Van Rensselaer Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Troy, New York.
- Location
- 85 Bloomingrove Drive, Troy, New York 12180
- CMS Provider Number
- 335265
- Inspections on file
- 16
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Van Rensselaer Manor during CMS and state inspections, most recent first.
Surveyors observed that wall corners and baseboards were in disrepair at all active nursing stations and unit dining rooms, and that walls in multiple resident rooms (including rooms in units A and B) were also damaged. These findings showed that the environment, including common and resident areas, was not adequately maintained to be safe, clean, comfortable, and homelike, as required by regulation.
Two residents experienced inadequate investigation and documentation of alleged incidents. One resident with mild cognitive impairment and visual issues was found on the floor with a forehead hematoma; the event was documented as an unwitnessed fall from a wheelchair, but the accident report lacked any resident statement or other explanation supporting that conclusion, despite the resident’s ability to communicate. Another resident with quadriplegia reported a missing bag of clothing after a hospital stay; although staff reported conducting an investigation and determining the items were not logged or labeled and would not be reimbursed, the accident report was closed without any documented investigative outcome.
Surveyors found that food service operations did not comply with professional food safety standards in the main kitchen and all unit nutrition rooms. Facility-made cold sandwiches were stored in multiple dietary and nutrition refrigerators without required expiration dates, and temperature logs for unit dietary refrigerators were incomplete, with no logs available for resident-owned refrigerators. In the walk-in refrigerator, a large pan of beef stew lacked a cooling log and, when checked about two hours after refrigeration, remained at 105°F instead of meeting the required 70°F cooling benchmark, indicating improper cooling and documentation practices.
Surveyors identified multiple failures in documentation and protection of resident information, including incomplete narcotic count records on several units where nurses either omitted required shift-change signatures or signed off in advance of the end of their shifts, sometimes only signing when prompted. A resident with anxiety disorder, macular degeneration, and asthma had nebulizer tubing changes documented on the treatment administration record that did not match the date on the tubing observed at bedside, indicating inaccurate treatment documentation. Additionally, two medication cart laptops were found open, logged in under nursing staff accounts, and left unattended with resident-identifiable information visible, while nursing staff were away from the carts.
The facility failed to post required daily nurse staffing information in a prominent, accessible location. During a surveyor observation, the main lobby lacked the Daily Staff Posting, and no such posting was found elsewhere in the building. When interviewed, the staffing coordinator stated they were not responsible for posting the daily staffing and directed the surveyor to the administrator. The administrator reported that the posting is normally placed in the main lobby but had not been posted due to an oversight after the prior day’s notice was removed, despite being aware that daily staffing and census information must be posted each day.
A resident with Parkinson’s disease, dementia, and anxiety, who was documented as cognitively intact for daily decisions, was involved in an incident where a CNA entered the room without knocking, physically pulled the resident into a wheelchair despite apparent resistance, and nearly caused a fall while reseating the resident. Video showed the CNA pushing the wheelchair while the resident tried to block the wheel, then pulling the chair backwards into the hallway, during which the resident stood and fell to the floor onto their side. The CNA then walked away, leaving the resident on the floor alone for several minutes before briefly returning with a mechanical lift and standing away from the resident, who remained unattended on the floor for at least four minutes until an LPN and the ADON arrived and began assessment. Facility leadership stated that staff are expected to treat residents with dignity, avoid physical redirection, and remain with a resident on the floor while summoning help, and that the CNA’s actions were not acceptable.
Two residents with dementia and other comorbidities were not protected from abuse and neglect when a CNA roughly handled one cognitively intact resident, pulled the resident into a wheelchair despite resistance, and left the resident on the floor unattended for several minutes after a fall, and when another resident with severe cognitive impairment sustained facial bruising after being turned in a way that caused impact with a wall. Multiple residents in this CNA’s assignment had unexplained or roughly handled-related bruises, yet staff initially attributed injuries to resident behaviors, environmental factors, or the need for additional education rather than potential abuse. Nursing leadership and other staff did not promptly recognize, report, or fully investigate these events as possible abuse or neglect until a pattern of injuries and video review later revealed neglectful handling and failure to remain with the fallen resident.
A resident with Parkinson’s disease and dementia, who was cognitively intact for daily decisions, was observed on video standing unsupervised in a room when a CNA entered without knocking and repeatedly pulled the resident into a wheelchair despite visible resistance, nearly causing a fall. The CNA then pulled the wheelchair backwards into the hallway; while moving, the resident stood and fell to the floor. The CNA walked away, leaving the resident on the floor alone for about two minutes before returning with a Hoyer lift but did not remain at the resident’s side. An LPN and the ADON then attended to the resident; the ADON performed only a limited ROM check of the arms and had the resident bend the knees, with no documented full ROM assessment of the legs, and the resident was manually lifted from the floor by the arms into the wheelchair instead of being transferred with the Hoyer lift as required by the facility’s post-fall policy.
