Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Majestic Care Of Flushing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities fell repeatedly, hit his head several times, and required hospital care, while neuro checks and 15-minute monitoring documentation were incomplete and no additional supervision interventions were documented beyond q15 checks. Two other residents with dementia and other serious diagnoses also had repeated falls with injury, and the DON stated that closer monitoring or 1:1 support was not used on a regular basis.
Failure to support nutrition and prevent weight loss: A resident with TBI, dementia, DM, depression, HF, and severe cognitive impairment had significant wt loss, appeared weak and very thin, and needed assistance with feeding and care. Meal intake declined, family reported he ate better with preferred outside foods and finger foods, and his missing dentures were not addressed in the care plan, which listed nutritional interventions but did not include those preferences.
Two residents who required assistance with ADLs were found to have long, soiled fingernails due to the facility's failure to provide routine nail care. One resident with multiple medical conditions and contractures had neglected nails despite care plan notes about scratching and skin breakdown risk, while another resident with dementia and arthritis had unclean nails and no documentation of recent nail care. Staff acknowledged nail care should occur during showers, but records did not confirm this was done.
A resident with a coccyx pressure ulcer did not receive wound care as ordered, with observations revealing a dressing unchanged for several days despite staff documentation indicating daily care. The resident reported infrequent dressing changes and was seen scratching the wound, leading to bleeding. Nursing staff had initialed wound care as completed without performing the task, and there was no documentation of care refusal.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
Surveyors identified multiple deficiencies in kitchen sanitation and equipment maintenance, including unclean food preparation tools, malfunctioning dishwashing equipment, and inadequate cleaning of kitchen fixtures. Staff interviews revealed inconsistent adherence to cleaning schedules and a lack of clear responsibility for maintaining sanitary conditions.
Surveyors found that the facility failed to implement a comprehensive infection prevention and control program, with staff not performing hand hygiene, missing hand sanitizer dispensers, and soiled equipment. The infection control nurse was unfamiliar with surveillance processes, and infection data was incomplete or inconsistent. In one case, a resident with a wound infection was not included in surveillance records or treated, and another resident's potential bed bug exposure was handled by maintenance staff instead of nursing, with no proper documentation or follow-up. Covid-19 cases were not consistently tracked or reported, and there was no evidence of outbreak investigation or health department notification.
The facility did not properly implement or document its Antibiotic Stewardship Program, as shown by incomplete infection surveillance records, missing laboratory data, and lack of documentation for antibiotic use in four residents. Several residents received antibiotics without clear evidence of infection, appropriate assessments, or monitoring, and staff were unable to explain or justify antibiotic choices due to missing or incomplete records.
A resident's bathroom was found with a large hole in the baseboard, a cracked toilet, and unsanitary conditions, while an environmental tour revealed widespread issues such as soiled linens on the floor, corroded sinks, missing emergency equipment, dirty vents, and unclean common areas. These deficiencies resulted in an unsafe, unsanitary, and uncomfortable environment for all residents and staff.
Multiple residents, all dependent on staff for ADLs and with significant medical needs, were left without accessible call lights or experienced long delays in staff response, leading to unmet toileting and personal care needs. Family members and residents reported staff inaction, and observations confirmed residents were left soiled, exposed, or unable to summon help, resulting in distress, skin irritation, and embarrassment.
Multiple residents who were dependent on staff for ADLs did not consistently receive showers, grooming, or hygiene care as required by their care plans. Observations and interviews revealed missed showers, unwashed hair, body odor, dirty nails, and soiled clothing, with staff citing workload and staffing shortages as reasons for missed care. Documentation did not reflect resident refusals, and residents expressed dissatisfaction and embarrassment over the lack of personal care.
Multiple residents reported significant delays in call light response, missed showers, and untimely incontinence care due to inadequate staffing. Staff interviews and facility records confirmed frequent call-ins, inability to secure coverage, and reliance solely on internal staff, resulting in unmet ADL needs and resident frustration.
Three residents experienced missed showers and inadequate personal hygiene due to the facility's failure to follow or revise ADL care plans. Residents reported infrequent bathing, unkept appearances, and dissatisfaction with care, while records showed a lack of individualized scheduling, incomplete documentation of preferences, and no recorded refusals despite missed showers.
