Williamsville Suburban, L L C
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamsville, New York.
- Location
- 193 South Union Road, Williamsville, New York 14221
- CMS Provider Number
- 335647
- Inspections on file
- 25
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Williamsville Suburban, L L C during CMS and state inspections, most recent first.
Multiple residents reported receiving cold, unappetizing, and sometimes inedible meals, with observations confirming that hot foods were served below required temperatures and meal delivery was delayed. Staff interviews revealed ongoing complaints about food quality, non-functioning kitchen equipment, and insufficient staffing, all contributing to the deficiency in providing safe and palatable meals.
Surveyors found extensive failures in food safety and sanitation, including improper food storage, undated and expired foods, soiled equipment and surfaces, lack of required hair and beard restraints, and malfunctioning refrigeration and dishwashing equipment. Multiple nourishment refrigerators were above safe temperatures and contained expired or unlabeled items, while staff were unclear about cleaning responsibilities and food labeling policies. The facility lacked a current kitchen cleaning schedule, and essential food safety practices were not consistently followed.
Surveyors found that the facility did not ensure a clean, sanitary, and homelike environment, with observations of torn and stained privacy curtains, soiled and discolored surfaces, broken fixtures, and soiled linens left on floors in both resident rooms and shower areas. Staff and residents reported ongoing issues with cleanliness, maintenance, and infection control, and documentation of daily cleaning could not be produced during the survey.
The facility did not properly contain and dispose of garbage and refuse outside both the South and North Buildings. Dumpsters were frequently left open and overfilled, with bagged garbage and loose debris observed on the ground, including food waste and other refuse. Staff interviews confirmed that dumpsters should be kept closed and the area clean, but these practices were not consistently followed.
Two residents with significant care needs did not receive timely assistance with personal hygiene and incontinent care. One resident was left without bathing or morning care for several days after admission, while another waited over an hour for requested incontinent care. Staff interviews confirmed that daily ADL support and prompt response to care requests were not consistently provided, contrary to facility policy.
Surveyors found that two residents did not receive treatment and care in accordance with physician orders and professional standards. One resident with pressure ulcers did not have consistent skin assessments or documentation of wound care, while another with a PICC line experienced delays in obtaining dressing change orders and incomplete documentation of required flushes and assessments. Staff interviews revealed confusion about care responsibilities and processes.
A resident with Alzheimer's disease and depression, who had a history of expressing sadness and making negative statements, did not receive a timely psychiatry consult as previously recommended. Despite family requests and staff awareness of the resident's mental health concerns, the facility failed to order or complete the consult due to lapses in provider coverage, communication breakdowns among staff, and lack of follow-up on provider recommendations.
Surveyors found that staff did not consistently follow enhanced barrier precautions and hand hygiene protocols during high-contact care activities for two residents with complex medical needs. Staff provided care without required gowns and failed to change gloves or perform hand hygiene between dirty and clean tasks, contrary to facility policy and posted instructions. Interviews revealed gaps in staff understanding of infection control requirements, contributing to the deficiency.
The facility did not consistently ensure that both incoming and outgoing nurses signed the controlled substance inventory sheets at each shift change, resulting in numerous missing signatures across multiple units. Despite clear policies requiring dual nurse verification and signatures for narcotic counts, staff interviews revealed that signatures were often omitted due to distractions, forgetfulness, or staff working double shifts. Supervisory staff confirmed that the records were incomplete and did not meet professional standards for accountability.
Surveyors found that the facility did not ensure a clean, safe, and homelike environment, with observations of dirty floors, stained ceiling tiles, damaged window blinds, soiled bathroom fixtures, and improper storage of personal care items. Staff and residents reported dissatisfaction with cleanliness, and interviews revealed that cleaning and maintenance standards were not consistently met, contributing to unsanitary and uncomfortable living conditions.
A resident with severe cognitive impairment and multiple diagnoses did not receive required assistance with shaving, resulting in unkempt appearance and facial hair longer than ¼ inch. Despite policies and staff acknowledgment that shaving should occur on shower days or as needed, documentation and interviews confirmed that the resident was not shaved as required, and no refusals were documented.
The facility failed to maintain sufficient staffing levels, leading to unmet resident care needs. Residents reported delays in personal care, and staff struggled to complete duties due to understaffing, particularly on weekends. The DON and Interim Administrator acknowledged the staffing issues and their impact on care.
The facility failed to maintain an effective antibiotic stewardship program, lacking documentation and tracking of antibiotic use from July to October 2024. A resident with multiple diagnoses, including a stage 4 pressure ulcer and osteomyelitis, was on several antibiotics, but there was no evidence of monitoring or tracking. Staff interviews revealed a lack of awareness and documentation, with the new DON still in training and the previous DON having left recently.