A deficiency occurred when the facility’s QAA/QAPI program and Supervised Care process were not implemented as required by facility policy to address repeated care concerns and adverse events involving a CNA. One resident with dementia and other comorbidities developed a nasal bruise after an incident during personal care, and another resident with Parkinson’s disease and dementia was mishandled by the same CNA, as shown on video, resulting in a fall and the resident being left on the floor unattended. Despite a policy requiring clear documentation, staff notification, active supervision, and auditing under Supervised Care, the CNA’s Supervised Care form contained only vague "care concerns," had signature irregularities, and there was no evidence of actual supervision or audits. The DON identified increased bruising, injuries, and falls on the CNA’s shift and discrepancies between the CNA’s reports and other information, yet these issues were not effectively brought through the QAA/QAPI process, and the Administrator reported that the investigation and concerns were not discussed in the QAPI meeting while present, demonstrating a failure to use established quality systems to monitor, investigate, and correct identified deficiencies in care and resident safety.
A resident with severe cognitive impairment and dysphagia was served regular chicken tenders instead of the required minced consistency after a CNA swapped meal plates among three residents, despite warnings from another aide. The resident choked and required immediate intervention. Facility policies and staff interviews confirmed that the CNA failed to follow the care plan and meal ticket instructions, resulting in neglect.
A resident with severe cognitive impairment was found with unexplained bruising near the eye, which was observed and discussed by multiple staff members, including RNs, NPs, and the medical director. Despite facility policy and state regulations requiring immediate reporting of injuries of unknown origin, the incident was not reported to the DON, administrator, or state health department within the mandated timeframe.
Two residents experienced incidents involving improper care—one was fed the wrong food consistency and choked after a CNA swapped meal trays, and another developed a bruise of unknown origin that was not promptly or thoroughly investigated. In both cases, the facility did not follow its own investigation protocols, failed to interview all relevant staff, and did not fully determine the circumstances or rule out abuse or neglect, as confirmed by leadership and staff interviews.
A resident with severe cognitive impairment and total dependence for toileting and bed mobility did not receive the required two-person assistance during incontinence care, as specified in their care plan. A CNA provided care alone, contrary to facility policy and staff expectations, despite clear documentation and staff awareness that two-person assistance was necessary for the resident's safety.
A resident with multidrug-resistant organism (MDRO) in their urine was on Enhanced Barrier Precautions, but staff failed to wear a gown during incontinent care as required. Although signage and PPE were present, staff were unclear about which resident required precautions, and the facility lacked specific written policies for Enhanced Barrier Precautions and other transmission-based precautions, leading to inconsistent infection control practices.
A resident identified as full code was found unresponsive by an LPN, who notified an RN. The RN assessed the resident, determined death, and did not check code status or initiate CPR as required by facility policy. Both staff failed to follow protocols for identifying code status and starting CPR, resulting in a delayed response. Nurse supervisors later initiated CPR, but the attempt was unsuccessful.
A CNA threw a water bottle at a resident with dementia, striking them on the back, while another CNA witnessed the event and intervened. There was a delay in removing the offending CNA from resident care, as staff did not immediately call security or remove the individual, contrary to facility policy. The resident was later assessed and found to have no signs of distress.
Failure to Maintain Walls and Common Areas in Good Repair
Penalty
Summary
Surveyors found that the facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by not providing effective maintenance services across all resident units. During facility tours conducted over several days between 9:00 AM and 3:00 PM, wall corners and baseboards were observed to be in a state of disrepair at all seven active nursing stations and all seven unit dining rooms. In addition, walls in specific resident rooms A104, A112, A122, B102, A205, A214, and A213 were identified as being in disrepair. These observations showed that the physical environment, including common areas and resident rooms, was not being adequately maintained. During an interview, the Director of Security stated that the facility had focused on ensuring resident safety when prioritizing repairs and that the facility was undergoing renovations in which almost all identified items would be replaced. The deficiency was cited under 10 New York Codes, Rules, and Regulations 415.14(h), related to maintaining a safe, clean, comfortable, and homelike environment.