A resident with dementia, dysphagia, and depression, who required assistance with ADLs and had impaired cognition, was repeatedly found in bed with no accessible activities and expressed ongoing boredom. Despite a care plan indicating preferences for independent activities, board games, and music, only limited group activities were documented, and there was no activity cart or consistent provision of materials of interest. The resident's environment lacked accessible engagement, and basic needs such as access to the TV and glasses were not met.
A resident with severe cognitive impairment, a history of falls, and multiple comorbidities was observed ambulating and toileting without staff assistance, despite care plan interventions requiring supervision and help with these activities. The resident was left unsupervised, stood from a wheelchair without brakes locked, and exposed themselves to the hallway while attempting to use the bathroom. Staff did not consistently follow care-planned interventions, resulting in unassisted ambulation and toileting for the resident.
A resident with multiple respiratory and cardiac conditions was found with a CPAP mask, tubing, and head strap that were visibly soiled with brown buildup over several days. Despite orders and documentation indicating weekly cleaning, the equipment remained dirty, and the resident reported it was not being cleaned. Staff confirmed the equipment was dirty, demonstrating a failure to provide appropriate respiratory care.
Two residents reported receiving cold, unappetizing meals that did not meet their stated preferences, with one resident also lacking regular access to fresh water. Multiple residents at a council meeting unanimously described ongoing issues with food quality, meal delivery delays, and unfulfilled menu choices, with staff interviews and observations confirming these deficiencies.
Three residents with recent amputations or surgical wounds did not receive timely or adequate wound assessment, monitoring, or treatment. One resident's surgical site was not assessed for two weeks, leading to infection and further surgery. Another resident's amputation site was not assessed or monitored until several days after admission, and care plan interventions were incomplete. A third resident's toe amputation wound was not consistently treated or documented, with no physician order in place despite ongoing wound care.
A resident with a PEG tube did not receive proper assessment and monitoring of the insertion site, resulting in a reddened, painful area that was noticed by family rather than staff. There was no documentation of PEG site care or assessment, no physician order for PEG care upon admission, and the resident's admission weight was not obtained until five days after arrival. Enteral nutrition orders were delayed, and the resident initially received a different formula than indicated. Facility policies for enteral feeding and weight monitoring were not followed.
A resident with multiple medical conditions did not receive several prescribed medications on time due to delays in pharmacy delivery, lack of emergency medication drops, and incomplete use of backup medication supplies. The DON confirmed that some medications were not administered as ordered and that the facility did not obtain medications from local pharmacies while waiting for contracted pharmacy deliveries.
A resident with multiple health conditions was admitted to a facility with pressure ulcers that were not documented by staff. Despite hospital records indicating the presence of these ulcers, the facility's initial assessment failed to identify them, leading to a deficiency in care. The facility's policy on wound prevention was not adequately followed, resulting in a lack of proper documentation and intervention for the resident's pressure ulcers.
A resident with end-stage renal disease did not receive scheduled dialysis treatments due to coordination issues at the facility, leading to her being sent to the ER with hallucinations and confusion. Despite attempts to arrange dialysis, the facility failed to monitor the resident's condition adequately, resulting in a five-day lapse in treatment. The facility's policy for monitoring postponed dialysis was not followed, as no weight or lab work was conducted to assess the resident's kidney function.
A resident with mental health issues attempted suicide twice due to inadequate supervision at an LTC facility. Despite requiring 1:1 supervision, the facility failed to provide continuous monitoring, leading to two incidents where the resident attempted strangulation. Staff interviews revealed miscommunication and a lack of clear policies to address suicidality.
The facility failed to provide adequate pressure ulcer care for three residents, leading to wound deterioration and infection. A resident's coccyx wound worsened due to inconsistent treatment orders and lack of proper care, resulting in sepsis. Another resident had a foot dressing that was not dated or initialed, and a third resident's heel protectant boots were not used as ordered, with dressings also lacking proper documentation.
Two residents in a LTC facility sustained injuries due to inadequate supervision and failure to follow post-fall assessment protocols. One resident, an active exit seeker, was startled by staff, resulting in a fall and head injury requiring emergency treatment. The facility did not document required neurological assessments post-fall. Another resident with dementia fell and fractured his hand while visiting another resident's room, against facility guidance. The care plan lacked increased supervision measures, contributing to the incident.