A resident with an indwelling catheter and stage IV pressure ulcer was not provided care in accordance with enhanced barrier precautions. CNAs failed to wear gowns during high-contact activities, despite clear signage and available PPE. Interviews confirmed staff awareness of the requirements, yet they did not comply, indicating a deficiency in the infection control program.
A resident with severe cognitive impairment was found with a hematoma of unknown origin on their forehead. The injury was not reported to the facility's Administrator and the State Survey Agency within the required two-hour timeframe. Staff interviews revealed uncertainty about the incident and delayed notification to the Director of Nursing, highlighting a failure to adhere to reporting protocols for potential abuse cases.
Two residents with cognitive impairments and diabetes did not receive necessary grooming and personal hygiene care, including nail trimming and bathing, as required by their care plans. Observations showed unkempt nails and facial hair, while documentation inaccurately reflected care provision. Staff interviews revealed communication lapses and failure to follow through with scheduled care.
A resident with a foley catheter developed a urinary tract infection due to improper catheter care. The catheter drainage bag was left on the resident's lap instead of being positioned below the bladder, contrary to facility policy. The resident, who had a history of UTIs and a stage IV pressure ulcer, reported a burning sensation, and a urinalysis confirmed the infection. Staff interviews confirmed the improper positioning of the catheter bag, which should have been placed below the bladder to prevent infection.
The facility failed to properly store controlled substances, specifically Lorazepam, in a medication room. The medication refrigerator was not affixed, and the locked compartment inside was not used due to a missing key. Staff, including an LPN and the DON, were unaware of the unsecured state and the need for affixed storage, leading to improper storage of controlled substances.
A resident with a chipped tooth did not receive necessary dental services due to a breakdown in the facility's process for scheduling appointments. Despite a recommendation for a crown, the resident's care plan was not updated, and no follow-up appointment was made. Staff interviews revealed communication failures and a lack of responsibility in ensuring the resident's dental needs were met.
The facility failed to post contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline in an accessible manner for residents and their representatives. Observations and interviews revealed that the information was not posted in the North building, and staff were unaware of their responsibility to ensure its visibility.
The facility failed to implement care plans for three residents, which included the use of stop signs on room doors to prevent other residents from entering. Despite being documented in care profiles, the stop signs were not in place, and staff were unclear about the documentation and responsibility for this intervention. This oversight affected residents with conditions such as anxiety, depression, and dementia.
The facility failed to protect a resident from physical abuse when another resident with a history of aggression grabbed and threw them to the floor, resulting in significant injuries. Despite care plans in place for both residents, the incident occurred while an LPN was engaged in a medication pass, leading to the injured resident's hospitalization.
The facility failed to thoroughly investigate an incident of resident-to-resident abuse involving two residents. Despite video evidence of the altercation, no statements were collected from staff witnesses, and the facility did not follow its policy to evaluate the events leading up to the abuse. The investigation was deemed incomplete by multiple staff members, including the Administrator and Director of Nursing.
Failure to Provide Palatable and Safe-Temperature Meals
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures for residents in both buildings, as well as on a test tray. Multiple residents reported that meals were consistently served cold, unappetizing, and sometimes inedible. Observations and interviews revealed that residents often received their meals late, with food items such as pork chops, mashed potatoes, and vegetables being served at temperatures well below the required hot holding threshold. Residents described the food as bland, tough, overcooked or undercooked, and lacking in flavor. Some residents reported missing meal components or receiving incorrect items on their trays, and several stated that they or their families had to supplement their diets due to the poor quality of the facility's food. Staff interviews confirmed ongoing issues with food temperature and palatability. Dietary and nursing staff acknowledged that residents frequently complained about cold and unappealing food, and that trays were often delivered late due to short staffing in the kitchen. Staff also reported that the plate warmer in the kitchen was not functioning and had not been replaced, and that the steam table was awaiting approval for replacement. The Food Service Director and Administrator were aware of the complaints and equipment issues, but there was no evidence that these problems had been resolved at the time of the survey. Staff also indicated that they were not always able to accommodate residents' requests for reheating food or providing missing items due to limited resources. Temperature checks conducted by surveyors during meal service confirmed that hot foods were not maintained at the required temperatures. For example, pork chops on the tray line were measured at 142.7 to 144.2 degrees Fahrenheit, but by the time they reached residents, the temperature had dropped to 99.2 degrees Fahrenheit. Other hot items, such as mashed potatoes and vegetables, were also served below the required temperature, while cold items were within acceptable ranges. The lack of functioning equipment, delayed meal delivery, and insufficient staffing contributed to the failure to provide meals that met regulatory standards for safety, palatability, and resident satisfaction.
