Warren Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Queensbury, New York.
- Location
- 42 Gurney Lane, Queensbury, New York 12804
- CMS Provider Number
- 335549
- Inspections on file
- 26
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Warren Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors identified that multiple residents were not treated with dignity and respect. A resident in the active dying phase was left in a dark room with no stimuli, lying partially off the bed, while staff walked past without entering to assess or provide comfort despite PRN orders for pain and anxiety medications. Another resident with cognitive impairment was observed self-toileting on a bedside commode in an open area without curtains drawn, surrounded by feces-stained landing strips and soiled tissues on the floor. A third resident reported that when they requested toileting, a CNA stated they were responsible for 20 residents, refused to toilet them, instructed them to relieve themselves in bed, and did not return until the next day shift.
The facility failed to protect several residents from abuse, neglect, and misappropriation of property, and did not ensure care consistent with assessed needs. One resident with dementia and anxiety was inappropriately touched on the breast by another cognitively intact resident with a documented history of sexually inappropriate behaviors, who was not under active 1:1 supervision at the time. Another resident with morbid obesity and lymphedema, care planned for two-person assistance with bed mobility, was provided incontinence care by a single CNA and slipped from the bed to the floor, with no further investigation or statements collected despite the care plan violation. A third resident with head and neck cancer, cirrhosis, and an artificial larynx was accused by an RN of consuming a crushed oxycodone dose left unattended in the room; the resident denied taking it, became distressed, contacted law enforcement, and the RN still documented the narcotic as given without recording an incident or triggering an investigation. For this same resident, the comprehensive care plan called for airway management and emergency preparedness related to an artificial larynx, but physician orders lacked any trach/laryngectomy care, suctioning, humidification, respiratory therapy involvement, or required bedside emergency airway supplies.
Surveyors found that the facility did not keep resident environments free from accident hazards when medications and supplements were left unsecured in resident rooms and fall-prevention equipment was used improperly. One resident had a cup with cream and crushed medication left at the bedside, while another had collagen peptides, alpha lipoic acid, and topical cream accessible in the room, even though the DON stated no residents self-administered medications and the Administrator indicated such items should be locked. A third resident, admitted with a femur fracture, acute respiratory failure, and HTN and care-planned for fall risk, had two thick floor mats stacked on one side of the bed, contrary to the care plan and staff expectations for mat placement, and staff acknowledged that this configuration could increase fall and tripping risk as the resident ambulated more independently.
The facility failed to ensure that nurses and nurse aides had validated competencies for specialized respiratory care and safe narcotic management. One resident with throat cancer, a tracheostomy, and HIV had physician orders for trach care every shift, yet surveyors observed an uncovered suction catheter on a canister with cloudy fluid, undated tubing and water, no Ambu bag at bedside despite the care plan, and the resident reported that trach care and suctioning were not being performed. An LPN who claimed to have provided trach care could not locate needed supplies, could not describe full trach care, and had no documented competency for tracheostomy or respiratory equipment management, while treatment records showed inconsistent documentation and directions inconsistent with the resident’s skilled care needs. Another resident with head and neck cancer, an artificial airway, and cirrhosis had a narcotic pain dose left crushed and unattended in the room by an RN; when the medication was found missing, the RN assumed ingestion despite the resident’s denial, yet still documented the narcotic as given on the MAR. The DON did not ensure required investigation, did not notify the physician or Medical Director of the narcotic discrepancy, and there was no evidence of staff interviews, root-cause determination, disciplinary action, or competency-based retraining, despite facility policies requiring incident investigation, narcotic discrepancy reporting, and staff competency validation.
A resident with morbid obesity, lymphedema, and GAD, who was care planned to require two staff for bed mobility, slipped from the bed to the floor when a CNA provided incontinence care alone and turned the resident onto their side. The facility’s incident report documented no injury and full ROM, but the event, an alleged neglect incident involving failure to follow the two-person assistance requirement, was not reported to the state health department within the required timeframe, and the DON later stated it was deemed non-reportable despite facility policy assigning responsibility to leadership to determine and complete required external reporting.