The facility failed to maintain an accurate infection control program, with inconsistencies in tracking infections and outdated policies. Discrepancies were noted in infection counts and antibiotic use, with some infections treated without meeting criteria. The infection preventionist was unaware of the need for education on infection increases, and the DON confirmed outdated policies and lack of audits on antibiotic stewardship.
The facility failed to provide scheduled showers for four residents, leading to a deficiency in ADL care. A resident with a self-care deficit due to obesity and amputation missed scheduled showers without documentation. Another resident with physical limitations reported missing showers due to staff shortages. Two residents refused showers multiple times, but no alternative bathing options were documented. The facility's ADL policy was not adhered to, indicating a failure to prevent deterioration in residents' abilities.
A facility's medication error rate exceeded 5% when an LPN was unable to administer pantoprazole and Entresto to a resident due to unavailability in the medication dispensing machine. Despite ordering the medications the previous day, they were not delivered by the pharmacy, leading to an 8% error rate.
The facility failed to properly label and secure medications, resulting in several deficiencies. An unlocked medication cart was found unattended with loose medications, and expired or undated medications were discovered in various locations. Facility policies on medication storage and administration were not followed, increasing the risk of decreased efficacy and potential drug diversion.
The facility failed to maintain sanitary conditions in the kitchen, with staff not adhering to hygiene practices like wearing hair and beard nets. Observations showed food debris on floors, improper food storage, and inadequate cleaning. A cook used the same gloves for multiple tasks without washing hands, and structural issues like an unfinished doorway and open drain were noted, posing health risks to residents.
The facility failed to maintain an effective vaccination program for four residents, with issues including missing consents, unadministered vaccines despite signed consents, and outdated policies. Interviews revealed that the infection preventionist lacked access to the vaccination database, and the DON acknowledged the need for better processes. An LPN could not explain why a resident did not receive vaccinations despite signed consents.
The facility failed to maintain essential equipment, including beds and wheelchairs, in safe condition, affecting multiple residents. A resident nearly fell due to an unstable bed, while another faced frustration with a non-functional bed remote. A wheelchair with loose wheels and a cracked overhead light fixture were also reported but remained unaddressed until surveyor intervention. The maintenance staff and administration were unaware of these issues, highlighting a lack of communication and systematic checks.
The facility failed to ensure dignified care and timely call light responses for several residents, leading to prolonged incontinence and frustration. Residents reported extended wait times for assistance, with some experiencing exposure and lack of privacy. A CNA refused to assist a resident, citing workload, further highlighting the facility's deficiencies in maintaining resident dignity and care.
A resident's Tramadol medication was misappropriated due to discrepancies in the controlled substance log and MAR. The facility's failure to accurately document and reconcile medications led to one pill being unaccounted for. The nurse involved was suspended pending further investigation.
A resident experienced a fall resulting in fractures to the right hand, which was not reported to the State Agency as required. The resident was found with an ice-wrapped hand and transferred to the ER, where fractures were confirmed. The facility's DON confirmed the failure to report the injury, violating the facility's Abuse Prevention Program.
A resident with dementia and severely impaired cognition sustained an injury of unknown origin, resulting in fractures to the hand. The facility failed to conduct a thorough investigation, as required by its policies, by not obtaining witness statements from staff who observed the incident. This oversight led to a deficiency with the potential for undetected abuse or neglect.
Two residents with PICC lines in an LTC facility were found to have non-occlusive dressings and lacked initial measurements upon admission. The facility's policy of weekly dressing changes was not followed, and there were discrepancies in documentation and untimely monitoring orders. The management acknowledged these deficiencies.
The facility failed to obtain informed consents for psychotropic medications for two residents, leading to the administration of potentially unnecessary medications. One resident received an antipsychotic for eight weeks without proper consent from her guardian, while another was given multiple psychotropic medications without any signed consents. The facility's policy did not address informed consents, contributing to the oversight.