Widespread Food Safety and Sanitation Deficiencies in Food Service Operations
Penalty
Summary
Surveyors identified multiple failures in food storage, preparation, distribution, and service that did not meet professional standards for food safety. Observations in both the South and North Building kitchens revealed personal coats stored in food and single service item storage areas, soiled and dusty surfaces, broken wall tiles, and improper thawing of meats. Staff were seen in food preparation areas without required hairnets or beard nets, and there were numerous instances of undated, outdated, or unlabeled refrigerated foods. Food labeled as 'Keep Frozen' was found stored in refrigerators for unknown periods, and a bench style can opener was heavily soiled with food residue. Cases of food and single service items were stored directly on the floor, and raw meat was stored above ready-to-eat foods in the walk-in cooler. Equipment issues included a reach-in freezer with a broken door and unsafe temperatures, active water leaks from dishwashers, flies in dishwashing areas, missing or nonfunctional thermometers, and a missing floor drain grate. Nourishment refrigerators on multiple units were found to be soiled, contained expired or unlabeled foods, and lacked thermometers. Air and food temperatures in these refrigerators were frequently above safe ranges, with some measured as high as 62 degrees Fahrenheit. Trays of nourishments, including dairy products, were stored unrefrigerated for extended periods, and staff were unclear about the frequency of refrigerator cleaning and monitoring. Staff interviews confirmed that dietary and nursing staff were not consistently following policies for labeling, dating, and discarding perishable foods, and that there was confusion regarding responsibility for maintaining nourishment refrigerators. In several cases, expired or improperly stored foods were voluntarily discarded by staff during the survey. Additional deficiencies included the absence of chlorine test strips for low-temperature dishwashers, nonfunctional or unreadable thermometers on dishwashing machines, and the use of dry wiping cloths instead of storing them in sanitizing solution. Staff from other departments entered food preparation areas without appropriate hair restraints, and there was no current kitchen cleaning schedule in place. The Food Service Director and other staff acknowledged these issues during interviews, noting that some equipment problems had been reported but not resolved, and that cleaning schedules and food safety practices were not being consistently implemented.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a sanitary, orderly, and comfortable environment in both the North and South Buildings, as required by regulation. Observations revealed multiple deficiencies, including torn and stained privacy curtains in resident rooms, soiled and discolored walls, floors, and baseboards, and shower rooms with soiled furnishings, loose toilet seats, and unlabeled personal care items. Additional findings included broken blinds, wall board in disrepair, stained ceiling tiles, rusty ceiling tile grids, and soiled linens left on floors in both shower rooms and resident rooms. These conditions were directly observed by surveyors and corroborated by resident and staff interviews, which described the environment as unsanitary and lacking in ambiance. Interviews with residents and staff further confirmed the ongoing issues. One resident reported that their privacy curtain was stained with blood and had been unsanitary since admission, despite reporting it to staff. Staff members, including CNAs, RNs, and housekeeping aides, acknowledged the poor quality of the environment, noting dirty baseboards, grimy floors, and the presence of fecal matter on bathroom fixtures and furniture. Staff also indicated that maintenance and housekeeping were aware of some issues, such as broken floor tiles and soiled areas, but these problems persisted over time. Housekeeping staff reported challenges with cleaning certain areas due to wax buildup and damaged equipment, and maintenance staff were sometimes unaware of specific deficiencies until informed by surveyors or other staff. Documentation review showed that the facility had established housekeeping procedures and daily cleaning checklists, but completed checklists could not be produced during the survey. The Housekeeping Supervisor stated that audits of privacy curtains had been conducted and new curtains ordered, but many issues remained unresolved at the time of the survey. The Administrator and supervisors acknowledged problems with cleaning equipment and the need for further maintenance, but the observed deficiencies indicated a failure to ensure a safe, clean, and homelike environment for residents, as required by facility policy and regulation.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse in both the South and North Buildings, as required by their policy and state regulations. Observations revealed that dumpsters outside both buildings were frequently left with open lids and sliding doors, and were often overfilled, with bagged garbage and debris extending above the top rim. Garbage and loose debris, including food waste, disposable gloves, milk cartons, and other refuse, were observed scattered on the ground around the dumpsters. In some instances, large items such as pieces of wood and broken ceiling tiles contributed to the dumpsters being overfilled and unable to be closed. Additionally, a bag of garbage was found left on the ground near a facility entrance. Interviews with the Maintenance Director and Housekeeping Director confirmed that the dumpsters should be kept closed and the surrounding areas clean, but these practices were not consistently followed. The Maintenance Director noted that cleaning around the dumpsters was a Maintenance department responsibility, but assistance had been requested from the Dietary department due to the nature of the waste. The Maintenance Director also indicated that the overflow was likely caused by large boxes occupying space in the dumpsters. Despite scheduled garbage pickups, the dumpsters remained overfilled and the surrounding areas were not maintained in accordance with facility policy.