A resident with COPD, pulmonary HTN, CHF, CKD, and hypoxic respiratory failure was discharged home after completing rehab, with documentation stating their health had improved sufficiently to no longer need facility services. In the days before discharge, a provider ordered PRN guaifenesin for cough and a COVID/flu respiratory panel, and the resident received cough medication twice, with one dose documented as ineffective. The swab was collected, but there was no documentation of the rationale for the orders, no evidence that test results were obtained or reviewed, and no provider evaluation of the resident’s clinical status after these orders and before discharge. Staff reported the resident had cough and congestion and that family requested testing, while leadership stated the resident had no respiratory symptoms at discharge and that results would not have been available due to outside lab processing. The complainant reported the resident was very ill at discharge and that attempts to delay discharge were unsuccessful. The resident was hospitalized shortly after discharge with shortness of breath, weakness, a one-week history of respiratory symptoms, and was found to have influenza and acute on chronic heart failure exacerbation, leading surveyors to cite a failure to ensure an appropriate and safe discharge.
A resident with end stage renal disease, type 2 DM, and chronic respiratory failure, who was cognitively intact, slipped from the side of the bed to the floor during incontinence care provided by a CNA. An Initial Event assessment documented the fall and initiation of interventions such as OT/PT evaluation as indicated, non-skid socks, and keeping the bed in the lowest position. The facility’s policies required the IDT to review and revise the comprehensive, person-centered care plan after such events and when resident conditions changed. However, there was no documentation that the resident’s fall care plan, which already identified fall risk related to deconditioning, gait/balance problems, and immobility, was reviewed or revised following this fall, despite the DON’s description that incident reports are discussed and care plans updated after such events.
Two residents with tracheostomy or laryngectomy tubes did not receive respiratory care in accordance with facility policy and professional standards. One resident with throat cancer and HIV reported not receiving trach care or suctioning despite documented orders, while surveyors observed uncovered and soiled suction equipment, undated respiratory supplies, and no Ambu bag at the bedside; an LPN could not locate needed trach supplies, described care as merely wiping the stoma, and admitted most nurses needed a skills refresher. Another resident with an artificial airway and cirrhosis had care plan interventions for respiratory monitoring and suctioning, but the health care proxy expressed concerns about staff competency to manage the airway and could not confirm the presence of emergency airway equipment. Interviews with the DON, an RN, and the Medical Director confirmed that clean, dated supplies, complete trach care, and an Ambu bag at bedside were expected, yet these standards were not consistently met.
Surveyors found that the facility did not follow its policy for safe storage of outside food, resulting in perishable items such as mayonnaise, milk, and lettuce being kept unrefrigerated in a resident’s room for at least two days, with the resident reporting they used the cool outdoor air as a refrigerator and received no staff guidance on proper storage. Another resident with a PICC line, adrenal insufficiency, atrial fibrillation, limited mobility, and malnutrition had a care plan addressing outside food and visitor education, yet developed Salmonella identified as foodborne during the stay, while the facility’s infection control reports showed no identification, tracking, or trending of foodborne illness and no documented monitoring of perishable food stored in resident rooms, despite routine monitoring of kitchen food temperatures.
The facility failed to update comprehensive care plans for three residents after incidents, including falls and alleged sexual abuse. Despite interventions being initiated, these were not documented in the care plans. Staff interviews revealed that assessments were documented but not consistently transferred to care plans, leading to regulatory deficiencies.
A resident with complex medical needs, requiring two-person assistance for bed mobility, was neglected when a CNA attempted to roll them alone, resulting in the resident falling and sustaining leg fractures. The CNA was aware of the care plan but chose to act independently, leading to the incident.