A facility failed to adhere to professional standards in medication administration and documentation for two residents. One resident had a discrepancy in the controlled substance log for Tramadol, with a missing pill unaccounted for. Another resident was offered Melatonin without a proper order, and the nurse involved backdated entries in the medical record. The nurse had a history of medication administration violations, and facility policies were not followed, resulting in inaccurate documentation.
The facility failed to complete yearly PASSAR and Level II evaluations for three residents, resulting in a lack of yearly follow-up and documentation. The Social Work Director and Director of Nursing acknowledged the issue and mentioned access problems with the OBRA system. The facility's PASSAR/Level II Screening Policy was requested but not provided during the exit interview.
Repeated Falls and Incomplete Monitoring for High-Risk Residents
Penalty
Summary
The facility failed to ensure appropriate interventions were in place to provide a safe and monitored environment to prevent falls with injuries for three residents who repeatedly fell and hit their heads. Resident #1 had diagnoses including history of traumatic brain injury, dementia, diabetes, depression, and heart failure, and the MDS showed severe cognitive loss with a BIMS score of 1/15 and need for assistance with all care. The record showed 16 falls since January 2026, with 6 head strikes, including a fall on 2/17/2026 that caused a large hematoma and bleeding, required ambulance transfer, and resulted in 3 staples to the back of the head. Resident #1 continued to fall after additional hospital evaluations, including falls on 3/6/2026, 4/22/2026, and 5/13/2026, with notes describing the resident as unstable, high fall risk, and repeatedly attempting to stand or walk from the wheelchair or self-transfer. The neurological assessments completed after suspected head injuries were incomplete in five of six sets reviewed, with missing vital signs, missing neurological testing, and some missing all documentation for several days. The care plan identified fall risk and included q15 minute checks, but no additional interventions related to monitoring or supervision were documented, and the 15-minute check records reviewed were incomplete and undated. Resident #4 had diagnoses including Alzheimer's dementia, depression, anxiety, psychosis, heart failure, epilepsy, COPD, and pulmonary fibrosis, and the MDS showed cognitive decline, need for assistance with care, and two or more falls with injury since admission. The incident reports showed 6 falls from January through April 2026, including repeated falls with head injury and a hospital transfer for change of condition. Resident #5 also had repeated falls with injury, and the report states that the facility failed to ensure appropriate interventions were in place for all three residents. The DON stated that everything had been tried, that closer monitoring or 1:1 monitoring was not used on a regular basis, and staffing on the unit was typically 3 to 4 nurse aides with 2 nurses.
Failure to Support Nutrition and Prevent Weight Loss
Penalty
Summary
The facility failed to ensure interventions were carried out to promote nutrition and prevent weight loss for one resident with a history of traumatic brain injury, dementia, diabetes, depression, heart failure, and severe cognitive impairment. The resident was admitted needing assistance with all care and was observed appearing very thin, weak, and sleepy while sitting near the nurses’ station. On one occasion, the resident had to be redirected and then assisted to bed, and staff documented that he was fed, changed, given a nutritional supplement, and then slept until dinner. Record review showed significant weight loss, including 14.2 lbs from January to May, 13.1 lbs over three months, and 6.6 lbs in 30 days. Meal intake documentation showed multiple meals eaten at reduced amounts, and the resident’s family member stated the resident could not feed himself well, was barely eating, and had previously eaten better when outside food he liked was brought in. The family member also stated staff told them not to bring in the outside food anymore, and that the resident had lost his dentures and they had not been replaced. The care plan included nutritional interventions such as supplements, appetite stimulant, liberalized diet, and honoring food/fluid preferences, but it did not mention that the resident ate better with finger foods, and the resident care team review noted significant weight loss without mentioning the missing dentures.
Failure to Provide Routine Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that routine nail care was provided for two residents who required assistance with activities of daily living (ADLs). One resident, with a history of bipolar disorder, anxiety, contractures, heart disease, neuropathy, and a recent finger fracture, was observed to have long, discolored, and jagged fingernails on a contracted hand. The care plan noted the resident's risk for skin breakdown and a tendency to scratch, but did not include specific interventions for nail care or alternative plans to address nail maintenance. The resident expressed concern about the condition of his nails, noting they were curling under, and agreed to have them trimmed when offered by staff. Documentation did not reflect consistent nail care assistance as part of his ADL support. Another resident, diagnosed with dementia, arthritis, gout, heart failure, and other chronic conditions, was observed with long, unclean fingernails and stated she needed her nails done. The care plan indicated that nail care should be provided on bath days and as necessary, but review of shower documentation showed the last shower occurred a week prior, with no record of nail care being completed. Staff confirmed that nail care was expected to be performed during showers, but there was no evidence this was done. The facility was unable to provide a nail care or shower policy upon request during the survey.
