Yonkers Gardens Center For Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Yonkers, New York.
- Location
- 115 South Broadway, Yonkers, New York 10701
- CMS Provider Number
- 335515
- Inspections on file
- 23
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Yonkers Gardens Center For Nursing And Rehab during CMS and state inspections, most recent first.
Kitchen food storage, labeling, and sanitation deficiencies were observed during survey. Expired dairy and beverage items were found in the walk-in refrigerator, an opened and uncovered box of frozen vegetables and an unlabeled bag of chicken patties were found in the freezer, and prepared sandwiches and cold cuts lacked proper labeling. Staff also used unlabeled refill bottles for grape jelly, one cook was not wearing a beard covering, and kitchen equipment and surfaces showed heavy grease buildup, a slippery floor area, and dripping pot wash faucets.
The facility failed to maintain an effective pest control program on multiple residential floors, as shown by resident and staff reports of roaches and mice and surveyor observations of live roaches and pest traps with dead bugs in resident rooms. Several residents reported seeing cockroaches in bathrooms and rooms and stated during resident council that roach and rat issues persisted despite pest control efforts. Review of pest control logs over several months documented ongoing roach infestation with repeated sightings on the units. The Administrator and the pest control company both acknowledged continued roach and mice activity, and CNAs reported seeing roaches in resident rooms and not noticing improvement, indicating that pest control measures were not effectively controlling the infestation.
Unsafe and unclean resident environment on floors 3 and 4. Surveyors observed damaged bathroom fixtures, broken furniture, stained doors and walls, a soiled mechanical lift, a clock hanging by a wire, damaged radiator and ceiling tiles, mismatched wall patches, rust-colored stains, and a stained privacy curtain. The D of M stated the issues were not reported by staff and were missed during rounds; a housekeeper also stated prior evening cleaning duties for hallways, doors, and resident equipment had been eliminated and not reassigned.
Failure to Provide Needed ADL Assistance for Grooming and Bathing: Three residents who were dependent on staff for hygiene, bathing, and grooming were observed or reported to have unmet ADL needs. One resident had long unshaven facial hair, another reported not having a shower for a long time and had unwashed hair, and a third was seen with greasy hair and a scraggly beard despite being scheduled for showers and requiring total assistance. Staff interviews showed grooming and bathing assistance was expected, but care was not consistently provided or documented.
A medication room was found unlocked with medications in unlocked cabinets, and a medication cart was observed unlocked and unattended when an RN stepped away. Methadone for two residents was also stored with other narcotics in a double-locked cabinet, despite the facility policy requiring methadone for addiction to be stored separately from other controlled meds.
Improper Linen Handling and Storage: Facility personnel did not ensure linens were handled and stored per policy. Surveyors observed clean linens, towels, gowns, pillows, and resident clothing stored on top of resident hampers in multiple rooms, while dirty linens, gloves, and socks were found on the floors of the 4th- and 5th-floor shower rooms. An RN UM, CNA, and IP all described expected linen handling practices, but the observed storage and disposal practices did not match those expectations.
Unsafe and Unclean Smoking Area and Damaged Elevator Interior: Surveyors observed the designated outdoor smoking area covered with snow and ice and littered with more than 50 cigarette butts, while elevator #1 had damaged wall paneling and air vent grates with exposed sharp metal prongs. The DON/maintenance and housekeeping leadership stated the area cleaning and snow removal responsibilities were split, but there was no set cleaning schedule for the smoking area and no current plan to repair the elevator damage.
A resident with opioid dependency and other medical conditions was readmitted from the hospital with an existing order for daily methadone, but the facility did not have the methadone on hand and the scheduled dose was not administered. Nursing documentation showed the medication was unavailable, and the resident became upset and verbally agitated when it was not provided. Staff interviews indicated the facility had not received discharge paperwork or prior notice of the resident’s return, the methadone clinic was closed on weekends, and coordination with the hospital to ensure methadone availability before discharge did not occur.
The facility failed to use its QAPI program to address ongoing pest control problems despite being aware of roach and mouse sightings on resident units. Review of QAPI meeting agendas for multiple quarters showed discussion of topics such as staffing, dignity, maintenance repairs, accident/incident reports, smoking compliance, pressure ulcers, antibiotic stewardship, exercise of rights, and documentation, but no inclusion of pest control. Staff and resident interviews confirmed continuing concerns about roaches and mice, and the Administrator acknowledged awareness of these issues while also stating that they had not been discussed within the QAPI process.
A resident with cerebral infarction, epilepsy, and HTN, and documented as cognitively impaired, was observed having blood drawn in the dining room while residents were waiting for lunch. A phlebotomist removed the resident’s sweater sleeve, performed the blood draw at the table, and then moved the supply tray to another resident’s table before an RN unit manager told the phlebotomist to leave the dining room. The facility’s Resident Rights policy required privacy for direct resident care procedures.
A resident with intact cognition and diagnoses including HTN, hepatitis, and major depressive disorder was not allowed to choose their bedtime despite care plan directions to offer as many choices as possible. The resident stated staff told them when to go to bed, that they preferred to stay up later, and that they did not feel free or given choices. A CNA said residents were told to go to bed near shift change, and an RN unit manager said the resident had to be in bed by shift change due to hourly fall monitoring and non-ambulatory status.
Quarterly personal funds statements were not made available to a resident’s designated representative. The resident had dementia and hydrocephalus with severe cognitive impairment, and the account had been managed by the facility for over two years. The representative said statements had stopped arriving and had to be requested from the business office, while the Medicaid Coordinator could not provide documentation showing the quarterly statements were sent.
Failure to thoroughly investigate alleged abuse: A resident with DM, depression, and epilepsy, who needed help with showering, was reported by family to have been beaten in the shower by CNAs and forced into a cold shower. The resident later told surveyors they were grabbed, stripped, showered, and beaten by two staff members. The facility documented that no one witnessed the incident and that the named aide did not work there, but it could not produce written staff statements or other documented evidence of a complete and thorough investigation.
A resident with CVA-related hemiplegia, CKD, worsening cognition, increased dependence with eating, urinary incontinence, and severe unplanned weight loss did not receive a significant change MDS within the required timeframe. Records showed progressive weight loss, poor PO intake, meal refusal, and notes from the dietitian and NP documenting significant decline, while the MDS Coordinator, Clinical Nutrition Manager, and DON acknowledged that a significant change assessment should have been completed but was missed.
Late Transmission of MDS Assessments: The facility failed to ensure that two completed MDS assessments were transmitted on time. An MDS coordinator stated the assessments had been completed but not sent, and another MDS nurse had entered an old validation code into the EMR, making it appear the records had been transmitted when they had not. The Administrator stated the MDS coordinator was responsible for timely completion and submission and was unaware the assessments were late.
A resident’s MDS did not accurately code tobacco use even though the care plan identified the resident as a known smoker, a nursing smoking assessment documented smoking, and a smoking contract was signed. The resident stated they smoked cigarettes three times a day in the smoking room, and the MDS Coordinator acknowledged that tobacco use should have been coded on the assessment.