Failure to Maintain Resident Dignity, Privacy, and Respect for Toileting and End-of-Life Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect and that their quality of life was maintained or enhanced. One resident with end stage renal disease, dementia, and anxiety, who was documented as cognitively intact, was observed over several days in the active dying phase lying in their room with the lights out, no stimuli, and positioned across the bed with feet partially hanging off the bed. On one of these days, the resident was noted to be restless, moaning, with deep respirations and dry mucosa, while several staff walked by the room throughout the day without entering to assess or provide interventions, despite the presence of PRN orders for Lorazepam and Morphine for anxiety and pain. Another resident with a history of a left humerus fracture, dementia, and anxiety, and documented moderate cognitive impairment, was observed using a bedside commode without privacy measures in place. The resident was self-toileting on the bedside commode in an open area with no curtains drawn while attempting to wipe themselves. The area around the commode had landing strips on the floor that were caked with brown material consistent with feces and other unidentifiable stains, as well as several soiled tissues on the floor that appeared to have been intended for the garbage bin but instead landed on the floor. A third resident with malnutrition, anxiety, and depression, and documented moderate cognitive impairment, reported that on a previous evening they requested to use the toilet at approximately 11:20 PM. According to the resident, a CNA stated they were in charge of 20 residents, did not have time to toilet them, and told the resident to relieve themselves in the bed. The resident further stated that no staff returned to their room until the following day shift arrived and got them up just prior to the interview, and that they were unable to identify the CNA because the aide did not wear a name tag and refused to identify themselves.
Failure to Prevent Abuse, Neglect, Misappropriation, and Inadequate Airway Management
Penalty
Summary
The deficiency involves multiple failures by the facility to protect residents from abuse, neglect, and misappropriation of property, and to ensure care consistent with residents’ assessed needs and care plans. One resident with end stage renal disease, dementia, and anxiety, who was cognitively intact, extended a handshake to another cognitively intact resident with dementia and a history of sexually inappropriate behaviors, including touching self in public, staring at women, making sexual comments, and inappropriate touching of staff and residents. During this interaction at an activity, instead of shaking hands, the resident with known sexual behavior issues reached out and touched the other resident’s left breast. The affected resident moved away from the situation and later verbalized distress related to the incident. The sexually inappropriate resident’s care plan documented prior sexually inappropriate behaviors and prior use of 1:1 supervision when out of bed, but at the time of the incident the resident was not on active 1:1 supervision. Another deficiency occurred when a resident with morbid obesity, lymphedema, and generalized anxiety, who was cognitively intact, was provided incontinence care by a single CNA despite the resident’s Care Kardex directing that rolling left and right required two staff with hands-on assistance. During this care, the resident was turned onto the left side and slipped off the side of the bed onto the floor. The incident and accident report documented the resident lying on the left side on the side of the bed, with full range of motion and no injury noted. The DON acknowledged signing off on the fall progress note and that an incident report was completed, but there was no further investigation, no statements collected, and the event was deemed non-reportable to the Department of Health, despite documentation that the resident required two-person assistance for bed mobility. A further deficiency involved another cognitively intact resident with malignant neoplasm of the head, face, and neck, cirrhosis, and an artificial laryngectomy tube. A nurse crushed an oxycodone tablet, placed it in a medication cup in the resident’s room, briefly left, and on return found the medication missing. The nurse assumed the resident had taken the medication, confronted the resident with this accusation, and the resident denied taking it. The nurse nonetheless documented the narcotic as administered on the MAR and did not document any incident in the record. The resident became visibly upset, cried, and contacted law enforcement; police responded but deferred the matter to the facility, and there was no documented facility investigation into the allegation of abuse or misappropriation of the medication. The Medical Director later stated they were not notified of the missing narcotic or missed dose and that the nurse should not have signed it as given if the facts were unclear. In addition, the same resident with an artificial larynx had a comprehensive care plan reflecting multiple high-risk clinical needs, including airway management related to a tracheotomy/artificial larynx, enteral nutrition, cancer-related pain, impaired communication, decreased mobility, and fall risk. The care plan included interventions such as monitoring respiratory status, managing secretions, providing suctioning as needed, maintaining airway patency, administering tube feedings, managing pain, and assisting with ADLs. However, review of the physician order summary for the relevant period showed no physician orders for tracheostomy or laryngectomy care, including suctioning, stoma care, humidification, respiratory therapy involvement, or bedside emergency airway supplies such as a spare tube, obturator, suction equipment, or emergency airway instructions. The orders were limited to general care such as medications, wound care, enteral feeding, and routine monitoring, creating a discrepancy between the resident’s documented clinical condition and care plan needs and the absence of corresponding physician orders.