Failure to Provide Timely ADL and Incontinent Care
Penalty
Summary
Two residents were not provided with necessary assistance for activities of daily living (ADLs), specifically related to personal hygiene and timely incontinent care. One resident, who had diagnoses including macular degeneration, congestive heart failure, and diabetes, was admitted to the facility and did not receive any bathing or morning care for several days after admission. The resident reported feeling unclean and uncomfortable, and observations confirmed the absence of personal hygiene supplies in the room, as well as visible signs of poor hygiene such as dry, flaking skin on bedsheets. Staff interviews revealed that morning care was not provided daily as required, and that personal care items should have been present upon admission but were not. Another resident, with a history of hemiplegia, hemiparesis, and amputation, was dependent on staff for toileting and hygiene. This resident reported requesting incontinent care over an hour prior to being assisted, and repeated requests for care were not promptly addressed. Observations showed that the resident's call bell remained unanswered for an extended period, and staff acknowledged that care was delayed due to workload and the need for two staff members to assist. Staff interviews confirmed that timely incontinent care was not provided, despite the resident's dependency and the importance of preventing skin breakdown. Facility policies required daily assistance with ADLs, including bathing, grooming, and toileting, to maintain residents' dignity, skin integrity, and overall well-being. However, the documented actions and inactions of staff resulted in residents not receiving the necessary care as outlined in facility procedures and policies. Staff and supervisory interviews consistently indicated that the care provided did not meet the expected standards for daily hygiene and timely response to resident needs.
Failure to Provide and Document Ordered Wound and PICC Line Care
Penalty
Summary
Surveyors identified deficiencies in the facility's provision of treatment and care according to physician orders and professional standards for two residents. For one resident with a history of stroke, congestive heart failure, and diabetes, there was a lack of ongoing skin assessments and incomplete documentation and administration of ordered wound care. The resident was admitted with three stage 2 pressure ulcers, and although an initial treatment order was in place, weekly skin assessments were not consistently performed or documented between late November and mid-December. The Treatment Administration Record showed that wound care was only documented as completed on six out of twenty-two days, and there was minimal progress note documentation regarding the resident's wounds during this period. Interviews with nursing staff revealed uncertainty about wound care responsibilities and processes, and the wound care provider was not involved as expected. For another resident with macular degeneration, congestive heart failure, and diabetes, there was a delay in obtaining orders for PICC line dressing changes and incomplete documentation of required PICC line flushes. Upon admission, the resident had a double lumen PICC line, but no orders for dressing changes or monitoring were obtained until several days later. The Treatment Administration Record indicated that PICC line flushes were only documented as completed three out of eleven scheduled times over a four-day period. There was also no evidence that the PICC line dressing was changed or that required measurements and assessments were performed as ordered. Nursing staff interviews confirmed that initial assessments and ongoing care for the PICC line were not consistently performed or documented. The facility's policies required thorough documentation and adherence to physician orders for wound and PICC line care, including regular assessments, dressing changes, and completion of treatments as ordered. However, the survey found gaps in both the performance and documentation of these essential care activities. Staff interviews highlighted a lack of clarity regarding responsibilities and processes for wound and PICC line care, contributing to the deficiencies observed during the survey.
Failure to Provide Timely Psychiatric Consultation for Resident with Mental Health Needs
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, depression, and a history of expressing sadness and making negative statements did not receive a psychiatry consult as previously recommended by a psychiatric provider. The facility's policy required behavioral health services to be provided as needed, but there was no evidence that a psychiatry consult was ordered or completed for the resident, despite documented recommendations and family requests. The resident's care plan included interventions such as psychiatry/psychology consults and monitoring for mood changes, but these interventions were not fully implemented. Multiple staff interviews and record reviews revealed that the facility experienced a lapse in psychiatric provider coverage due to the previous provider discontinuing services and delays in securing a replacement. During this period, the resident's family expressed concerns about negative and potentially suicidal statements, requesting a psychiatric evaluation. Nursing staff implemented increased monitoring and communicated with the nurse practitioner, who evaluated the resident and recommended a psychiatry consult. However, no order for a psychiatry consult was placed, and the recommendation was not followed through. Further interviews indicated breakdowns in communication and follow-up among nursing, social work, and administrative staff. The social work department was unaware of the resident's negative statements and did not complete an assessment or facilitate a psychiatric referral. The nurse practitioner did not place an order for a psychiatry consult, citing the absence of an in-house provider at the time. The administrator and director of nursing acknowledged gaps in the process, including lack of documentation, missed follow-up, and unclear protocols for handling provider recommendations and psychiatric referrals.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for two of five residents reviewed. For one resident with multiple medical conditions, including a PICC line, Foley catheter, and a wound requiring a wound vac, staff did not adhere to enhanced barrier precautions as required. Certified Nurse Aides provided hands-on care, such as bathing, turning, and catheter care, while wearing gloves but not gowns, despite signage and facility policy mandating both gown and glove use for high-contact activities. Interviews with staff revealed a lack of understanding regarding the specific requirements of enhanced barrier precautions and the appropriate use of personal protective equipment (PPE) based on the type of precaution indicated. In another instance, a resident dependent on staff for toileting and hygiene care received fecal incontinence care from a Certified Nurse Aide who failed to remove gloves and perform hand hygiene before handling clean briefs, applying barrier cream, and touching clean linens and the bed remote. This action was contrary to the facility's hand hygiene policy, which requires glove removal and hand hygiene after contact with bodily fluids and before handling clean items. The staff member acknowledged during interview that they should not have touched clean items with contaminated gloves, recognizing the risk of cross-contamination. Further interviews with nursing staff, including LPNs and the Director of Nursing, confirmed that the expectation was for staff to follow enhanced barrier precautions and proper hand hygiene protocols to prevent the spread of infection. The deficiency was attributed to staff not consistently following established infection control policies, including the use of PPE and hand hygiene practices during resident care activities involving high risk for transmission of communicable diseases.