Inadequate supervision and smoking reassessment for a resident with repeated smoking noncompliance. A cognitively intact resident with nicotine dependence, PTSD, and behavioral issues had a smoking plan that was not updated after repeated reports of smoking in the room, a strong smoke odor, and disputes with another resident. Surveyors observed smoke residue and burn marks in the resident’s room, while staff said nursing had not reassessed the resident’s smoking safety in years and there was no special monitoring plan in place.
Oxygen Delivered at Incorrect Flow Rate: A resident with COPD, DM2, and asthma had a physician order and care plan for continuous O2 at 4 L via NC, but was observed receiving 2 L via NC. The resident stated they had been on 2 L for years, while an LPN said the resident was always on 2 L and did not check the order daily. An RN unit manager stated oxygen should have been given as ordered, and the DON noted the TAR did not show the order and could not explain the discrepancy.
The facility did not ensure its QAPI committee had the required members, including the Infection Control Practitioner, Medical Director, Administrator, and DON. Record review showed the Infection Control Preventionist did not attend or sign in for three quarterly QAPI meetings, and the Administrator acknowledged the absence and could not explain it.
Three residents with cognitive impairments exited the facility unsupervised on separate occasions due to failures in supervision, monitoring, and response to exit alarms. In each case, staff did not promptly identify the residents' absence, and required safety measures such as wander guards and sign-out procedures were not consistently implemented or enforced. Security staff did not respond to alarms or ensure proper monitoring of exits, resulting in residents leaving the premises without authorization.
A resident with a history of cognitive impairment and sexually inappropriate behaviors was not adequately monitored or managed after multiple incidents, including a serious episode involving another cognitively impaired resident. Despite repeated observations and staff awareness of the behaviors, care plans were not updated and interventions were not implemented to prevent further abuse, resulting in Immediate Jeopardy and substandard quality of care.
A resident with moderate cognitive impairment was found in a sexually inappropriate situation with another resident who had severe cognitive impairment. Although administration was notified promptly, the incident was not reported to the Department of Health within the required two-hour window due to staff being off-site and lacking computer access, resulting in a delay that violated state reporting requirements.
A deficiency was identified when two residents with cognitive impairment were involved in an alleged sexual abuse incident, and the facility failed to conduct required head-to-toe assessments, did not ensure both were sent for hospital evaluation, and lacked documentation of 1:1 monitoring, contrary to facility policy and staff instructions.
A resident with a history of inappropriate sexual behaviors towards others was involved in multiple incidents, including physical contact and attempts to enter other residents' rooms. Despite these events being documented by staff, the care plan was not updated with new interventions or monitoring strategies to address the behaviors or protect other residents. Nursing leadership confirmed that the care plan was not revised after these incidents, resulting in a deficiency related to abuse prevention and care plan management.
A survey found that several residents were dressed in hospital gowns, contrary to their care plans, due to issues with clothing management and availability. Additionally, a nurse improperly assisted a resident with a meal by standing over them. Staff interviews revealed inconsistencies in the process of obtaining and managing clothing for residents, contributing to the deficiency.
A facility failed to protect residents from abuse, with multiple incidents of resident-to-resident altercations involving six residents. One resident repeatedly engaged in physical altercations, causing injuries, while another resident exhibited aggressive behavior towards peers. The facility's policies on abuse prevention were not effectively enforced, and care plans were not consistently updated, leading to ongoing risks of harm.
The facility failed to submit timely 5-day investigative reports for resident altercations, as required by state law. Incidents involved residents with conditions like dementia and anxiety disorder, resulting in injuries such as bruising and lacerations. Despite internal documentation, reports were submitted late or not at all, with the DON unable to explain the delays.
The facility failed to maintain adequate staffing levels on the 3rd floor Dementia Unit, with staffing consistently below the required levels across various shifts. Despite efforts to schedule additional staff and use agency staff, frequent call-outs led to understaffing, leaving CNAs to manage 35-40 residents with insufficient support. The Director of Nursing acknowledged the staffing challenges, noting improvements but persistent issues with lateness and call-outs.
The facility was found to have multiple environmental deficiencies, including chipped paint, scuff marks, and visible dirt across various floors. Interviews with the Director of Maintenance and the Administrator revealed challenges in maintaining the facility due to limited staff and experience constraints. Both acknowledged the need for additional maintenance staff to address these ongoing concerns effectively.
A resident with severe cognitive and physical impairments developed a Stage 3 pressure ulcer due to the facility's failure to provide consistent turning and repositioning care. The resident's care plans lacked a Braden scale assessment, and there was no documented physician order for necessary interventions, leading to inadequate care as evidenced by missing documentation on certified nurse assistant accountability forms.
The facility's assessment failed to include a detailed staffing plan necessary for competent resident care during routine operations and emergencies. The assessment, last updated in November 2024, did not specify staff assignments or the number of staff needed per unit per shift. The Administrator was unaware of the requirement to include unit-specific staffing needs.
Kitchen Food Storage, Labeling, and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure that food was stored, prepared, and distributed in accordance with professional food safety standards, and it did not maintain essential kitchen equipment in a clean and sanitary condition. During the kitchen tour, surveyors observed three 10-pound plastic containers of sour cream with an expiration date of 1/19/2026 and a half-gallon container of unsweetened Almond Breeze with an expiration date of 1/24/2026 stored in the walk-in refrigerator. Sandwiches and cold cuts prepared for distribution were wrapped in plastic but were not properly labeled. In the walk-in freezer, surveyors observed an opened and uncovered box of diced butternut squash and a bag of Tyson breaded white chicken patties outside of its original box and without an expiration date. Additional observations showed food preparation and sanitation issues throughout the kitchen. A Food Service Worker was using unlabeled bottles of grape jelly in food preparation and stated that empty grape jelly bottles were washed, relabeled by removing the original label, and refilled with regular grape jelly. During tray line observation, a staff member was not wearing a beard covering and stated they had forgotten to put it on. The glass doors of the countertop hot box food warmers were covered with large brown and black accumulations of burned grease, the floor area adjacent to the warmers was slippery, and the faucets at the pot wash sink were dripping despite being turned off. The Clinical Nutrition Manager stated employees were not permitted to use unlabeled bottles or refill containers with different products, and the Food Service Director stated the kitchen was to be cleaned after each food preparation and that maintenance work orders were submitted for malfunctioning equipment.