Unsecured Medications and Improper Use of Floor Mats Create Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident environments were as free from accident hazards as possible and that adequate supervision was provided to prevent accidents for three residents reviewed for accidents and hazards. Facility policies required that medications be administered only by licensed or permitted personnel, that falls be managed through appropriate interdisciplinary interventions, and that accident or incident conditions, including safety hazards, be monitored and evaluated. Despite these policies, surveyors observed unsecured medications and environmental hazards in resident rooms. For one resident, a medication cup containing a cream and crushed medication was observed on the bedside table, accessible to residents, visitors, and staff. Another resident had collagen peptides, alpha lipoic acid, and Aspercreme at the bedside and in the window area; the resident reported taking the collagen peptides and alpha lipoic acid for wound healing and stated that these items were brought in by family. Record review showed the facility cared for residents with diminished cognitive status, and the DON stated that no residents in the facility self-administered medications, while the Administrator stated that self-administered medications would need to be locked up. These observations showed that medications and supplements not ordered or controlled by facility staff were accessible in resident rooms. A third resident, admitted with a left femur fracture, acute respiratory failure, and hypertension, was identified as cognitively intact but at risk for falls due to a history of falls, ambulating without assistance, and rolling out of bed. The care plan for falls included interventions such as maintaining a clutter-free environment, using an upper perimeter mattress, keeping the bed in the lowest position, and ensuring appropriate footwear and non-skid socks. However, surveyors observed two floor mats, approximately two inches thick, stacked on top of each other on one side of the bed, and later observed the same mats still stacked, with the resident in bed and a walker positioned by the wardrobe. Staff interviews revealed uncertainty about the resident’s fall history and the use of floor mats, and both nursing staff and the DON acknowledged that stacked floor mats on one side of the bed were not in the care plan and could increase fall risk, and that floor mats could become a tripping hazard as someone becomes more independent.
Failure to Ensure Nursing Competency in Respiratory Care and Safe Narcotic Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff, including nursing leadership, possessed the competencies and skills necessary to provide specialized respiratory care and safe medication practices, as required by facility policy. The facility’s competency policy required managers to ensure job-specific training and competency validation on hire, annually, upon changes in duties or processes, and when performance concerns were identified, with documentation of training and validation. Despite this, surveyors found that staff providing tracheostomy and respiratory care lacked documented competencies in these areas, and that the Director of Nursing did not carry out required oversight functions related to investigation of incidents, physician notification, and corrective actions. For one resident with throat cancer, a tracheostomy, and HIV, the Minimum Data Set documented that the resident was cognitively intact, required substantial to maximal assistance with activities of daily living, and received suctioning and tracheostomy care. Physician orders required tracheostomy care every shift and as needed. During observations on two separate dates, the resident’s tracheostomy setup included an uncovered suction catheter lying on top of a suction canister containing cloudy fluid, with no dates on tubing or equipment, and later the same setup was seen unchanged with a used urinal directly below and an undated water bottle connected to the tracheostomy collar. The care plan called for an Ambu bag at bedside, but no Ambu bag was present. The resident reported that tracheostomy care and suctioning were not being performed, that staff were not skilled to perform it, and that they did not offer the care. When interviewed, an LPN stated they had performed tracheostomy care for this resident on a specific date, but the supplies in the room appeared unchanged from prior observations. The LPN was unable to locate necessary supplies, could not describe full tracheostomy care, and stated they had required additional training to be competent in proper tracheostomy care. Review of the Treatment Administration Record showed inconsistent documentation of ordered tracheostomy care across shifts, with multiple staff initials and variability in completion, and included directions to encourage the resident