenced by a strong pervasive odor of urine throughout the unit, including in resident rooms. Observations were made on multiple occasions, noting the intense odor upon entering the unit and specific rooms, as well as a sticky wooden floor and a musty damp smell in each resident room. The unit, which houses residents with dementia, had both carpeted and wooden floors, and the odor was particularly strong in certain rooms. Interviews with staff revealed that the unit did not have a housekeeper at night, and nursing staff attempted to clean floors when residents had accidents. However, deep cleaning was only performed when housekeeping staff arrived in the morning. The carpets were cleaned weekly, but the unit's condition was exacerbated by the residents' incontinence and the humid weather. The housekeeping director noted that the unit required constant cleaning due to the residents' conditions, and the administrator stated that carpets were shampooed weekly, with spot cleaning available as needed. Despite these efforts, the odor persisted, indicating a deficiency in maintaining a clean and homelike environment.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner for a resident who was at risk for falls. Specifically, the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and Bipolar Disorder, was not updated following a fall incident. The resident had a history of falls, and the care plan included interventions such as encouraging the resident to stay in supervised settings, wearing non-skid footwear, and providing reality orientation. However, after a fall on April 2, 2024, where the resident hit their head, there was no documented evidence that the care plan was reviewed or revised. Interviews conducted during the survey revealed a lack of clarity regarding responsibilities for updating care plans. A Licensed Practical Nurse (LPN) stated that they were not responsible for initiating or updating care plans, which was the responsibility of the unit managers. The Assistant Director of Nursing confirmed that LPN Unit Managers are responsible for initiating and updating care plans, but they must be reviewed and signed by a Registered Nurse. Despite this protocol, the care plan for the resident in question was not updated following the fall incident, indicating a lapse in the facility's adherence to its care plan policy.
Failure to Update Dementia Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency was identified during a survey, where it was found that the resident's comprehensive care plan was not reviewed and revised to address increasing dementia-related behaviors. The resident, who was admitted with diagnoses of Lyme disease and unspecified dementia, exhibited physical aggression and wandering behaviors, which were not adequately addressed in their care plan. The resident's care plan, initiated in May and updated in July, included goals and interventions to manage behavioral symptoms and impaired cognition. However, despite documented episodes of aggression, wandering, and agitation, there was no evidence that the care plan was reviewed or revised to include individualized approaches to these behaviors. Nursing notes and psychiatric consultations documented the resident's ongoing agitation, restlessness, and exit-seeking behaviors, yet the care plan remained unchanged. Interviews with staff revealed that while they were aware of the resident's behaviors and had received dementia care training, they were not responsible for updating care plans. The medical doctor responsible for the unit was not alerted to any escalation of behaviors, and the facility's staffing issues were acknowledged by the Director of Nursing. Despite these challenges, the facility did not take the necessary steps to update the resident's care plan to address their changing needs.
Inadequate Facility Assessment and Staffing on Dementia Unit
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care, particularly on the [NAME] Unit, a specialized dementia unit. The assessment did not identify the unit as a specialized dementia care area nor did it define the staffing assignments required for its day-to-day operations. The facility's policy on facility assessment was intended to guide decisions on budget, staffing, training, equipment, and supplies, but there was no documented evidence that these needs were addressed for the [NAME] Unit. During the survey, it was observed that the night shift staffing on the [NAME] Unit was insufficient, with only 2 Certified Nursing Assistants and 1 Licensed Practical Nurse for 40 residents, some of whom required two-person assistance and others who wandered at night. The lack of housekeeping staff during the night shift led to nursing staff having to manage cleaning tasks, which was not ideal. Despite concerns raised by staff about the need for more personnel, no changes were made to the staffing schedule. The Administrator acknowledged responsibility for managing the Facility Assessment but relied on the Director of Nursing for insights into resident acuity and staffing needs.
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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