Failure to Maintain Effective Pest Control Program for Roaches and Mice
Penalty
Summary
The facility failed to maintain an effective pest control program on three of five residential floors, as evidenced by ongoing roach and mice activity observed and reported by residents and staff. During the recertification and abbreviated surveys, residents reported seeing cockroaches on bathroom floors and described a lot of mice and roaches, with one resident stating that a housekeeper told them nothing could be done. Surveyors observed a pest trap with dead bugs under a heating unit in one room and a live roach on the floor under an overbed table in another room. Multiple residents at a resident council meeting reported issues with roaches and rats and stated that pest control efforts were ineffective. Review of the facility’s Pest Control Log from September 2025 through February 2026 documented repeated pest concerns and an ongoing roach infestation, with numerous entries noting roaches and bugs observed on the units over several months. The Administrator acknowledged awareness of roach and mice issues on the units and confirmed that the pest problem had not been discussed as part of the facility’s QAPI program. The pest control company confirmed an active contract, frequent site visits, awareness of continued roach and mice sightings, and changes in chemicals due to ongoing issues. CNAs reported an ongoing roach problem in residents’ rooms, believed pest control visits were infrequent, and had not noticed improvement, further demonstrating that the pest control program was not effectively preventing or addressing the infestation.
Unsafe and Unclean Resident Environment on Floors 3 and 4
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment on two of five resident floors, specifically floors 3 and 4. On floor 3, observation found a resident bathroom with missing wall tiles behind the toilet and a toilet seat that was peeling and cracked. In another room on floor 3, the dresser had broken and missing drawers, the closet door had a detached loose doorknob and was hanging off the track, and the wall and door had dried food stains. A mechanical lift on floor 3 also had dried brown streaks and dust and grime on the bottom metal base. On floor 4, observation found a clock hanging off the wall by a wire, a damaged and missing portion of the radiator, wall patches that did not match the surrounding paint, warped and stained ceiling tiles, and large rusty brown dried stains running from the ceiling down to the radiator. The resident hall bathroom on floor 4 had a privacy curtain with brown stains on the floor. The Director of Maintenance stated these issues had not been reported by staff and were missed during prior rounds. Housekeeping and nursing staff described routine rounds and reporting processes, and a housekeeper stated an evening position that had previously cleaned hallways, doors, mechanical lifts, wheelchairs, and other resident equipment had been eliminated in 10/2025 and those duties were not reassigned.
Failure to Provide Needed ADL Assistance for Grooming and Bathing
Penalty
Summary
The facility did not ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene for three residents reviewed. The deficiency involved Resident #11, Resident #7, and Resident #78, all of whom had assessments and care plans showing they needed staff help with hygiene, bathing, and grooming tasks. Resident #11 had diagnoses including non-Alzheimer's dementia, schizophrenia, and depression. The resident's assessment documented moderately impaired cognition and the need for partial assistance with personal hygiene and substantial assistance with toileting hygiene and showering. During observations, Resident #11 was seen with long, unshaven facial hair and stated a preferred staff member usually shaved their face, but the resident could not recall when that had last occurred. A CNA stated they were responsible for grooming, including shaving, but had not been able to shave the resident on the last assigned date because they were busy with showers for other residents, and they could not remember when the resident was last shaved. The CNA also stated the facial hair was too long to shave with a razor and would need trimming first. An RN stated CNAs were responsible for grooming activities and had not received report that the resident refused care. Resident #7 had diagnoses including hypertension, hepatitis, and major depressive disorder. The resident's assessment documented slight cognitive impairment and dependence on staff for oral hygiene, toileting, and showering, and the care plans documented dependence on staff for hygiene, grooming, bathing tasks, and daily ADL needs. The resident stated they had not had a bath or shower for a very long time, only received bed baths, and wanted to wash their hair; the resident's hair appeared unwashed during observation. A CNA stated the resident had not received a shower since admission and that the resident refused every time a shower was offered. However, the CNA accountability record for January and February did not document any shower refusals, and the unit manager stated they could not recall any report that the resident was not getting showers and that refusals should have been documented. Resident #78 had diagnoses of dementia and hydrocephalus and was severely cognitively impaired, totally dependent on staff for transfers, bathing, shower transfers, and personal hygiene, with no rejection of care documented. The resident was observed in bed wearing a hospital gown with greasy, unkempt hair and a full scraggly beard. The designated representative stated the resident should be transferred out of bed daily, showered twice weekly, and clean shaven. A CNA stated the resident required total assistance of two staff for bathing, transfers, and personal hygiene, did not refuse care, and was scheduled for a shower but instead received a bed bath; the CNA stated they only slightly wet the resident's head and dried it with another towel because the water was cold and there was no shower stretcher on the unit. The nursing supervisor stated every floor had a shower stretcher available and that the resident should be transferred out of bed for showers, while the DON stated there were concerns with residents receiving assistance with ADLs and that CNAs were expected to document the assistance provided.
Unsecured medication storage and improper methadone storage
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional standards when a 5th floor medication room was observed unlocked and unattended, with medications stored in unlocked cabinets over the sink. During interview, the RN Supervisor stated the room should have been locked and did not know why it was unlocked, and an LPN stated they were aware the room should have been locked. A 6th floor medication cart was also observed unlocked and unattended in the hall when an RN stepped away to enter the medication room, and the RN stated the cart should have been locked when they left it. The facility also did not store methadone separately as required by its policy. The facility policy stated that when methadone is prescribed for narcotic addiction only, it must be stored separately from other controlled medications in a double locked cabinet designated for that purpose. On observation, methadone for two residents was stored in a double locked cabinet with other narcotics in the 5th floor medication room. The DON stated medication rooms and carts should always be locked and that methadone was supposed to be stored separately from other narcotics, while the Pharmacy Consultant and Medical Director also stated methadone should be stored separately and staff needed to abide by the rules when storing it.
Improper Linen Handling and Storage
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when facility personnel did not ensure linens were handled and stored in a manner to prevent the spread of infection. During observations, clean linens and towels were seen stored on top of resident hampers in multiple resident rooms, and linens and resident clothing were also observed stored on top of hampers in additional rooms. Dirty linens were observed in a pile on the floor of the 4th-floor shower room, and dirty linens, gloves, and socks were observed on the floor of the 5th-floor shower room. A pillow, linens, towels, and gowns were also observed stored on top of resident hampers in resident rooms. During interview, the RN Unit Manager stated CNAs were responsible for bringing linens into resident rooms and were responsible for putting dirty linens into the laundry, and stated they were not aware that linen was stored on top of resident hampers. A CNA stated they had been trained on proper storage of linens, said linens should be stored in the clean utility room and/or the cart in the hall, and stated they left linens on the laundry bin or a chair in resident rooms. The Infection Preventionist stated proper handling of linen was part of environmental in-service, clean linen was to be stored in carts on units, and dirty linen should be bagged and placed in the laundry chute, but stated they did not know why linen was being stored elsewhere.