Incomplete Documentation of Controlled Substance Counts
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards, specifically regarding the documentation of controlled substance inventory counts. Review of the Controlled Substance Inventory Sheets for several units revealed 149 blank signature spaces between 12/1/2025 and 12/19/2025, indicating that the required shift-to-shift counts were not consistently signed off by both the incoming and outgoing nurses. Facility policy and the inventory record form both require that two nurses perform and sign off on the count at each shift change. Multiple staff interviews confirmed that the process was not always followed, with some nurses attributing the missing signatures to distractions, forgetfulness, or staff floating between units. In some cases, nurses working double shifts did not sign between shifts, despite having counted and verified the medications. The Director of Nursing and other supervisory staff acknowledged that the expectation was for both nurses to count and sign for controlled substances at every shift change, regardless of staffing patterns or shift length. The incomplete records were confirmed by several nurses and supervisors during interviews, who emphasized the importance of signatures for accountability and tracking access to narcotics. There was no indication of a staffing shortage contributing to the issue, and the missing signatures were attributed to lapses in following established procedures.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on the second floor of the South Campus and the C Wing of the North Campus. Observations revealed dirty and sticky floors, stained ceiling tiles, window blinds with missing or damaged slats, and residue on shared bathroom sinks. In several resident rooms, there was food debris, sugar packets, tissues, paper, and other debris on the floors and under furniture. Unlabeled bedpans and wash basins were found on the floors of shared bathrooms, and some rooms labeled as 'detailed-full clean' still contained debris, soiled surfaces, and unclean bathroom fixtures. Stained and bowing ceiling tiles were also noted, and some rooms lacked proper window coverings, impacting privacy and the homelike atmosphere. Interviews with staff, including housekeeping aides, supervisors, CNAs, LPNs, and the Director of Housekeeping, confirmed that daily cleaning and maintenance expectations were not consistently met. Housekeeping staff acknowledged that rooms were not cleaned to standard, with some admitting that the conditions would not be acceptable for their own family members. Nursing staff and supervisors expressed concerns about infection control due to unclean floors, soiled bathroom fixtures, and improper storage of personal care items. Maintenance staff reported issues with replacing damaged blinds and ceiling tiles due to supply shortages, and acknowledged that these deficiencies detracted from the environment's cleanliness and safety. Residents also reported dissatisfaction with the cleanliness and comfort of their living spaces, describing their rooms as dirty, unhomelike, and lacking privacy due to damaged or missing blinds. Staff interviews further revealed that environmental concerns were sometimes reported but not always addressed promptly, and that staff shortages and supply delays contributed to the ongoing issues. The facility's own policies required regular cleaning and maintenance of resident rooms and environmental surfaces, but these standards were not upheld, resulting in unsanitary and unsafe conditions for residents.