Failure to Provide Wound Care as Ordered and Inaccurate Documentation
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with multiple medical conditions, including a pressure ulcer on the coccyx. Physician orders specified daily cleansing of the coccyx wound with normal saline, application of collagen wound filler, and comfort foam, to be changed every day and as needed. However, during observation, the resident's wound dressing was found to be dated four days prior, shriveled, and appeared to have not been changed as required. The resident reported that the dressing was changed about once a week, and was observed scratching the wound, causing bleeding. Review of the Medication Administration Record/Treatment Administration Record showed that staff had initialed daily completion of wound care, including on days when the dressing had not been changed. Interviews with nursing staff and the Director of Nursing revealed that some nurses had documented completion of wound care without actually performing the dressing change. There was no documentation in the progress notes to indicate that the resident had refused care on the days in question. The facility's wound care policy was requested but not provided prior to the survey exit.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Maintain Sanitary Kitchen and Equipment Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not ensure that kitchen equipment and fixtures were in good working condition. During a kitchen tour, surveyors observed multiple instances of unclean food preparation equipment, including kitchen knives with dried food, a can opener with a black dried substance, plates with food particles, and a steam table with crumbs and dried food. Additional observations included a professional oven and microwave with dried food residue, and utensils with broken pieces and dried batter. The kitchen's cleaning schedules indicated that these items were supposed to be cleaned daily or weekly, but the observed conditions did not align with these schedules. Surveyors also found that the large dishwasher was malfunctioning, spraying hot water onto the floor and staff due to a loose water shield and damaged curtains, with no safety mats in place despite their availability. The three-compartment sink was leaking water from the faucet, and maintenance staff were unaware of the issue. The walk-in cooler fan covers were covered in black dust and dirt, and there was no documentation or set schedule for their cleaning. The floor drain under the cook's sink was filled with dirt, dust, and food items, and the milk cooler had dried milk residue both inside and on the floor. Metal pans with significant wear were found on the clean pan rack, and the cleaning of walk-in fan covers was delayed for several days after initial observation. Interviews with dietary and maintenance staff revealed a lack of awareness or adherence to cleaning responsibilities and schedules. Staff acknowledged that certain equipment should be cleaned after each use or weekly, but these practices were not consistently followed. Maintenance staff also indicated that they relied on dietary staff to notify them about cleaning needs for certain equipment, such as the walk-in cooler fan covers, rather than following a set schedule.
Failure to Implement Comprehensive Infection Control Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control program, as evidenced by multiple observations and interviews. Surveyors observed that hand hygiene practices were not followed by staff, including dietary and nursing assistants, who did not use hand sanitizer or wash hands before leaving residents' rooms after delivering food or providing care. Hand sanitizer dispensers were missing from some resident rooms, and staff were seen touching contaminated surfaces and moving between residents without performing hand hygiene. Additionally, soiled room divider curtains and lack of accessible hand hygiene equipment were noted. The infection control (IC) program lacked accurate and complete outcome and process surveillance. The IC nurse was unfamiliar with the facility's surveillance processes, could not explain discrepancies in infection data, and was unaware of the water management plan. Infection surveillance documentation was incomplete, with missing summaries and analyses, inconsistent line listings, and lack of documentation for some infections. For example, a resident with a wound culture positive for infection was not included on the line list and did not receive documented treatment. Another resident's infection was listed twice with conflicting information, and there was no documentation of whether infections met McGeer criteria. Covid-19 cases were not consistently tracked or reported, and there was no evidence of health department notification or outbreak investigation. The facility also failed to respond appropriately to a staff report of potential bed bugs. When aides reported possible bed bugs in a resident's bedding, the maintenance director, who lacked clinical credentials, conducted a skin assessment instead of nursing staff. No nursing skin assessment or follow-up documentation was found in the resident's medical record. The pest control company was called and then canceled by the maintenance director without proper investigation or documentation. Staff were not informed of the incident during shift reports, and there was no clear policy or procedure for handling such situations. Overall, the facility's infection control program was disorganized, with inadequate documentation, lack of staff education, and insufficient monitoring of both residents and staff for infections.