Unsafe and Unclean Smoking Area and Damaged Elevator Interior
Penalty
Summary
The facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During observation, the designated outdoor smoking area had a large accumulation of snow and ice bordering a narrow-shoveled path from the facility door to benches on the left, and there were more than 50 cigarette butts littering the ground and mixed in with the ice and snow. The facility policy titled Homelike Environment stated that outdoor areas would be maintained for the safety and access of residents and visitors and that grounds, walkways, and entrances would be free of tobacco-related waste. Elevator #1 also had damaged conditions observed during the survey. Two damaged metal air vent grates at the base of the right wall had exposed sharp protruding metal prongs, and the right wall paneling had a large section broken off at the lower left-hand corner. The Director of Maintenance stated the elevator was functioning and the air vents were working despite the damaged grate covers, and there were no current plans to repair the wall paneling and metal grates. The Director of Housekeeping stated Maintenance was responsible for clearing snow and ice from the outdoor smoking area, Housekeeping was responsible for sweeping cigarette butts, and there was no set cleaning schedule for the area.
Failure to Ensure Availability of Methadone for Readmitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a prescribed methadone medication was available and administered to meet the needs of a resident upon readmission. The resident had diagnoses including opioid abuse with unspecified opioid-induced disorder, anxiety disorder, and obstructive uropathy, and the MDS documented that the resident was cognitively intact and received opioid medication daily. A physician’s order directed that methadone oral solution 40 mg be given once daily for opioid dependency, and the comprehensive care plan instructed staff to administer medications as ordered. The resident was hospitalized for hypoxia and pneumonia and later returned to the facility with medications documented as unchanged and with two antibiotics added. On the day following readmission, the MAR showed the methadone order, but a progress note documented that the methadone dose was not given because the medication was not on hand. Nursing notes recorded that the resident was unable to receive methadone, became upset, and was yelling and using profanity due to not getting the medication. The RN Supervisor was informed that there was no methadone bottle available, and the physician was notified and indicated the resident would obtain methadone from the clinic on Monday. Interviews with the RN Supervisor, DON, Director of Admissions, and Medical Director revealed that the facility did not receive discharge paperwork or prior notification of the resident’s return from the hospital, that the methadone clinic was closed on weekends, and that there was an expectation for coordination with the hospital before discharge to ensure methadone availability. As a result, the resident did not receive the scheduled methadone dose after readmission.
Failure to Integrate Ongoing Pest Infestation Issues into QAPI Activities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its Quality Assurance and Performance Improvement (QAPI) program made good faith efforts to identify and correct known quality deficiencies related to pest control. Surveyors reviewed the facility’s QAPI policy, last revised in March 2025, which described a QAPI committee/subcommittee working with facility leadership and the Quality Assessment & Assurance committee. They also reviewed 2025 quarterly QAPI meeting attendance sheets and agendas dated 4/8/2025, 7/23/2025, and 11/12/2025. These agendas documented discussion topics such as staffing, dignity, maintenance repairs, accident/incident reports, smoking compliance, pressure ulcers, antibiotic stewardship, exercise of rights, and documentation, but did not include pest control or infestation issues. During recertification and abbreviated surveys conducted in early February 2026, surveyors identified ongoing concerns about roaches and mice in the facility, as referenced in F925. Interviews with staff and residents during this period confirmed that there were continuing sightings of roaches and mice on the units. In an interview, the Administrator acknowledged being aware of these pest issues but stated that the pest problem had not been discussed as part of the QAPI program. There was no evidence that the QAPI process had been used to address or correct the pest control concerns, despite the facility’s awareness of the problem.
Failure to Provide Privacy During Blood Draw
Penalty
Summary
Resident #181, who was admitted with diagnoses including cerebral infarction, epilepsy, and hypertension and was documented on the 12/15/2025 MDS admission assessment as cognitively impaired with no behavior, did not have dignity maintained during a blood draw. During an observation on 02/06/2026 at 12:49 PM, in the dining room where residents were waiting for lunch, a phlebotomist stood in front of Resident #181 with a tray of supplies, removed the resident’s left sweater sleeve, and drew blood from the resident’s left arm. The phlebotomist then walked to another table in the dining room and placed the tray of supplies in front of another resident. Registered Nurse Unit Manager #19 arrived in the dining room, spoke to the phlebotomist, and told them to leave the dining room. The facility’s Resident Rights policy stated that for any procedure involving direct resident care, privacy should be provided for the resident.
Resident Choice for Bedtime Not Supported
Penalty
Summary
The facility did not promote and facilitate resident self-determination through support of resident choice for one resident reviewed for choices. Resident #7 had diagnoses including hypertension, hepatitis, and major depressive disorder. The admission MDS dated 5/27/2025 documented intact cognition and noted that it was somewhat important to the resident to be able to choose their bedtime. The comprehensive care plan for behavior disturbance, last updated 01/10/2026, documented to give the resident as many choices as possible about care and activities. During interview, the resident stated that staff told them when they had to go to bed, that they did not like to go to bed early, and that their preference was to stay up later. The resident also stated that they did not feel free in the facility and were not given choices. A CNA stated that the next shift of aides got mad when residents were still up and that if it was close to shift change, residents were told they had to go to bed. The CNA added that residents who could get themselves into bed could stay up, but those who could not must go into bed. An RN unit manager stated that the resident had to be in bed by shift change because they were on hourly monitoring for fall risk and because they were non-ambulatory.
Quarterly Personal Funds Statements Not Provided
Penalty
Summary
The facility did not ensure quarterly statements of a resident’s personal funds account were made available to the resident’s Designated Representative. Resident #78 had diagnoses of dementia and hydrocephalus, and the MDS 3.0 assessment documented severe cognitive impairment with family participation in the assessment. The Resident Account Statement dated 02/10/2026 showed the facility had managed the resident’s funds since 08/10/2023, but there was no documented evidence that quarterly statements were provided to the Designated Representative. During a telephone interview, the Designated Representative stated they had previously received quarterly statements of the resident’s personal funds account activity until about 18 months earlier, but then had to repeatedly contact the facility’s business office to request copies. The Designated Representative reported concerns to the business office, but said the facility had not changed its accounting practices. The Medicaid Coordinator stated they were responsible for providing quarterly account statements to cognitively intact residents, while the off-site corporate business office was responsible for sending quarterly statements to designated representatives of residents with cognitive impairments, but no documented evidence could be provided showing the resident’s quarterly statements were sent to the Designated Representative.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who had diagnoses including diabetes mellitus, depression, and epilepsy and who required partial/moderate assistance with showering. The resident’s care plan identified a risk for verbal, physical, or sexual abuse, neglect, or mistreatment. After the resident’s family reported that certified nurse aides had beaten the resident in the shower, the facility documented that no staff or individuals witnessed the incident and that there was no staff member by the name reported by the family. The record shows that on the morning of the event, the resident was found in the hallway asking for help putting on pants, was pale and not at baseline, stated they had a seizure, had an oxygen saturation of 66% on room air, and was transferred to the hospital. The resident was later hospitalized with pulmonary emboli. The facility’s incident report stated the family alleged the resident was punched in the head, face, arms, and legs, forced to take a cold shower, and let fall to the floor, but the facility also documented that there were no bruises or injuries observed at transfer and that the resident’s statement could not be obtained. During the survey, the resident stated they remembered being forced to take a shower and being beaten by two staff members who grabbed them, removed their clothes, and showered them while they screamed and yelled. The family representative repeated the allegation of being beaten in the shower room and given a cold shower. Although the DON stated an internal investigation would include interviews and written statements, and the Administrator stated staff were called by telephone, the facility was unable to provide written statements from staff. The investigation documentation relied on interviews with staff and residents and on the absence of a staff member with the name provided by the family, but there was no documented evidence of a complete and thorough investigation with statements.