Failure to Provide Necessary Assistance with Personal Hygiene and Grooming
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dementia, cerebral infarction, and seizure disorder did not receive necessary assistance with personal hygiene, specifically shaving. The resident required partial to moderate assistance with personal hygiene and had no documented refusals of care. Despite facility policies requiring support for activities of daily living and maintaining dignity, the resident was observed on multiple occasions to have facial hair longer than ¼ inch and appeared unkempt. Documentation showed the resident received showers, but there was no indication that shaving was performed, nor was there evidence of refusal. Interviews with staff revealed that shaving was expected to occur on shower days or as needed, and that maintaining grooming was important for dignity. Multiple staff members acknowledged that the resident should have been shaved during their scheduled shower, but this was not done. The assigned CNA admitted to forgetting to shave the resident, and other staff confirmed that shaving was part of the grooming routine. The lack of documentation and follow-through resulted in the resident not receiving the necessary services to maintain personal hygiene and grooming, as required by facility policy and state regulation.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis to meet the needs of all residents, as evidenced by multiple instances of understaffing on specific dates. The facility did not meet its assessed minimum staffing levels for Certified Nurse Aides (CNAs) on several occasions, including 8/24/2024, 9/8/2024, 9/16/2024, 9/22/2024, 10/5/2024, 10/6/2024, and 10/20/2024. The facility's policy stated that adequate staffing should be provided to meet the care and services needed by the resident population, but this was not adhered to, leading to unmet care needs. Residents expressed concerns about the impact of low staffing levels on their care during resident council meetings. They reported issues such as delays in getting out of bed, missed personal hygiene care, and inadequate attention to activities of daily living. Interviews with residents revealed specific instances where they experienced delays in receiving care, such as not being able to get out of bed until late in the day or not having their nails and facial hair groomed. Staff interviews corroborated these concerns, with CNAs and nurses reporting difficulties in completing their duties due to insufficient staffing. The staffing issues were particularly pronounced on weekends, as noted by the staffing coordinator and several staff members. The lack of adequate CNAs led to challenges in providing essential care, such as showers and nail care, and affected the ability of nurses to complete their charting and supervisory duties. The Director of Nursing and the Interim Administrator acknowledged the staffing shortages and the resulting impact on resident care, highlighting ongoing efforts to recruit more staff to address these deficiencies.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of documentation and tracking of antibiotic use from July 2024 to October 2024. The policy titled 'Antibiotic Stewardship - Review & Surveillance of Antibiotic Use & Outcomes' required that antibiotic usage and outcomes be documented and reviewed by the Infection Preventionist. However, there was no evidence that this process was followed. Interviews revealed that the Licensed Practical Nurse was unaware of any current tracking process, and the Corporate Infection Preventionist could not provide documentation to support the tracking of antibiotic use. The Director of Nursing, who was responsible for the program, had recently left, and the new Director of Nursing was still in training. Resident #84, who had diagnoses including chronic pain syndrome, a stage 4 pressure ulcer, and osteomyelitis, was on multiple antibiotics. Despite the comprehensive care plan's requirement to monitor for side effects and report them, there was no documentation of antibiotic tracking for this resident. The Pharmacy Consultant's role was limited to checking the accuracy of the order's duration and diagnosis, and they were not directly involved in the stewardship process. The Interim Administrator acknowledged the importance of an effective antibiotic stewardship program and admitted that the current system was inconsistent and ineffective.
Inadequate PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of Certified Nurse Aides (CNAs) #2, 4, 5, and 6, who did not adhere to the required personal protective equipment (PPE) protocols during care activities for a resident on enhanced barrier precautions. This resident, identified as Resident #84, had an indwelling catheter and a stage IV pressure ulcer, conditions that necessitate strict adherence to infection control measures. Despite the presence of an orange sign outside the resident's room indicating the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact care activities, the CNAs failed to comply. Observations revealed that during a mechanical lift transfer and subsequent care activities, CNAs #5 and #6 only donned gloves, neglecting to wear gowns as required. They handled the resident's foley catheter and performed incontinence care without the appropriate PPE. Additional CNAs, #2 and #4, also entered the room and participated in care activities without wearing gowns, despite the clear signage and available PPE supplies outside the resident's room. Interviews with the CNAs confirmed their awareness of the enhanced barrier precautions and the necessity of wearing gowns, gloves, and masks, yet they did not follow these protocols during the observed care activities. Interviews with nursing staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), further highlighted the expectation for staff to adhere to the enhanced barrier precautions to prevent infection transmission. The Corporate Quality Assurance/Infection Preventionist and the Interim Administrator also acknowledged the requirement for staff to follow the established infection control policies. Despite the training and resources provided, the CNAs' failure to wear the appropriate PPE during high-contact care activities for Resident #84 represents a significant deficiency in the facility's infection prevention and control program.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged violation involving abuse, specifically an injury of unknown source, within the required timeframe for a resident with severe cognitive impairment and multiple health conditions. The resident, who was dependent on staff for transfers and care, was found with a hematoma on their forehead, the origin of which was unknown. The incident was not reported to the facility's Administrator and the State Survey Agency within the mandated two-hour window, as required by the facility's policy and state regulations. The incident occurred when two Certified Nurse Aides were caring for the resident, and the injury was noticed during care. Despite the initiation of neurological checks and documentation by nursing staff, the injury was not reported to the appropriate authorities until several days later. Interviews with staff revealed a lack of immediate recall of the incident and uncertainty about the timing of notifications to supervisors and the Director of Nursing. The delay in reporting was acknowledged by the facility's Interim Administrator and the Director of Nursing at the time, who emphasized the importance of timely reporting of injuries of unknown origin due to their potential link to abuse.