Failure to Properly Investigate and Document Injury and Missing Property Incidents
Penalty
Summary
The facility failed to investigate and document alleged violations and incidents according to its own policies and professional standards for two residents. For one resident with anxiety disorder, macular degeneration, and asthma, an unwitnessed incident occurred in which the resident was found lying on the floor with a 3.5 x 3.5 cm purple bump on the left forehead. The accident report described the event as an unwitnessed fall with injury and stated the outcome was that the resident fell asleep and fell forward out of their wheelchair. However, the report contained only two statements describing that the resident was found on the floor and did not include any statement from the resident or any other person explaining how it was determined that a fall from the wheelchair caused the injury. At the time of assessment, the resident’s MDS documented that they could usually be understood, usually understood others, and were mildly cognitively impaired. During observation, the resident was seen in a wheelchair with a dark purple raised area on the left forehead and was unable to report how the injury occurred. A reviewing RN stated they were not present at the time of the injury and, after reviewing the accident report, could not determine how the conclusion of a fall was reached. The DON stated that for an unwitnessed fall with injury, they would expect to see a resident statement or other statement clarifying how the event was determined to be a fall, and confirmed that this resident would have been able to vocalize if they had been abused or had fallen. For another resident with anxiety disorder, quadriplegia, and polyneuropathy, an accident report documented that the resident phoned the social worker to report a missing storage bag containing sweaters and sweatshirts that had been in their room before a hospital transfer and was missing upon readmission. The accident report was closed without any documented outcome of the investigation. The resident later stated they had reported the missing clothing to the social worker and did not believe an investigation was started, and that when they asked the administrator about the missing clothing, they were told there was no justification to reimburse or replace the items. The social worker reported that an investigation had been started but the resident could not list the items and they were not logged or labeled on the belongings list, and the Director of Social Work recalled spending time on the investigation and determining the facility could not replace or reimburse the items, but acknowledged they only thought they had documented the outcome, which was not present in the record.
Failure to Follow Food Storage, Dating, and Cooling Standards in Kitchen and Unit Nutrition Rooms
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in the central kitchen and all seven resident unit nutrition rooms. During inspection of the central kitchen, cold, facility-made sandwiches were found in multiple locations, including the sandwich prep station refrigerator and several unit dietary/nutrition refrigerators, without proper expiration dates. Temperature logs for dietary refrigerators on all units were incomplete, and no unit could provide temperature logs for resident-owned refrigerators. In the walk-in refrigerator, surveyors observed a full-size kitchen pan filled with beef stew without a corresponding cooling log to verify that proper cooling procedures were followed. When the temperature of the stew was checked approximately two hours after being placed in the refrigerator, it measured 105°F, which exceeded the required 70°F threshold specified by food safety requirements for that cooling interval. These findings demonstrated noncompliance with New York State food safety regulations and 10 NYCRR 415.14(h) regarding proper food storage, dating, temperature monitoring, and cooling practices.
Incomplete Narcotic Documentation, Inaccurate Treatment Records, and Unsecured PHI on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to maintain medical records and controlled substance documentation in accordance with accepted professional standards, and to safeguard resident-identifiable information. Surveyors’ review of narcotic count record books on multiple units showed missing signatures for both oncoming and off-going nurses at various shift changes, indicating incomplete controlled substance records. Observations revealed nurses signing the narcotic count books in advance of the end of their shifts, and one nurse delayed providing the narcotic sign-off book to the surveyor until they signed it in the surveyor’s presence, without a clear explanation for why it had not been signed earlier. In interviews, nursing staff acknowledged they had not signed when required, stated they were busy or had forgotten, and some reported they routinely signed in this manner and had not been told not to do so. The facility also failed to ensure accurate treatment documentation and protection of resident-identifiable information. For one resident with anxiety disorder, macular degeneration, and unspecified asthma, the treatment administration record showed nebulizer tubing changes documented as completed on three separate dates in March, but an observation later in the month found the nebulizer tubing still labeled with an earlier date, suggesting the documented changes had not occurred as recorded. Additionally, surveyors observed two separate medication cart laptops left open and unattended, logged in under nursing staff accounts, with readable resident information accessible while the responsible staff were not present at the carts. In one instance, the nurse later stated they usually minimize or close the laptop but had forgotten to do so.
Failure to Post Daily Nurse Staffing Information in Prominent Location
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily at the beginning of each shift in a prominent place readily accessible to residents and visitors, as required. During an observation of the entrance lobby on 04/01/2026 at 11:30 AM, surveyors noted that the Daily Staff Posting was not present, and they were unable to locate any Daily Staff Posting elsewhere in the building. In an interview at 11:40 AM, the staffing coordinator stated they were not responsible for posting the Daily Staffing and referred questions to the administrator. In a subsequent interview at 11:45 AM, the administrator acknowledged that the Daily Staff Posting, which is normally posted in the main lobby, was not posted due to an oversight after the previous day’s posting had been taken down, and further stated awareness that daily staffing and census information should be posted each day. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the absence of the required daily nurse staffing posting and the staff’s acknowledgment of the oversight and responsibility for posting.