Failure to Complete Significant Change MDS for Resident With Major Decline
Penalty
Summary
The facility did not ensure that a significant change MDS assessment was completed within the 14-day requirement for a resident who experienced major changes in condition. The resident was admitted with diagnoses including cerebral infarction with hemiplegia and hemiparesis affecting the left non-dominant side and stage 3 chronic kidney disease. The record showed progressive weight loss from 178.0 lbs. in September 2025 to 165.0 lbs. in October 2025, 147.0 lbs. in November 2025, 132.2 lbs. in December 2025, 130.2 lbs. in January 2026, and 117.6 lbs. in February 2026. The resident’s 11/29/2025 Medicare 5-day MDS documented intact cognition, substantial/maximum assistance for eating, frequent urinary incontinence, and weight loss meeting criteria for significant loss. The 01/05/2026 quarterly Medicare 5-day MDS documented impaired cognition, dependence with eating, always incontinent of urine, and continued significant weight loss. A 01/23/2026 dietitian note documented 21% weight loss over 3 months, multiple hospitalizations, puree diet, suboptimal oral intake, and use of Ensure Plus to support weight goals. A 02/04/2026 dietitian note documented 9.6% unplanned weight loss in less than 30 days and 20% significant weight loss over 3 months, with staff and SLP reporting meal refusal and very poor intake. A 02/09/2026 nurse practitioner note documented acute delirium, auditory and visual hallucinations, HIV, failure to thrive in adult with weight loss and poor oral intake, and UTI contributing to acute mental status change. During interviews, the MDS Coordinator stated the resident had changes in ADLs, urine incontinence, cognition, and weight loss between the November and January assessments and that a significant change MDS should have been completed when identified. The Clinical Nutrition Manager and DON also stated the resident’s significant weight loss and related changes should have triggered a significant change MDS, but it was missed.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within the required timeframe for two residents reviewed for MDS compliance. Resident #83’s discharge MDS 3.0, with an assessment reference date of 09/22/2025 and completion date of 10/07/2025, was not transmitted until 02/09/2026. Resident #96’s discharge MDS 3.0, with an assessment reference date of 09/26/2025 and completion date of 10/07/2025, was also not transmitted until 02/09/2026. The facility’s MDS policy stated that MDS completion should be timely in accordance with State and Federal operation manuals. During interview, the MDS Coordinator stated that after reviewing the MDS schedule, two assessments had not been transmitted even though they were completed, and that another MDS nurse had entered an old code from a validation report into the electronic medical record software, which made it appear the records had been transmitted when they had not. The Administrator stated the MDS Coordinator was responsible for ensuring MDSs were completed and submitted timely and was unaware the assessments were transmitted late.
MDS Did Not Accurately Reflect Tobacco Use
Penalty
Summary
The facility did not ensure that the Minimum Data Set assessment accurately reflected Resident #46’s tobacco use. During the recertification survey, surveyors reviewed the 12/10/2025 MDS admission assessment and found that it documented the resident as cognitively intact, with no upper extremity impairment, and as not using tobacco, even though other facility records identified the resident as a smoker. The resident’s care plan for psychosocial history documented that the resident was a known smoker, and a smoking assessment completed by the RN Unit Manager documented that the resident smoked. A smoking contract also contained the resident’s and Recreation Director’s signatures. During interviews, the resident stated they smoked cigarettes three times a day in the smoking room and kept their lighter and cigarettes locked up in the cart downstairs. The MDS Coordinator stated they were responsible for the accuracy and completeness of MDS assessments and acknowledged that tobacco use should have been coded on the assessment.
Inadequate supervision and smoking reassessment for a resident with repeated smoking noncompliance
Penalty
Summary
The facility did not ensure adequate supervision to prevent accidents for a resident who smoked and had a history of noncompliance with smoking rules. The resident had diagnoses including adjustment disorder, post-traumatic stress disorder, and nicotine dependence, was cognitively intact, and required supervision or setup assistance with activities of daily living. The resident’s smoking assessment documented understanding of the smoking policy and no history of noncompliance, but several questions about smoking behavior were left unanswered, and there was no documented reassessment of the resident’s ability to smoke safely after later incidents of noncompliance. The resident’s record showed repeated concerns related to smoking behavior. Notes documented that the resident reportedly smoked in the room, had a strong cigarette smell in the room, and was involved in disputes with another resident about smoking in the bathroom. The resident also had a smoking contract that addressed storage of tobacco and smoking materials and warned of possible loss of smoking privileges, but the record did not show that the smoking contract was consistently reviewed with the resident after continued agitation and smoking-related incidents. The care plan related to smoking stated the resident would smoke in designated areas under supervision, but it was not revised to include additional interventions after the resident’s noncompliance. Survey observations on 02/05/2026 found the resident’s room empty with the door open, a strong smell of stale smoke, a soda can with cigarette ashes on the baseboard near the radiator, burned edges on the can, and three brown burn marks on the floor near the bed. The resident stated they had violated the smoking policy in the past but denied smoking in the room recently. Staff interviews confirmed that nursing was responsible for assessing smoking ability, but staff were unsure how often reassessments occurred and stated the resident had not been reassessed since 2024. Staff also stated there were no special monitoring instructions for the resident in the designated smoking area and no plan in place to more closely monitor the resident for smoking noncompliance.
Oxygen Delivered at Incorrect Flow Rate
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for one resident reviewed for respiratory care. Resident #92 had diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes, and Asthma. The quarterly MDS documented that the resident’s cognition was intact, the resident required supervision or touching assistance with activities of daily living, and the resident used oxygen. A physician order dated 08/26/2025 documented continuous oxygen at 4 liters via nasal cannula, and the Oxygen Therapy Care Plan dated 01/26/26 also documented oxygen at 4 liters via nasal cannula. During observations on 02/05/2026 and again on 02/09/2026, Resident #92 was receiving oxygen via nasal cannula at 2 liters per minute. The resident stated they had been on oxygen at 2 liters for 5 years. During interview, an LPN stated the resident was on 2 liters of oxygen via nasal cannula and that they did not check the order every day because it was documented on the TAR, adding that as far as they knew the resident was always on 2 liters. An RN unit manager stated oxygen should have been delivered as prescribed in the physician order. The DON reviewed the TAR and stated they did not see the order, did not know why the resident would receive 2 liters if the order documented 4 liters, and was unsure why the care plan documented oxygen at 4 liters; they also stated that if the resident had been on 2 liters for a while, the medical provider should have been consulted regarding the discrepancy.