to allow staff or self-clean, which was inconsistent with the resident’s documented need for skilled nursing interventions. The LPN’s competency records showed validation for infection control, medication administration, and blood glucose monitoring, but no documented competency validation for tracheostomy care or respiratory equipment management. For another resident with head and neck cancer, an artificial laryngectomy tube, and cirrhosis, the care plan identified pain management needs and respiratory needs related to the artificial airway, including monitoring respiratory status, observing for signs of respiratory distress or changes in secretions, and providing suctioning as ordered. The Medication Administration Record documented that a narcotic pain medication had been administered by an RN and that pain was reassessed and evaluated as effective, with no incident documented in the medical record. However, an incident statement later documented that the RN had placed a crushed narcotic in a medication cup in the resident’s room, left it unattended, and upon return found the medication missing. The RN assumed the resident had taken the medication, confronted the resident, and the resident denied taking it, yet the MAR for the surrounding dates documented the narcotic as administered by the RN. The facility’s narcotic management policy required that all narcotics be secured, accounted for, and discrepancies immediately reported to the Director of Nursing, and the notifications and accident/incident policies required prompt reporting, investigation, and physician notification of incidents and adverse events. The Medical Director stated they were not notified of the narcotic discrepancy and that the medication should not have been documented as administered if the facts were unclear. A law officer reported that they had deferred further action based on the DON’s assurance that the facility would conduct an internal investigation. The DON acknowledged responsibility for oversight of clinical care and investigations but did not provide evidence that a complete investigation was conducted, and there was no documentation of staff interviews, fact-finding, determination of cause, or corrective actions. There was also no evidence that the resident’s physician was notified of the missing narcotic or the allegation that the resident consumed the medication, no documentation of disciplinary or performance action for the nurse involved, and no evidence that performance concerns led to competency evaluation or retraining. Additionally, although the care plan identified airway management and monitoring needs for this resident, physician orders did not reflect airway management needs or emergency equipment. These findings collectively demonstrated that the facility failed to ensure nursing staff competency in respiratory care, safe medication practices, and appropriate investigation and physician notification, as required by policy and regulation.
Failure to Report Alleged Neglect Incident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged incident of neglect to the New York State Department of Health as required. Record review and interviews showed that an alleged violation involving neglect for one resident was not reported within 24 hours after the allegation was made, and there was no documented evidence that the incident was reported at all. The facility’s policy on Accident-Incidents, last reviewed on 6/01/2024, states that the DON and Administrator are responsible for reviewing incidents and investigations to determine if they require reporting to outside agencies such as the Department of Health, and that all incidents and accidents will be evaluated by the interdisciplinary team, which will review the investigation, determine root causes, and document an interdisciplinary team note. During interview, the DON stated the incident was deemed non-reportable to the Department of Health. The resident involved had diagnoses including morbid obesity, lymphedema, and generalized anxiety disorder, and was documented on the Minimum Data Set as cognitively intact and able to understand and be understood by others. The resident’s care Kardex dated 5/01/2025 specified that bed mobility, including rolling left and right, required two staff providing hands-on assistance. On 5/04/2025, an Incident and Accident report documented that the resident was observed lying on their left side on the side of the bed, with full range of motion in all extremities and no injury, after a CNA provided incontinence care alone without a second staff member. During this care, the resident was turned onto their left side and slipped off the side of the bed onto the floor. This event, constituting an alleged neglect incident involving failure to follow the two-person assistance requirement for bed mobility, was not reported to the Department of Health as required by 10 NYCRR 415.4(b)(2).