Resident Left on Floor After Fall and Rough Handling by CNA
Penalty
Summary
The deficiency involves a failure to ensure a resident’s right to dignity, respect, and care in a manner that promotes quality of life. The facility’s own Resident Handbook states that residents have the right to dignity, respect, a comfortable living environment, quality care without discrimination, freedom of choice, privacy, freedom from abuse and restraints, and the ability to exercise their rights without fear of reprisals. The resident involved had diagnoses including Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. An MDS dated 08/08/2025 documented that this resident could be understood, could understand others, and had intact cognition for decisions of daily living. Care plans directed staff to encourage the resident to ask for assistance, orient the resident to changing surroundings, respect the resident’s right to refuse activities, initiate conversation frequently, maintain preferred independent leisure activities, provide escort or transportation as needed, and, for falls, to investigate the cause of any fall immediately, provide reality orientation, keep the resident in a high-profile area when possible, and report unsafe behavior to nursing. On the date of the incident, an incident report documented that a CNA observed the resident standing in their room, assisted them to their wheelchair, and that when exiting the room the resident grabbed the wall handrail and pulled themselves from the wheelchair. The CNA’s written account stated that while attempting to reseat the resident, the resident needed to be lowered to the floor to prevent a fall, and that the resident’s self-propelled standing from the wheelchair was attributed to gastric distress. However, the facility’s abuse investigation, which included video footage, showed that the CNA entered the resident’s room without knocking, placed hands on the resident’s arms, and pulled the resident into the wheelchair while the resident appeared to resist. The resident stood again and was again pulled into the wheelchair, nearly missing the chair and almost falling. The video further showed the CNA pushing the resident in the wheelchair while the resident attempted to block the front wheel with their foot, then turning the wheelchair to move it backwards into the hallway. As the wheelchair was being pulled backwards, the resident stood up and fell to the floor onto their side. The CNA appeared to throw their hands down at their sides and then walked away, leaving the resident lying on the floor. The resident remained alone on the floor for approximately two minutes before the CNA returned in the camera’s view with a mechanical lift, walked past the resident, spoke briefly, and then stood in a nearby doorway at least five feet away. The resident was left unattended on the floor for a minimum of four minutes between 10:49 a.m. and 10:53 a.m. before nursing staff, including an LPN and the Assistant Director of Nursing, arrived and began interacting with and assessing the resident. Interviews with the RN unit manager, the Assistant Director of Nursing, and the Director of Nursing confirmed that staff were expected to treat residents with respect and dignity, that physical redirection was not acceptable, that a CNA who lowered a resident to the floor should stay with the resident and obtain help via call bell or by calling out, and that it was not appropriate to leave a resident unattended on the floor for multiple minutes. The DON stated that the CNA’s actions were not acceptable and not in line with expectations for kind and dignified treatment.
Failure to Protect Residents From Abuse and Neglect by CNA and Inadequate Investigation of Injuries
Penalty
Summary
The deficiency involves the facility’s failure to prevent abuse, neglect, or mistreatment of residents and to adequately investigate and respond to incidents involving a CNA’s handling of residents. The facility’s Abuse & Neglect Policy, updated on 04/03/2025, stated that residents had the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation, and involuntary seclusion. Despite this policy, an abbreviated survey found that two of four residents reviewed for abuse, neglect, or mistreatment were not protected from willful infliction of abuse, neglect, or mistreatment. The facility did not fully investigate an incident on 08/02/2025 in which CNA #1 lowered Resident #1 to the floor, and later-obtained video footage showed abusive handling and the resident being left on the floor unattended for several minutes. Resident #1 had diagnoses including Parkinson’s disease with dyskinesia and fluctuations, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. An MDS dated 08/08/2025 documented that this resident could understand and be understood and had intact cognition for decisions of daily living. An incident report dated 08/02/2025 documented CNA #1’s account that the resident stood in their room, was assisted into a wheelchair, and, while being taken from the room, grabbed the wall handrail and lifted themselves up, prompting the CNA to lower the resident to the floor to prevent a fall. However, video footage from 08/02/2025 showed CNA #1 entering the resident’s room without knocking, pulling the resident into the wheelchair despite resistance, repeating the maneuver with a near fall, and then moving the wheelchair backward while the resident attempted to block the wheel with their foot. The footage showed the resident standing and falling to the floor on their side, after which CNA #1 gestured toward the resident, walked away, and left the resident on the floor alone for approximately two minutes before returning briefly with a mechanical lift and then leaving again. The resident remained on the floor for about four minutes total before a nurse arrived, and the review of the video concluded that CNA #1 neglected the resident by walking away after the fall. Resident #3 had diagnoses of unspecified dementia with other behavioral disturbances, hypothyroidism, and major depressive disorder. An MDS documented that this resident was usually able to understand others, was usually understood, and was severely cognitively impaired. The care plan indicated the resident required one-person assistance for bed mobility and ADLs and had a history of hitting and screaming at staff and resisting care, with