QAPI Committee Missing Required Infection Control Participation
Penalty
Summary
The facility did not ensure the Quality Assurance & Performance Improvement Committee included the required members, specifically the Infection Control Practitioner, the Medical Director, the Administrator, and the Director of Nursing. Record review showed the facility’s QAPI policy, revised in March 2025, described a QAPI committee/subcommittee working with facility leadership and the Quality Assessment & Assurance committee. The committee member list included the Administrator, DON, Director of Social Services, MDS Coordinator, Medical Director, Infection Preventionist, and two RN Unit Managers, but review of the 2025 quarterly QAPI attendance sheets for 4/8/2025, 7/23/2025, and 11/12/2025 showed the Infection Control Preventionist did not sign in. During interview, the Administrator stated QAPI meetings were held quarterly and acknowledged that the Infection Control Practitioner/Preventionist had not been attending the meetings and could not explain the absence for the three quarterly meetings in 2025.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision to prevent elopement for three residents. In one instance, a resident with schizoaffective disorder, a history of wandering, and moderately impaired cognition exited the facility unsupervised through an alarmed rear exit patio door. The alarm was triggered, but the security officer did not respond, and the resident was not located until they arrived at the hospital emergency department. The resident had previously refused to wear a wander guard, and staff did not notice the resident's absence during routine activities such as dinner service. Another resident with schizophrenia, alcohol abuse, and moderately impaired cognition left the facility unsupervised and was later found at a friend's house. The resident was not identified as missing until after the last staff observation, and it was determined that the resident likely exited through the front door, which was not alarmed at the time. The security desk's location partially obstructed the view of the lobby, and the security officer did not ensure that all individuals leaving the facility signed out, as required by policy. A third resident with dementia and moderately impaired cognition was last seen interacting with peers and was later found missing during dinner service. The resident was not previously assessed as being at risk for elopement and did not have a wander guard in place. The resident was located by police the following day and returned to the facility. Family members expressed concern about the lack of supervision and questioned why a resident with dementia did not have additional safety measures in place. Staff interviews revealed inconsistent practices regarding monitoring, safety checks, and the use of elopement prevention tools.
Failure to Prevent and Address Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically failing to implement and update care plans and interventions after multiple incidents of sexually inappropriate behavior by a resident with a history of cerebral infarction and vascular dementia. Despite documented incidents where this resident engaged in inappropriate touching and behavior towards other residents, there was no evidence that the care plan was revised or that effective interventions were put in place to prevent further abuse. The care plans in place included general monitoring and support, but did not address the specific behaviors or provide targeted strategies to protect other residents after each incident. On several occasions, the resident was observed engaging in or attempting sexually inappropriate acts with other residents, including an incident where the resident was found half-naked on top of another cognitively impaired resident, with their mouth on the other resident's genital area. Staff interviews and documentation revealed that after these incidents, the resident's care plan was not updated to reflect new interventions, and there was no evidence of consistent 1:1 monitoring or other measures to prevent recurrence. Additionally, after being moved to a different unit, the resident was able to return undetected to the original resident's room, indicating a lack of effective supervision and monitoring. Documentation gaps were also noted, as some incidents were not recorded in the residents' progress notes, and there was confusion among staff regarding protocols for monitoring and updating care plans. Interviews with staff and administration confirmed that protocols for separating residents, notifying physicians, and transferring residents to the hospital were not consistently followed. The failure to implement adequate interventions and update care plans after repeated incidents resulted in a situation of Immediate Jeopardy and substandard quality of care, with a likelihood of serious harm to the residents involved.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to report an alleged incident of abuse to the New York State Department of Health within the required two-hour timeframe. On 1/5/2025 at approximately 1:30 PM, a resident with moderate cognitive impairment and ambulatory status was found half naked on top of another resident with severe cognitive impairment, with their mouth on the other resident's genital area. The incident was observed by staff, and administration was notified at 1:43 PM. However, the incident was not reported to the Department of Health until 4:10 PM, exceeding the mandated reporting window. The facility's abuse policy requires immediate reporting of suspected abuse, neglect, or mistreatment to the appropriate authorities. Documentation and staff interviews confirmed that the delay in reporting was due to lack of computer access and staff not being present on-site during the weekend. The residents involved had significant cognitive and physical impairments, with one requiring assistance for most activities of daily living. The failure to report the incident in a timely manner constituted noncompliance with state regulations.
Failure to Investigate and Ensure Safety After Alleged Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an incident of alleged sexual abuse involving two residents. One resident with moderate cognitive impairment and ambulatory status was found half naked on top of another resident, with their mouth on the other resident's genital area. The facility's abuse and incident investigation policies required thorough assessment and reporting, including head-to-toe assessments and hospital evaluations for involved residents. However, there was no documented evidence that these assessments were performed for either resident, nor that both residents were transferred to the hospital for medical evaluation as required by policy and as instructed by the Director of Nursing. The incident was reported to administration, law enforcement, and the Department of Health. Nursing notes indicated that one resident was to be placed on 1:1 monitoring and the other was to be sent to the emergency room, but documentation did not confirm that these actions were carried out. Interviews with facility staff, including the Assistant Director of Nursing and the Medical Director, confirmed that both residents should have been assessed and transferred to the hospital, but this did not occur. There was also no evidence that 1:1 monitoring was implemented for the resident as indicated in the investigative summary. Both residents involved had significant cognitive impairments and required varying levels of assistance with activities of daily living. The facility's failure to conduct thorough assessments, ensure hospital evaluations, and document required monitoring and interventions constituted a violation of its own policies and regulatory requirements regarding the response to alleged abuse.
Failure to Revise Care Plan After Repeated Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to review and revise the comprehensive care plan with measurable objectives, time frames, and appropriate interventions for a resident with a history of sexually inappropriate behaviors. Despite multiple documented incidents where the resident engaged in inappropriate sexual contact or behaviors towards other residents, there was no evidence that the care plan was updated to address these behaviors or to implement interventions to prevent further incidents. The care plan remained unchanged after several events, including the resident being observed touching another resident inappropriately, standing outside other residents' rooms, and being found in a compromising position with another resident. The resident in question had diagnoses of cerebral infarction and vascular dementia, with assessments indicating varying levels of cognitive impairment and ambulatory status over time. Progress notes and staff interviews documented repeated incidents of inappropriate sexual behavior, including physical contact with other residents and attempts to enter other residents' rooms. Despite these documented behaviors, the care plan did not reflect any new strategies or interventions to address the resident's actions or to protect other residents from potential abuse. Staff interviews revealed that while some monitoring and reporting occurred, there was a lack of clear documentation or care plan updates specifying how the resident should be monitored or what interventions should be implemented. The responsibility for updating care plans was acknowledged by nursing leadership, but it was confirmed that the care plan for the resident was not revised following the incidents. This failure to update the care plan as required by facility policy and regulation resulted in a deficiency related to the prevention of abuse and the management of resident behaviors.