Deficiency in Personal Hygiene and Grooming Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene. Specifically, two residents, one with hemiplegia, dysphagia, and diabetes mellitus, and another with diabetes mellitus type 2 and dementia, were observed with unkempt, dirty, and jagged fingernails. The first resident also had unwanted facial hair and reported not having received a bath or shower in two weeks. Documentation discrepancies were noted, as the Bath & Shower Sheets inaccurately recorded that care had been provided. The first resident, who was moderately cognitively impaired and required substantial assistance for personal hygiene, had a physician's order for weekly nail trimming. However, observations revealed that their nails were not maintained, and they had not been shaved. Interviews with staff indicated a lack of communication and follow-through, as the Certified Nurse Aide responsible did not notify the nurse of the missed shower or nail care, and the Licensed Practical Nurse was unaware of the resident's care status. The second resident, severely cognitively impaired and dependent on staff for personal hygiene, also had long, yellow fingernails with debris. Their care plan did not include instructions for nail care, and observations confirmed that nail care was not adequately performed. Interviews revealed that the Certified Nurse Aide only cleaned under the nails, and the Licensed Practical Nurse, who was responsible for nail trimming due to the resident's diabetes, was not informed of any refusals or issues. The Assistant Director of Nurses acknowledged the oversight and the need for licensed nurses to trim diabetic residents' nails.
Improper Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling foley catheter, leading to a urinary tract infection. The resident, who had a history of urinary tract infections and a stage IV pressure ulcer, was observed with the catheter drainage bag improperly placed on their lap instead of below the bladder. This improper positioning was noted during an observation and interview, where the resident reported a burning sensation, a symptom of a urinary tract infection. The facility's policy required the drainage bag to be positioned lower than the bladder to prevent backflow and infection, but this was not adhered to by the staff. The resident's care profile did not document the presence of the foley catheter, and the comprehensive care plan indicated a need to monitor for infection signs. Despite the resident's complaints of burning and the collection of a urine sample for analysis, the catheter bag was left on the resident's lap by a Certified Nursing Assistant, contrary to the facility's procedures. Interviews with various staff, including a Nurse Practitioner and the Director of Nursing, confirmed that the drainage bag should have been placed below the bladder to prevent infection. The failure to follow proper catheter care procedures resulted in a confirmed urinary tract infection, as indicated by the bacteriology report.
Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs in one of the medication rooms observed. Specifically, three bottles of liquid Lorazepam, a Schedule IV controlled substance, were stored in a removable locked box inside a small refrigerator that was not permanently affixed. This refrigerator was located in a room with an unlockable door, involving Resident #32. The facility's policy required that refrigerated controlled substances be stored in a refrigerator with a locked, affixed narcotic box, and the refrigerator itself must be affixed to the floor or wall. During the survey, it was observed that the medication refrigerator was not affixed, and the locked compartment inside the refrigerator was not being used due to the absence of a key. Interviews with staff, including an LPN, the President of Clinical Services, the LPN Unit Manager, the Director of Nursing, and the Interim Administrator, revealed a lack of awareness regarding the unsecured state of the refrigerator and the availability of a key for the affixed locked compartment. The staff expressed that they were unaware of the need for the refrigerator and narcotic box to be affixed and secured, which led to the improper storage of controlled substances.
Failure to Provide Dental Services for Resident
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident, leading to a deficiency. The resident, who had a chipped front tooth, did not receive follow-up care for a recommended crown. The facility's policy required the Director of Nursing or designee to notify Social Services of dental needs and coordinate appointments, but this process was not effectively executed. The resident, who had moderate cognitive impairment and was dependent on staff for oral hygiene, expressed self-consciousness about the chipped tooth and had not seen a dentist for the issue. The facility dentist had noted the need for a crown during an initial visit, but the recommendation was not followed up with an outside appointment. The care plan did not reflect the chipped tooth, which was necessary for monitoring potential issues such as weight loss, pain, or difficulty chewing. Interviews with staff revealed a breakdown in communication and responsibility. The dental consults were placed in the medical records mailbox and distributed to unit managers, who were supposed to address recommendations and schedule appointments. However, the process failed, as the unit manager and unit clerk did not ensure the appointment was made. The Interim Administrator acknowledged the need for an additional step to verify appointment scheduling.
Failure to Post Ombudsman and Complaint Hotline Information
Penalty
Summary
The facility failed to post contact information for the State Long-Term Care Ombudsman Program and the State Agency Complaint Hotline in a manner accessible and understandable to residents and their representatives. This deficiency was identified during a Standard Survey completed on 10/28/24, specifically in the North building of the facility. The policy titled Resident Rights, dated 3/1/17, guarantees residents the right to communicate with outside agencies, but the survey found that this was not being upheld. During a Resident Council meeting, residents expressed that they were unaware of where these contact numbers were posted, indicating a lack of communication and visibility of this important information. Observations throughout the North building confirmed the absence of postings for the Ombudsman and State Agency Complaint Hotline numbers in key areas such as the reception area, bulletin boards, nursing stations, elevators, and hallways. Interviews with facility staff, including the Assistant Director of Activities, Director of Nursing, Director of Social Work, and the Interim Administrator, revealed a general lack of awareness and responsibility regarding the posting of these contact numbers. Staff acknowledged that the information should be accessible to residents and family members, but it was not clear who was responsible for ensuring this was done, leading to the deficiency.