Failure to Implement and Document Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program, as evidenced by incomplete documentation, lack of analysis, and insufficient monitoring of antibiotic use for four residents reviewed for antimicrobial treatment. Infection control documentation for January 2025 did not include a summary or analysis of infections, and the Monthly Infection Surveillance Report was missing critical information, such as whether infections met McGeer’s Criteria for 15 out of 31 cases. The infection control nurse (IC RN K) was unable to explain missing data or confirm the appropriateness of antibiotic treatments due to incomplete records and lack of laboratory results. For one resident treated for a UTI, the line listing omitted the date antibiotic treatment was started, did not specify if the infection was facility or community acquired, and lacked laboratory testing results. The IC nurse could not explain why certain organisms were not documented or confirm if the prescribed antibiotic was appropriate, as sensitivity data was missing. Another resident was treated for a UTI, but the facility lacked a culture and sensitivity report, and the infection was incorrectly classified as community acquired when it was actually facility acquired. The IC nurse could not evaluate the appropriateness of antibiotic treatment due to missing documentation and assessments. Additional deficiencies included a resident started on two antibiotics after a podiatry visit without any progress notes, assessment, or documentation of infection signs and symptoms. The IC nurse and DON were unable to provide documentation or rationale for the antibiotic orders, with the DON indicating antibiotics may have been prescribed prophylactically. Another resident was prescribed a prolonged course of antibiotics without documentation of the infection being treated, the organism involved, or monitoring of ongoing antibiotic use. The resident was not included in the infection control line listing, and the facility could not provide supporting documentation for the extended antibiotic therapy.
Widespread Environmental Deficiencies Compromise Facility Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and staff, as evidenced by multiple observations throughout the building. One resident was found to have a bathroom with a large hole in the baseboard exposing cement and debris, a cracked toilet base, and an unknown brown substance around the toilet. The resident expressed concern about potential falls due to the bathroom's condition. Additional issues in the same bathroom included missing baseboards and exposed cement block above the hand sanitizer dispenser. During an environmental tour, numerous deficiencies were identified in various areas of the facility. These included clean linen and gowns on the floor, soiled vents blowing onto uncovered clean linen, corroded sink drains, uncovered suction equipment, dead sewer flies, soiled gloves on the floor, missing emergency pull cord light, missing shampoo dispenser handle, dusty vents, and unlabelled body wash. Other areas had stained or bowing ceiling tiles, holes in air vent grates, hazardous chemicals at bedsides, damaged privacy curtains, exposed wood and scratched walls, soiled sinks, missing tiles, clutter, and dirty equipment. The resident activity room and laundry room were also found to be unclean, with debris, cobwebs, soiled blinds, and standing water present. The facility's job descriptions for the Housekeeping Supervisor and Maintenance Director require them to ensure a clean, orderly, safe, and attractive environment, as well as efficient functioning and upkeep of the building. However, the observed conditions indicate a failure to meet these responsibilities, resulting in an environment that is not safe, sanitary, or comfortable for residents, staff, and the public.
Failure to Ensure Resident Dignity and Timely Assistance with Call Lights and Toileting
Penalty
Summary
Surveyors identified multiple failures by facility staff to honor residents' rights to dignity, self-determination, and communication. Several residents, all dependent on staff for activities of daily living (ADLs) due to complex medical conditions such as heart disease, kidney disease, cognitive impairment, and mobility limitations, were observed without accessible call lights or experienced extended call light response times. In some cases, residents were unable to reach their call lights, were unaware of their location, or reported that staff did not respond in a timely manner. Family members corroborated these accounts, with one family member stating they had to provide incontinence care themselves due to staff inaction. Resident Council meeting notes further documented widespread complaints about delayed call light responses, with reports of waits exceeding an hour and staff not meeting residents' needs. Additional deficiencies were observed in the provision of toileting and personal care. One resident, dependent on staff for toileting and personal hygiene, was left soiled and told to wait for assistance until after eating, despite having both urinary and fecal incontinence. The resident was observed attempting to eat without adaptive equipment, with food spilled on their clothing and a strong odor of bowel movement present. Staff were unable to identify who delivered the food tray or provide timely incontinence care, contrary to the resident's care plan, which required routine checks and assistance with toileting and eating. Another resident was observed with their pants down, exposed to the hallway while attempting to access the bathroom independently, indicating a lack of timely staff assistance with toileting and a failure to maintain the resident's dignity and privacy. These incidents, supported by resident interviews, observations, and care plan reviews, resulted in residents experiencing fear of abandonment, anger, skin irritation from prolonged exposure to urine and feces, and embarrassment.