interventions such as allowing time to de-escalate, reapproaching if refusing care, and placing a soft object in the resident’s hands if combative. An incident report dated 08/01/2025 documented a blue/gray bruise on the resident’s nose, with contributing factors listed as poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and resting their head on a table when fatigued. However, the ADON documented that CNA #1 had previously provided personal care and turned this resident in a way that caused them to hit their face on the wall, causing injury. The facility attributed the injury to environmental and resident factors and did not treat the event as potential abuse, instead viewing CNA #1 as needing more education on bed mobility. The facility’s broader investigation, dated 08/15/2025 through 09/03/2025, showed that CNA #1 was suspended after being possibly responsible for multiple injuries on more than one resident in their care assignments. On 07/19/2025, a bruise and abrasion on Resident #2’s forehead were attributed to rough handling during bed mobility. On 08/01/2025, bruising on the right side of Resident #3’s face and around the eye and nose was attributed to another CNA rolling the resident into the wall and to ill-fitting glasses. On 08/15/2025, bruising on Resident #4’s neck, appearing multiple days old, was attributed to the resident being resistive to care. Interviews with nursing leadership and staff showed that, at the time of the incidents, they did not suspect abuse by CNA #1, did not immediately remove the CNA from resident care, and did not fully investigate the events as potential abuse or neglect until a pattern of injuries and video review prompted further scrutiny. The DON and ADON acknowledged that the actions captured on video were not acceptable and that leaving a resident unattended on the floor for multiple minutes was not appropriate, but these acknowledgments occurred after the events that led to the deficiency. Interviews also revealed gaps in immediate reporting and investigation. CNA #1 stated they gave a verbal statement on the day of Resident #1’s fall but were unable to enter a written statement into the computer and that no written statement was taken from them at that time. LPN #4 reported being told by CNA #1 that the resident had been ambulating when they were not supposed to and did not suspect the explanation was inaccurate, despite the later video evidence. The ADON described that if there had been any indication from Resident #1 of an issue with CNA #1, they would have handled the situation differently, such as interviewing the staff member privately or changing assignments, but this did not occur at the time. The DON and Administrator described that video footage was typically reviewed only for certain types of incidents, such as falls with injuries or resident-to-resident issues, and that no staff raised concerns about CNA #1 until the DON began questioning employees. These actions and inactions contributed to the failure to protect residents from abuse and neglect and to promptly and thoroughly investigate potential mistreatment as required by regulation.
Failure to Perform Complete Post-Fall Assessment and Safe Transfer After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-centered care and to follow its own post-fall policy and professional standards when responding to a fall. The facility’s Post Fall Routine policy required that an RN assess the resident for injury and provide emergency treatment as necessary, that all residents be assisted off the floor with a Hoyer lift (with limited supervisory discretion), and that residents be monitored and assessed for injury, including range of motion, before being moved. For the fall event in question, video footage and interviews showed that these requirements were not followed, and that a complete assessment, including full range of motion, was not performed before the resident was manually lifted from the floor and placed in a wheelchair. The resident involved had Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, as well as anxiety. The MDS documented that the resident could be understood, could understand others, and had intact cognition for daily decision-making. The resident’s care plans addressed falls, vision, and activity participation, including interventions such as investigating the cause of falls immediately, providing reality orientation, maintaining the resident in high-profile areas when possible, and reporting unsafe behavior to nursing. On the day of the incident, video footage showed the resident standing unsupervised in their room when a CNA entered without knocking, placed hands on the resident’s arms, and pulled the resident into a wheelchair despite apparent resistance. The CNA repeated this action when the resident stood again, nearly causing a fall as the resident almost missed the wheelchair. The video further showed the CNA pushing the resident in the wheelchair, with the resident attempting to block the front wheel with their foot. The CNA then turned the wheelchair and pulled it backwards into the hallway; while the wheelchair was moving, the resident stood up and fell to the floor onto their side. Contrary to the CNA’s written account, there was no video evidence of the resident grabbing a handrail and pulling themselves from the wheelchair. After the fall, the CNA appeared to throw their hands down and walked away, leaving the resident on the floor alone for approximately two minutes before returning with a Hoyer lift, then again standing away from the resident. An LPN arrived to attend to the resident, followed by the Assistant DON, who spoke with the resident and performed only a limited range of motion assessment on the resident’s arms and had the resident bend their knees. Without documented evidence of a full range of motion assessment, particularly of the legs, the Assistant DON and LPN manually lifted the resident from the floor by the arms and placed them in the wheelchair, instead of using the Hoyer lift as required by policy. Interviews with the DON and Assistant DON confirmed that a full assessment, including range of motion and pain assessment, was expected after a fall and that leaving a resident unattended on the floor for multiple minutes and manually lifting them in this manner was inconsistent with facility expectations and policy.