Failure to Ensure Clinically Appropriate Discharge with Pending Respiratory Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge was appropriate based on the resident’s clinical status and that the resident was prepared for a safe discharge. The facility’s discharge/transfer policy required coordination of a safe transfer or discharge, documentation of the resident’s current medical status, and provision of written interdisciplinary discharge instructions summarizing the resident’s condition at the time of discharge. For this resident, the transfer/discharge notice stated that the resident’s health had improved sufficiently so that they no longer needed the services of the facility, citing successful completion of sub-acute rehabilitation. However, the resident refused to sign the notice, and the administrator signed as a witness. The complainant reported that as the planned discharge date approached, the resident became increasingly ill and incapacitated and was in no condition to be sent home, and that attempts to stop or postpone the discharge were unsuccessful. The resident had significant medical diagnoses including type 2 diabetes, COPD, pulmonary hypertension, congestive heart failure, chronic kidney disease, and hypoxic respiratory failure. A physician treatment encounter note dated several days before discharge documented that the resident was clinically stable to discharge home with family. In the days immediately preceding discharge, a physician order was initiated for PRN guaifenesin liquid for cough, and the medication administration record showed that the cough medicine was given on two occasions, with one administration documented as ineffective and the next as effective. A physician order was also entered for a one-time COVID/influenza swab, and the MAR documented that the swab was collected by an RN. Staff interviews indicated that the resident had cough and congestion one to two weeks prior to discharge, that the family requested COVID/flu testing, and that a respiratory panel for COVID, influenza, and RSV was obtained because the resident was having symptoms, although staff also stated that symptoms were starting to resolve. Despite the ordered diagnostic testing and symptomatic treatment, there was no documentation in the clinical record explaining the rationale for ordering the cough syrup and COVID/flu swab prior to discharge. There was also no documentation that the results of the COVID/flu swab were obtained or reviewed by facility staff, and no evidence that a medical provider evaluated the resident after the 12/31 treatment encounter to reassess clinical status in light of the new cough and respiratory testing orders before discharge. The RN who collected the swab stated they never received the results and were uncertain if the test was sent out, and the DON stated that test results could not be found. The rehabilitation manager recalled the resident reporting not feeling well around the time of discharge and being tested for COVID/flu. The complainant reported that the resident was sent home while vomiting and very weak, and that the resident’s cough did not improve at home. The resident was sent home on oxygen with equipment and services arranged, and the administrator reported that the resident had no acute respiratory distress at the time of discharge and that the testing and cough syrup were ordered largely at the family’s request. Two days after discharge, the resident was admitted to the hospital from the emergency department with shortness of breath, weakness, and a one-week history of malaise, weakness, cough, and shortness of breath, and was found to have pulmonary congestion, a positive viral panel for influenza, and an elevated heart failure marker, with an assessment of acute on chronic heart failure exacerbation in the setting of viral pneumonia. The medical director stated that influenza testing was usually based on symptoms and that they would expect documentation of the rationale for ordering a COVID/flu swab and cough medicine. The DON stated that if a COVID/flu swab was completed it should have been sent out, and that the order would have been canceled if not completed, but acknowledged that results could not be located. The administrator explained that respiratory panels were being sent to outside labs with a four-day turnaround, so results would not have been available before discharge, and maintained that the resident had no symptoms at discharge. Nonetheless, the record lacked documentation of a provider reassessment after the onset of cough and respiratory symptoms and after the diagnostic test was ordered, and there was no evidence that the pending test results were obtained or considered before proceeding with discharge. These omissions led surveyors to determine that the facility failed to ensure the discharge was appropriate based on the resident’s clinical status and failed to ensure the resident was prepared for a safe discharge, in violation of 10 NYCRR 483.21(c)(1).