Resident Dignity and Clothing Management Deficiency
Penalty
Summary
The facility failed to ensure the residents' right to a dignified existence, as observed during an abbreviated survey. On the 6th floor, four residents were seen dressed in hospital gowns while seated in the hallway. These residents had various diagnoses, including dementia, bipolar disorder, and traumatic brain injury, and required different levels of assistance with daily activities. The facility's policy on resident rights emphasizes the importance of dignity and respect, yet these residents were not dressed appropriately, which contradicts their care plans that aim for them to be well-groomed and dressed daily. Additionally, in the 5th floor dining room, a registered nurse was observed standing over a resident while assisting them with their meal, which is against the facility's guidelines for meal assistance. This resident also had multiple diagnoses, including dementia and major depressive disorder, and required moderate assistance with eating. The nurse acknowledged awareness of the proper procedure but did not adhere to it during the observation. Interviews with staff revealed issues with clothing availability and management. Certified Nurse Assistants reported that some residents lacked personal clothing due to housekeeping issues or lack of family support. There were also inconsistencies in the process of obtaining donated clothing for residents, leading to some being left in hospital gowns. The Director of Nursing and the Director of Housekeeping outlined procedures for addressing clothing needs, but these were not effectively implemented, resulting in the observed deficiencies.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents of resident-to-resident altercations involving six out of nine residents. Resident #2 was involved in several physical altercations with other residents, including hitting Resident #5 with a walker, resulting in bruising, and engaging in a physical fight with Resident #4, causing lacerations. Despite being cognitively intact, Resident #2's aggressive behavior was not adequately managed, leading to repeated incidents. Resident #6 also exhibited aggressive behavior, hitting Resident #9 and threatening Resident #7. These incidents were not isolated, as Resident #6 continued to display aggression towards other residents, including Resident #8. The facility's failure to implement effective interventions to manage Resident #6's behavior contributed to the ongoing risk of harm to other residents. The facility's policies on abuse prevention were not effectively enforced, as evidenced by the repeated altercations and lack of adequate interventions to separate aggressive residents from their peers. The care plans for residents involved in altercations were not consistently updated to reflect new incidents, and the facility did not ensure that residents with known aggressive behaviors were kept apart, increasing the likelihood of further incidents.
Failure to Timely Report Resident Altercations
Penalty
Summary
The facility failed to submit timely 5-day investigative conclusion reports to the New York State Department of Health for incidents involving resident-to-resident altercations, as required by state law. Specifically, there were delays in reporting incidents involving multiple residents, including one where a resident hit another with a walker, resulting in bruising, and another where two residents engaged in a physical altercation, leading to lacerations. In some cases, the reports were submitted late, and in one instance, there was no documented evidence of submission at all. The incidents involved residents with various diagnoses, including dementia and anxiety disorder, and occurred over several months. Despite the facility's internal documentation of these incidents and the completion of investigative summaries, the required reports were not submitted within the mandated timeframe. The Director of Nursing was unable to provide explanations for the delays or omissions in reporting, indicating a lapse in the facility's compliance with state reporting requirements.
Inadequate Staffing on Dementia Unit
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents on the 3rd floor Dementia Unit, as evidenced by a review of staffing schedules and interviews with staff. The staffing grid indicated that the unit required 5 certified nurse assistants (CNAs) during the day shift, 4 during the evening shift, and 2 during the night shift. However, the actual staffing levels were consistently below these requirements across various shifts in January, February, and March 2024. This discrepancy was particularly pronounced on certain days when only 1 or 2 CNAs were present, despite the unit housing 35-40 residents. Interviews with staff, including the Staffing Coordinator and several CNAs, revealed that the facility frequently experienced call-outs, leading to understaffing. The Staffing Coordinator mentioned attempts to schedule additional staff and use agency staff to fill gaps, but these efforts were not always successful. CNAs reported starting shifts with fewer staff than scheduled, sometimes working alone or with just one other CNA for the entire unit. This situation was exacerbated by the need to pull CNAs from the unit to accompany residents to appointments, further reducing the available staff to care for the remaining residents. The Director of Nursing acknowledged the staffing challenges, noting that while the Provider Average Ratio (PAR) for the day shift was 5 CNAs, the facility often operated with only 3 or 4. The Director also mentioned that staffing had improved compared to earlier in the year, but issues with lateness and call-outs persisted. The deficiency in staffing was particularly concerning given the high acuity and specific needs of the dementia unit residents, who require consistent and attentive care to maintain their well-being.
Environmental Deficiencies in Facility Maintenance
Penalty
Summary
The facility was found to have multiple environmental deficiencies during an abbreviated survey. Observations revealed that on every unit, there were areas with chipped paint, scuff marks, visible dirt, and stains on the walls and floors. Baseboards were chipped and coming off the walls, there were holes in the walls, chipped tiles, caving ceiling tiles, and foul odors present. These issues were noted across various floors, including the 2nd, 3rd, 4th, 5th, and 6th floors, affecting hallways, dining rooms, and resident rooms. Interviews with the Director of Maintenance and the Administrator highlighted challenges in maintaining the facility's environment. The Director of Maintenance, responsible for repairs and maintenance, stated that they have limited staff and experience constraints, which impacts their ability to address the numerous repair needs promptly. They mentioned that tasks are generally completed within a day, but more complex repairs requiring additional materials may take longer. The Director also noted that they are actively trying to hire more skilled staff to manage the workload effectively. The Administrator, who has been with the facility since February 2024, conducts environmental rounds at least weekly, focusing on ensuring the facility is free of clutter and identifying maintenance issues. They communicate identified issues to the maintenance department and expect repairs to be completed within a reasonable timeframe, depending on the severity of the issue. Both the Director of Maintenance and the Administrator acknowledged the need for additional maintenance staff to address the ongoing environmental concerns effectively.
Failure to Provide Adequate Care Leads to Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, resulting in the development of a Stage 3 pressure ulcer. The resident, who was dependent on staff for all care due to conditions including dementia, quadriplegia, and legal blindness, did not have a documented physician order for turning and repositioning. The certified nurse assistant accountability forms for February and March 2024 showed no evidence of consistent assistance with bed mobility, with 30 and 32 occasions, respectively, lacking documentation of care. The resident's care plans noted the need for skin care and monitoring, but there was no Braden scale assessment to classify the resident's risk for pressure ulcers. A Registered Nurse's assessment on March 12, 2024, documented the development of a Stage 3 pressure ulcer on the resident's left hip. The Director of Nursing confirmed that if turning and positioning orders were present, they would be reflected in the accountability forms, and the absence of documentation indicated the care was not provided.
Facility-Wide Assessment Lacks Detailed Staffing Plan
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment, last updated on 11/7/2024 and reviewed on 9/18/2023, did not specify individual staff assignments, systems for coordination, or continuity of care required for day-to-day operations, including nights and weekends. During a review on 12/19/2024, it was found that the assessment lacked a detailed staffing plan, including the number of staff needed per unit per shift. The Administrator acknowledged the omission, stating they were unaware of the requirement to include unit-specific staffing needs.