Failure of QAA/QAPI and Supervised Care Processes to Address Staff Care Concerns and Adverse Events
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assessment and Assurance (QAA)/Quality Assurance Performance Improvement (QAPI) program functioned as described in its own policies to identify, analyze, and correct quality problems, including adverse events and staff performance concerns. The facility’s QAPI policy required consistent data collection, monitoring, and analysis of care and services, including adverse event tracking and implementation of action plans to prevent recurrence. Despite this, the facility did not ensure that the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies, and did not implement written policies and procedures for feedback, data collection systems, and monitoring related to performance improvement plans, staff correction, and resident safety. One resident, identified as having unspecified dementia with behavioral disturbances, hypothyroidism, and major depressive disorder, was found on an incident report to have a blue/gray bruise on the nose. The report attributed contributing factors to poor safety awareness, dementia, ill-fitting glasses, an unpadded wall, and the resident resting their head on the table when fatigued. The report also documented that a CNA described the resident as difficult during care, stated the resident swung their hands during personal care, and hit their head on the wall while rolling over, though the CNA reported not seeing an injury at that time. This event triggered the use of the facility’s “Supervised Care” process for the CNA, but the documentation and implementation of that process did not follow the facility’s own Supervised Work and Supervised Care policy, which required clear documentation of reasons, staff notification, and ongoing supervision and auditing until the staff member was deemed safe to perform their job. Another resident, with Parkinson’s disease with dyskinesia and unspecified dementia without behavioral disturbance, was involved in an incident where the CNA reported that the resident stood from their wheelchair, grabbed a handrail, and had to be lowered to the floor to prevent a fall. However, video footage reviewed during the facility’s abuse investigation showed the CNA entering the resident’s room without knocking, physically pulling the resident into a wheelchair despite apparent resistance, nearly causing a fall, and later pulling the wheelchair backward while the resident stood, resulting in the resident falling to the floor. The CNA then walked away, leaving the resident on the floor for approximately two minutes before returning with a mechanical lift and then leaving again as an LPN began attending to the resident. This sequence of events, combined with prior concerns about bruising, injuries, and falls on the CNA’s shift, demonstrated that the facility’s systems for monitoring adverse events, reconciling staff accounts with objective evidence, and escalating concerns through QAA/QAPI were not effectively implemented. The facility’s Supervised Care policy required that any employee who failed to follow resident care, medication, or treatment policies, or whose care was under review, be placed on Supervised Care with documented job responsibilities, supervisory sign-off each shift, and Department Head review with notification to the Administrator if problems were identified. In this case, the Supervised Care form for the CNA listed only vague “care concerns,” lacked detailed reasons such as bruising or rough care, and had signature discrepancies, including a misspelled version of the CNA’s name that did not match other documents. There was no documented evidence that any actual auditing of the CNA’s care occurred, and the CNA stated they were never informed they were on Supervised Care and were not supervised while working. The DON later stated they did not believe the CNA was truly placed on Supervised Care and that the form may have been retroactively documented or not appropriately implemented. Additionally, the Administrator reported that the last QAPI meeting did not address this investigation while they were present, and the DON acknowledged that video footage was only reviewed reactively after an increase in bruising and incident reports, rather than as part of a systematic monitoring process. These facts show that the facility did not operationalize its QAA/QAPI policies to ensure consistent monitoring, investigation, and corrective action for identified quality and safety concerns involving staff performance and resident adverse events. Interviews further underscored the breakdown in the facility’s quality systems. The DON reported noticing a notable increase in incident reports of bruising, injuries, and falls on the unit and during the CNA’s shift, with discrepancies between the CNA’s accounts and other staff reports or observed injuries, yet there was no evidence that these concerns were effectively brought through the QAA process or resulted in a properly implemented Supervised Care plan. The Assistant DON described Supervised Care in this case as primarily an educational tool without one-to-one supervision, while the DON described Supervised Care as meaning the staff member should not be alone and should receive hands-on instruction and audits. The CNA denied being placed on Supervised Care and alleged the Supervised Care form signature was forged. The Administrator stated they were not aware of the care concerns surrounding the CNA until suspicions of multiple cases of abuse arose and acknowledged that the incident and related concerns were not discussed in the QAPI meeting while they were present. Collectively, these actions and inactions demonstrate that the facility did not follow its own policies for Supervised Care, did not consistently monitor and track adverse events and staff performance issues, and did not ensure that the QAA/QAPI committee developed and implemented appropriate plans of action to correct identified quality deficiencies.