Failure to Revise Fall Care Plan After Resident Fall Event
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to review and/or revise a resident’s Comprehensive Care Plan following a fall event. Facility policy on Comprehensive Care Plans required that care plans be comprehensive, person-centered, include measurable objectives and timetables, and be revised as resident conditions changed, including when desired outcomes were not met. The facility’s Fall Management and Prevention policy further required the interdisciplinary team to identify and implement appropriate interventions to reduce fall risk and to review and revise the interdisciplinary care plan when a change was identified after an event. Despite these policies, there was no documented evidence that the Comprehensive Care Plan for one resident was reviewed or revised after a documented fall. The resident involved had diagnoses of end stage renal disease, type 2 diabetes, and chronic respiratory failure, and was documented on the MDS as cognitively intact and able to communicate. An Initial Event assessment documented that the resident slipped from the side of the bed to the floor while being turned on their left side during incontinence care by a CNA; the resident did not hit their head. Interventions initiated after the fall included OT and PT evaluation and treatment as indicated, use of non-skid socks, and keeping the bed in the lowest position. The existing Comprehensive Care Plan for falls already identified the resident as at risk for falls or having had an actual fall related to deconditioning, gait/balance problems, and immobility, but there was no documentation that this care plan was reviewed or revised after the fall event. During interview, the DON stated that incident/accident reports were discussed in morning meeting with the interdisciplinary team and that care plans were updated once agreed-upon interventions were put into place, but the record for this resident did not contain such updates following the fall.
Failure to Provide Competent Tracheostomy Care and Maintain Required Airway Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory and tracheostomy care in accordance with its own policy and professional standards for two residents with artificial airways. For one resident with throat cancer, HIV, and a tracheostomy, the MDS documented the need for suctioning and tracheostomy care, and the care plan required an Ambu bag at the bedside. Surveyors observed an uncovered suction catheter, cloudy liquid in a suction canister, and undated tubing and water bottle connected to the trach collar. The resident repeatedly reported not receiving tracheostomy care or suctioning despite feeling the need, and stated that staff did not know how to perform the care and that there was limited access to staff able to suction. During observed tracheostomy care for this resident, the LPN/unit manager entered the room where the tracheostomy setup appeared untouched, with a deep suction catheter uncovered and resting on a half-full cloudy suction canister and a used urinal directly below. The LPN could not locate necessary tracheostomy supplies in the room, was unaware of where to obtain them, and asked the resident where supplies were kept; the resident wrote that they had not had correct supplies in months. The LPN described prior tracheostomy care as simply wiping the stoma opening, could not clearly describe complete tracheostomy care procedures, and acknowledged that they and most other nurses needed to refresh their tracheostomy skills. The LPN also stated the resident could perform their own tracheostomy care, while the resident stated they were not comfortable doing so. The Treatment Administration Record documented that tracheostomy care had been completed on a date when the resident reported it had not been done. Staff interviews, including with an RN and the Medical Director, confirmed that supplies should have been clean, covered, and dated, that tracheostomy care consists of more than cleaning the site, and that an Ambu bag should be at the bedside; however, an LPN was unable to identify an Ambu bag in the room, and the resident stated an Ambu bag had never been available at the bedside. For a second resident with cancer of the head/neck, an artificial laryngectomy tube, and cirrhosis, the care plan identified respiratory needs related to the artificial airway, including monitoring respiratory status, observing for signs of respiratory distress or changes in secretions, and providing suctioning as ordered. The resident’s health care proxy reported concerns about staff competency to manage the laryngectomy tube, including suctioning and airway care, and stated the resident could not independently manage their own care. The proxy was unable to recall whether emergency airway equipment, including an Ambu bag, was present at the bedside. Corporate nursing staff stated that acceptance of a resident with a tracheostomy or similar airway needs reflected the facility’s determination that it had the capacity and competency to provide the required level of care. The Medical Director reported that tracheostomy care was assumed to be provided by the facility, expressed concerns about the facility’s ability to provide such care, and stated that the lack of ability to provide appropriate tracheostomy care should have been thoroughly investigated. The DON stated the facility was able to provide tracheostomy care, but was unaware of the lack of an Ambu bag at the bedside and acknowledged that this should not have occurred.