Failure to Implement Care Plans for Resident Safety
Penalty
Summary
The facility failed to implement person-centered care plans for three residents, leading to a deficiency in meeting their medical and nursing needs. Specifically, the care plans for these residents included the use of a stop sign across their room doors to deter other residents from entering, but this intervention was not provided. Observations and interviews revealed that the stop signs were missing, and staff were unsure of the documentation and implementation process for these interventions. Resident #1, who was cognitively intact and had diagnoses including anxiety, depression, and diabetes, expressed concerns about other residents entering their room. Despite a care profile indicating the need for a stop sign, the comprehensive care plan did not document this intervention, and the stop sign was not in place. Similarly, Resident #2, with moderate cognitive impairment and diagnoses including anxiety and bipolar disorder, also lacked a documented stop sign in their care plan, despite previous issues with other residents entering their room and taking belongings. Resident #3, with moderate cognitive impairment and diagnoses including dementia and depression, also did not have a stop sign documented in their care plan, although it was noted in their care profile. Interviews with staff, including a CNA, RN Unit Manager, and the Director of Nursing, revealed a lack of clarity and communication regarding the documentation and responsibility for ensuring the stop signs were in place. This oversight resulted in the failure to meet the residents' expressed wishes and care needs as outlined in their care plans.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility did not ensure residents had the right to be free from physical abuse, as evidenced by an incident involving two residents. Resident #2, who had a history of aggressive behavior, grabbed Resident #1's arm and threw them to the floor, resulting in significant injuries including a compression fracture of the T2 vertebra, and fractures of the left elbow and hip. This incident occurred while Resident #1 was wandering in the hallway and was witnessed by an LPN who was engaged in a medication pass at the time. Resident #1 had severe cognitive impairment, advanced dementia, and was known to wander daily. Their care plan included interventions to keep them away from other residents exhibiting aggressive behavior. Resident #2, who also had severe cognitive impairment and a history of psychosis and mood disorder, had a care plan that included measures to manage their aggressive behavior, such as encouraging participation in activities and providing psychological services. Despite these measures, the altercation occurred, leading to Resident #1's hospitalization and subsequent palliative care. The incident was captured on video surveillance, which showed Resident #2 approaching Resident #1 and forcefully grabbing and throwing them to the floor. Interviews with staff confirmed that Resident #2's actions were intentional and constituted physical abuse. The facility's policies and procedures on abuse, neglect, and exploitation were not effectively implemented to prevent this incident, resulting in harm to Resident #1.
Incomplete Investigation into Resident-to-Resident Abuse
Penalty
Summary
The facility did not ensure that all alleged allegations of abuse were thoroughly investigated for two residents. Specifically, the facility failed to complete a thorough and accurate investigation into resident-to-resident abuse, including conducting interviews with witnesses and other pertinent staff. The policy and procedure titled 'Abuse, Neglect and Exploitation of Residents' required the Administrator/DON or designee to conduct an investigation, gather written and signed witness reports, and follow the procedure for reporting and investigating incidents of resident abuse. However, this was not adhered to in the case of the altercation between Resident #1 and Resident #2. Resident #1, who had advanced dementia, depression, and anxiety, was identified as being at risk for resident altercations due to wandering into peers' rooms. Resident #2, diagnosed with psychosis, aphasia, and mood disorder, had a history of impaired social interactions and resident-to-resident altercations. On the day of the incident, video surveillance footage revealed that Resident #2 forcefully grabbed Resident #1's right arm and threw them to the floor. Despite this, there was no documented evidence of statements or interviews conducted with witnesses, and the facility did not implement their policy to evaluate the events leading up to the abuse. Interviews with various staff members, including the Administrator, Certified Nurse Aide #3, Licensed Practical Nurse #1, Licensed Practical Nurse Unit Manager #2, Assistant Director of Nursing #1, Director of Nursing, and Regional Director of Nursing, confirmed that no statements were collected from staff who witnessed the incident. The Assistant Director of Nursing admitted to not gathering statements, focusing instead on the immediate care of Resident #1. The Director of Nursing and Regional Director of Nursing acknowledged that the investigation was incomplete without these statements, which would have provided perspective on the root cause of the abuse. The Administrator also confirmed that the investigation was not thorough due to the lack of collected statements.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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