Neglect Due to Failure to Follow Dietary Consistency Leading to Choking Incident
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide failed to follow a resident's care plan regarding dietary meal consistency, resulting in the resident being served food of the wrong texture. The resident, who had diagnoses including dementia with agitation, chronic obstructive pulmonary disease, and bladder cancer, was assessed as cognitively severely impaired and required a mechanically altered diet with ground meats due to dysphagia and impaired swallowing. The resident's care plan and dietary assessments clearly indicated the need for a mechanical soft diet with minced meats, and the meal ticket on the resident's tray specified this requirement. During a supper meal, the Certified Nurse Aide intentionally swapped meal plates among three residents, providing the resident with regular chicken tenders instead of the required minced consistency. Despite being warned by another aide that the food was not the correct consistency, the aide proceeded to feed the resident the regular chicken. This resulted in the resident choking and requiring immediate intervention, including back thrusts and mouth sweeps, to clear the airway. Staff interviews confirmed that the aide did not read the meal ticket and failed to follow established procedures for obtaining alternative meals, such as contacting the kitchen. Facility policies and staff education materials emphasized the importance of following care plans, meal tickets, and dietary restrictions to prevent neglect and ensure resident safety. The incident was witnessed by multiple staff members, and statements from nursing and medical staff indicated that the aide's actions were negligent and directly led to the resident's choking episode. The failure to adhere to the resident's prescribed diet and established protocols constituted neglect as defined by facility policy.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an injury of unknown origin involving a resident was reported to the Administrator and the State Survey Agency within the required timeframe. According to facility policy, all incidents, accidents, and injuries of unknown source must be reported immediately, or no later than two hours after discovery, to the appropriate authorities. In this case, a resident with diagnoses including dementia, hypertension, and peripheral vascular disease was found to have discoloration and bruising below the right eye, which was first documented by a registered nurse as purpura. The resident was cognitively severely impaired and unable to recall how the injury occurred. Despite multiple staff members, including registered nurses, nurse practitioners, and the medical director, being aware of the injury over several days, the incident was not reported to the Director of Nursing, Administrator, or the New York State Department of Health within the mandated timeframe. Progress notes and staff statements indicated that the injury was observed, discussed among staff, and assessed by medical personnel, but the required notifications and reporting were not completed as per facility policy and state regulations. The facility's own documentation and staff interviews confirmed that the injury was of unknown origin and should have triggered immediate reporting. Interviews with facility staff, including the DON, Administrator, and Medical Director, revealed a consensus that the initial nurse who identified the injury should have reported it for further assessment and to the appropriate authorities. The failure to report the injury of unknown origin in a timely manner constituted a violation of both facility policy and state regulations, as all agreed that the incident met the criteria for mandatory reporting within 24 hours.
Failure to Thoroughly Investigate Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving potential abuse, neglect, or mistreatment, as required by its own policies and federal regulations. In the first incident, a resident with severe cognitive impairment and dysphagia was fed regular consistency chicken tenders instead of the prescribed mechanical soft, minced diet. This error occurred after a certified nurse aide intentionally swapped meal plates among three residents without verifying dietary restrictions, resulting in the resident choking and requiring emergency intervention. The facility's investigation did not determine where the incorrect food originated, nor did it include a review of the dietary plans or meal tickets for the other residents involved in the plate swap. Key staff, including the therapy director, nurse practitioner, and medical director, were unaware of the full extent of the incident, and the director of nursing acknowledged the investigation was incomplete. In the second incident, a resident with dementia and a history of behavioral symptoms was found to have a bruise of unknown origin below the right eye. Documentation showed that the discoloration was first noted as purpura by a registered nurse, but no provider assessment or investigation was initiated at that time. The facility's investigation began several days later, did not review all relevant progress notes, and failed to interview all staff assigned to the resident during the period when the injury could have occurred. Several staff members, including those who provided care during the relevant shifts, confirmed they were not interviewed as part of the investigation. Both the director of nursing and the administrator later acknowledged that the investigation was not thorough and did not follow the facility's established procedures for injuries of unknown origin. In both cases, the facility's failure to conduct comprehensive investigations meant that not all potential causes or responsible parties were identified, and the required steps to rule out abuse or neglect were not completed. The deficiencies were confirmed through staff interviews, record reviews, and direct admissions from facility leadership that the investigations were incomplete and did not meet policy or regulatory standards.