Failure to Monitor and Safely Store Perishable Outside Food in Resident Rooms
Penalty
Summary
The facility failed to ensure that food brought in from outside sources was stored, labeled, and maintained according to its own policy and professional standards, resulting in perishable items being kept unrefrigerated in resident rooms. The facility’s policy required all perishable foods to be refrigerated, labeled, and discarded within 48 hours, and specified that foods left without temperature control for more than two hours were to be discarded. Nursing staff were responsible for monitoring resident rooms for spoilage, contamination, and safety, but surveyors found no documentation or evidence that perishable food stored in resident rooms was being monitored or overseen. One resident with diabetes mellitus, major depressive disorder, and exocrine pancreatic insufficiency had documented nutritional problems related to diabetes and was on a therapeutic diet with goals to maintain adequate intake and blood glucose levels. Observations on two consecutive days showed a jar of mayonnaise, two cartons of milk, and a head of lettuce stored on the windowsill in this resident’s room. The resident reported using the cool outdoor air as a refrigerator and stated that family members brought in additional food options, and that staff did not provide further options or guidance regarding storage. During this period, outdoor temperatures ranged between 67°F and 70°F, and the perishable items remained unrefrigerated on the windowsill. Another resident, who had a PICC line, primary adrenal cortical insufficiency, atrial fibrillation, limited mobility, and malnutrition, had a care plan that acknowledged receipt of outside food from visitors and included interventions such as educating visitors on safe food handling temperatures and providing a food safety handout to family. During this resident’s stay, the resident was diagnosed with Salmonella, and emergency room documentation identified the illness as foodborne and related to food consumption. Despite this, the facility’s infection prevention and control monthly reports and associated line lists for the relevant months contained no documented evidence that foodborne illness was identified, tracked, or trended. While kitchen food temperatures were routinely monitored and maintained at appropriate levels, there was no documentation of monitoring or oversight of perishable food stored in resident rooms.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #1, who had a history of falling, experienced five falls between January and April 2024. Despite interventions such as non-skid socks being initiated, these falls and interventions were not documented in the resident's care plan. Resident #2 was involved in an incident of alleged sexual abuse in April 2024, but the care plan was not updated to reflect this incident or the necessary interventions such as monitoring for further behaviors and enhanced monitoring. Resident #3, with a history of falling, experienced a fall in April 2024, but the care plan did not document this fall or the intervention to keep a front-wheeled walker within reach. Interviews with facility staff revealed that while assessments and interventions were documented in the initial event documentation, they were not consistently transferred to the comprehensive care plans. The Assistant Director of Nursing and the Registered Nurse Manager acknowledged that it was not the facility's practice to document the date of each fall on the care plan focus, and the responsibility for updating the care plans was not adequately fulfilled. This lack of documentation and updating of care plans led to deficiencies in the facility's compliance with care planning regulations.
Neglect of Resident Care Plan Leads to Injury
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by an incident involving Certified Nurse Aide #1 and Resident #3. Resident #3, who had diagnoses including hemiplegia, hemiparesis, conversion disorder with seizures, and spastic hemiplegic cerebral palsy, required physical assistance from two staff members for bed mobility. Despite this requirement being clearly documented in the resident's care plan, Certified Nurse Aide #1 attempted to roll the resident in bed without assistance from another staff member. During the incident, Resident #3's left leg began to slide off the bed, leading to the resident's entire body sliding to the floor. This resulted in fractures to both of the resident's legs. Initially, the resident reported no pain or discomfort immediately following the fall, but later reported pain the following morning, leading to a hospital transfer where the fractures were confirmed. Certified Nurse Aide #1 acknowledged awareness of the care plan requirement for two staff members but believed they could manage the task alone. The facility's investigation confirmed that the aide acted against the care plan, and the facility was sufficiently staffed at the time of the incident. The resident expressed frustration with the aide for not heeding their warning about the improper positioning, which led to the fall and subsequent injuries.
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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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