Latest citations in New York
A resident with dementia, severely impaired cognition, and known risk for dehydration had documented 0% meal intake over multiple consecutive meals, with CNAs recording refusals but not documenting fluids and not reporting the poor intake to an LPN or RN as required by facility policy. Nursing staff, including LPNs and RN supervisors, reported they were unaware the resident was not eating and did not assess or notify the MD despite ongoing 0% intake and the absence of a care plan addressing meal refusal or poor appetite. The resident was only assessed by an RN after a marked change in mental status and rapid decline were observed, at which point the MD was finally notified and medical interventions were initiated, resulting in a deficiency for failure to provide care in accordance with professional standards and the facility’s nutrition and hydration policies.
A resident with dementia and type 2 DM, assessed and care planned to require two staff for transfers, was transferred using a mechanical lift by only one CNA, in violation of facility policy requiring two caregivers for such transfers. The CNA, who had been trained on mechanical lift use, reported proceeding alone because they believed no one was available to help and the resident was asking to go to bed near the end of the CNA’s shift. The resident was later found on the floor near the lift with a significant leg laceration, and subsequent review confirmed the lift and sling were functioning properly while other staff reported that two aides had been working on each hallway during that shift.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
Two residents experienced significant changes in condition and treatment without required notifications. For one resident with multiple fractures and hypertension, a provider ordered 0.9% sodium chloride via clysis for hydration, which was initiated and then refused by the resident; documentation showed the provider was informed of the refusal, but there was no evidence that the resident’s family representative was notified of either the start of IV fluids or the refusal. For another resident with severe pain rated 10/10, the physician adjusted pain medications, but was not notified when the revised pain regimen was ineffective, contrary to facility policies requiring timely notification of representatives and practitioners for significant changes.
Failure to Assess and Respond to Prolonged Poor Oral Intake
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and facility policy regarding nutrition and hydration monitoring and response. The resident had dementia with declining mental and functional status, pulmonary venous congestion, severely impaired cognition, and required partial/moderate assistance with eating. A dietary care plan identified the resident as at risk for dehydration due to dementia and varied oral intake, with interventions to observe for signs and symptoms of dehydration and explore reasons for decreased intake. Physician orders placed the resident on a no added salt mechanical soft diet with thin liquids, later downgraded to puree solids per speech therapy. Certified Nursing Assistant (CNA) documentation showed that the resident had no documented oral intake from the morning of 03/14/2026 through early afternoon on 03/16/2026, totaling eight missed meals. CNAs reported that the resident had a history of poor appetite, combative behavior during care, and variable intake ranging from 25% to 75% of meals. For the relevant period, CNAs stated they documented 0% food consumption because the resident refused to eat, and they acknowledged offering fluids or juice but did not document fluid intake. They also stated they did not report the resident’s refusal to eat to the LPN, despite facility policy requiring staff to report poor intake and meal consumption of less than 50% to the nurse immediately. Nursing staff, including LPNs and RN supervisors, reported that they did not receive information from CNAs that the resident was not eating or drinking during the days in question. LPNs stated they would have encouraged intake and notified supervisors if they had known the resident was not eating, and they reported that they did not observe the resident as weak or less responsive during their shifts. The RN supervisors stated they did not receive reports of poor appetite or meal refusal and indicated that CNAs were expected to notify the unit nurse when a resident refused or did not eat. There was no care plan addressing the resident’s refusal of meals or poor appetite, and there was no documentation that a nurse assessed the resident for poor intake or that the physician was notified until 03/16/2026 at 3:44 PM, when the RN Supervisor assessed the resident with a change in mental status, rapid decline, weakness, lethargy, and minimal responsiveness, and noted that the resident had not been eating and was spitting up brown secretions. Only at that time was the physician contacted and medical interventions initiated. The facility’s own policy on Meal Consumption required CNAs to document intake percentages for each meal, record refusals and behaviors, and promptly report poor intake, and required nurses to review intake documentation daily, assess residents with poor intake, document interventions and outcomes, and notify the medical provider as indicated. The policy also required physician notification when intake was consistently less than 50% or when significant decline in intake was observed. Despite this, the resident’s extended period of no documented oral intake and repeated 0% meal consumption entries were not acted upon by nursing staff, and the physician was not notified until after a significant change in condition was observed. This sequence of inaction and lack of assessment and notification in the face of documented poor intake led to the cited deficiency under 10 NYCRR 415.12.
Single-Staff Mechanical Lift Transfer Leads to Resident Fall and Laceration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision during a mechanical lift transfer, resulting in a resident fall and injury. Facility policy for "Resident Transfer Using a Total Mechanical Lift" required that two or more caregivers be present and assisting at all times, with at least two caregivers having hands-on contact with the resident and the lift. The resident involved had dementia and type 2 diabetes mellitus, was cognitively impaired, and was assessed on the Minimum Data Set as needing assistance of two staff members for transfers. The resident’s care plan also documented dependence on two staff for transfers using a gait belt. On the date of the incident, the resident was transferred via mechanical lift by a single CNA, contrary to policy and the resident’s assessed needs. The CNA reported they could not find another staff member to assist, knew they should not perform the transfer alone, but proceeded because the resident repeatedly requested to go to bed and it was the end of the CNA’s shift. The resident was later found on their left side near the mechanical lift with a six-inch laceration on the left leg and was sent to the emergency room. Subsequent examination of the sling and lift by nursing leadership found the equipment to be in good working order. Staff interviews confirmed that two staff members were expected for mechanical lift transfers and that other aides had been available on the unit at the time of the incident.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Notify Representative and Physician of Significant Changes in Condition and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies requiring timely notification of residents’ representatives and practitioners when there is a significant change in condition or treatment. The facility’s “Notification of Families” policy directs nursing staff and supervisors to inform residents’ primary contacts or legal representatives of significant changes in physical status, significant alterations in treatment, and decisions related to transfers or other major events. The “Change of Condition” policy requires staff to monitor residents for changes, assess them, and notify the practitioner with details of the change, assessment findings, interventions attempted, and the resident’s response. Surveyors found that these notification requirements were not followed for two residents when significant changes in condition and treatment occurred. For one resident with fractures of the left fibula and tibia and essential primary hypertension, the provider ordered 0.9% sodium chloride solution at 50 mL/hour via clysis for hydration. Nursing documentation showed that the clysis was started and that the resident later refused the treatment, with the provider being notified of the refusal. However, there was no documented evidence that the resident’s family representative was notified either of the initiation of intravenous fluids/clysis or of the resident’s refusal of this treatment. For another resident who was assessed with pain at a level of 10/10, the physician ordered adjustments to the pain medication regimen, but the physician was not notified when the adjusted pain medication was ineffective. These omissions in notification to the resident’s representative and to the physician occurred despite the facility’s written policies requiring such communication when significant changes in condition or treatment occur.
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