Failure to Provide Two-Person Assist for Dependent Resident's Incontinence and Bed Mobility Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia with agitation, generalized anxiety disorder, and major depressive disorder, who was assessed as cognitively severely impaired and totally dependent for toileting hygiene and bed mobility, did not receive care as outlined in their comprehensive care plan. The care plan, as well as the Certified Nurse Assistant Assignments Summary, specified that the resident required the assistance of two or more staff members for incontinent care and bed mobility due to their total dependence and risk for skin breakdown. However, during an observed episode of incontinence care, a single Certified Nurse Aide provided all care and repositioning without the required second staff member, despite the resident intermittently vocalizing during the process. Interviews with multiple staff members, including the CNA involved, another CNA, an LPN, an RN, the Director of Nursing, and the Administrator, confirmed that the expectation and documented plan of care was for two-person assistance for this resident's incontinent care and bed mobility. The CNA acknowledged not following the care plan and not requesting assistance, while all other staff interviewed stated they would have expected the care plan to be followed for the resident's safety. The facility's policy required comprehensive, person-centered care plans to be implemented as written, but this was not adhered to in this instance.
Failure to Implement Enhanced Barrier Precautions and Lack of Transmission-Based Precaution Policies
Penalty
Summary
A deficiency was identified when staff failed to implement proper infection prevention and control practices for a resident on Enhanced Barrier Precautions due to the presence of extended-spectrum beta-lactamase-producing bacteria in their urine. During an observation, a Certified Nurse Aide provided incontinent care involving exposure to urine and feces without donning a gown, as required by the posted Enhanced Barrier Precaution signage. The signage clearly indicated that gloves and gowns were to be worn during high-contact resident care activities, such as dressing, hygiene, and changing briefs. The Certified Nurse Aide acknowledged awareness of the signage but was uncertain about which resident required precautions and did not follow the required protocol during care. Interviews with facility staff, including the Certified Nurse Aide, Registered Nurses, the Director of Nursing, the Infection Preventionist, and the Medical Director, confirmed that the expectation was for staff to wear gowns and gloves when providing care to residents on Enhanced Barrier Precautions. However, it was revealed that the facility did not have specific written policies and procedures for Enhanced Barrier Precautions or for other types of transmission-based precautions, such as airborne, droplet, and contact precautions. Staff reported relying on CDC guidelines and posted signage but lacked formalized facility policies to guide their actions. The resident involved had significant cognitive impairment, was frequently incontinent of bowel and bladder, and had a care plan indicating the need for staff to use personal protective equipment per the posted precaution card. Despite these documented needs and the presence of signage and PPE supplies, the lack of clear, facility-specific policies and procedures contributed to inconsistent implementation of infection control measures, as evidenced by the observed failure to use appropriate PPE during high-risk care activities.
Failure to Initiate Timely CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to provide emergency basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was a full code and found unresponsive. The facility's policies required that residents who had chosen CPR be clearly identified with green wristbands, stickers, and other visual cues, and that staff initiate CPR in accordance with the resident's advance directives and physician orders. Despite these protocols, when the resident was found unresponsive, both the LPN and RN involved did not immediately check the resident's code status or initiate CPR. The LPN discovered the resident unresponsive and notified the RN, who assessed the resident and determined the resident had expired without checking the code status or starting CPR. The RN then began the process of notifying the family and funeral home, and left the unit without calling a code or informing a supervisor or physician. It was only after the RN began charting and realized the resident was a full code that the issue was brought to the attention of nurse supervisors, who then initiated CPR, but the attempt was unsuccessful. Interviews and documentation revealed that both the LPN and RN were aware of the resident's full code status but did not follow facility policy or physician orders to initiate CPR. The delay in identifying the resident's code status and the failure to start CPR in a timely manner resulted in Immediate Jeopardy Past Noncompliance, with the potential for serious harm to the health and safety of all residents. The incident was attributed to staff not following established protocols for identifying code status and responding to unresponsive residents.
Delay in Removal of Staff Following Resident Abuse Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) threw a water bottle at a resident with non-Alzheimer's dementia, osteoarthritis, and age-related debility. The incident took place in a hallway near the nurses' station, where the resident, who had severe cognitive impairment but could communicate, was sitting in a wheelchair. The CNA first threw the bottle, missing the resident, then retrieved it and threw it again, striking the resident on the back and causing water to spray onto them. This act was witnessed by another CNA, who intervened by moving the resident away from the situation. Despite the immediate risk, there was a delay in removing the offending CNA from resident care. The witnessing CNA reported the incident to an LPN, who then attempted to locate a supervisor. During this time, the CNA who committed the abuse remained in the area, and staff did not immediately call security or remove the perpetrator from the unit. The LPN instructed staff to monitor the CNA until a supervisor arrived, at which point the CNA was finally removed from the facility by security. The facility's policy required immediate reporting and removal of staff suspected of abuse, but this protocol was not followed. Interviews with staff confirmed that there was confusion and hesitation in responding to the incident, resulting in a delay in protecting residents from further potential harm. The resident involved was assessed and showed no signs of physical or psychological distress following the event.
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A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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