Failure to Provide Consistent ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), including bathing, grooming, and hygiene, for multiple residents who were dependent on staff for these services. Several residents did not receive scheduled showers or bed baths as documented in their care plans, with records showing missed showers on specific dates and no documentation of resident refusals. Observations and interviews revealed residents with unwashed hair, body odor, dirty or untrimmed nails, and soiled clothing, indicating a lack of consistent personal hygiene care. Residents expressed dissatisfaction and distress regarding the lack of assistance with ADLs. Some reported that showers were not given regularly, and that staff would often tell them to wait for the next shift or only provide a quick wash with a wet cloth. Staff interviews confirmed that showers and other ADL tasks were sometimes missed due to staffing shortages or workload, and that not all residents' preferences or needs were being met as outlined in their care plans. In several cases, there was no documentation of refusals or alternative care provided when showers were missed. The affected residents had significant medical histories and cognitive impairments, making them reliant on staff for daily care. Observations included residents with dried food and wet spots on clothing, long and dirty fingernails, unshaven facial hair, and unchanged or soiled clothing. These findings were corroborated by both staff and resident interviews, as well as review of care plans and ADL task sheets, which consistently showed gaps in the provision of required personal care services.
Failure to Provide Adequate Staffing for Resident ADL Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the Activities of Daily Living (ADL) needs of residents, as evidenced by multiple resident complaints and staff admissions. During a Resident Council meeting, all sixteen residents present unanimously reported a shortage of staff, resulting in delayed call light responses, missed showers, and untimely incontinence care. Residents described waiting extended periods—sometimes up to two hours—for assistance, with some staff turning off call lights without providing the requested help or telling residents to wait until the next shift for care. Several residents reported having to wait so long for assistance that they experienced incontinence or had to seek help at the nurse station themselves. Interviews with residents further corroborated these issues, with consistent reports of insufficient staff, poor attitudes among aides, and a lack of empathy. Residents described staff as being overworked, with some aides refusing to adjust their routines to meet residents' immediate needs. Night shift staffing was particularly problematic, with reports of residents not receiving water, being left unattended for long periods, and staff failing to return after initially responding to call lights. Some residents also noted that showers were infrequent and dependent on which aide was working, and that some aides were not adequately trained to provide proper shower care. Staff interviews and facility records confirmed the staffing challenges. The staff scheduler acknowledged frequent call-ins and an inability to secure adequate coverage, as the facility does not use agency staff and relies solely on internal staff. The Nursing Home Administrator admitted to ongoing staff turnover and issues with staff performance, including some staff hiding or not doing their work. The facility's call light audits only tracked response times, not whether the requested service was actually provided. Observations by the surveyor also noted staff complaints about being short-staffed. The facility's own policies and job descriptions require sufficient staffing and competency in ADL care, but these standards were not being met, as evidenced by the consistent resident and staff reports.
Failure to Follow and Revise ADL Care Plans for Bathing and Hygiene
Penalty
Summary
The facility failed to follow and/or revise care plans for Activities of Daily Living (ADL) related to bathing and personal hygiene for three residents. Observations and interviews revealed that residents experienced missed showers and unkept appearances, including body odor, without documented refusals or individualized care plans reflecting their preferences. For example, one resident was observed to have body odor on multiple occasions and reported that showers were not given regularly. The care plan indicated staff assistance for sponge baths twice weekly and as needed, but did not specify individualized days or whether a sponge bath was the resident's preferred method of bathing. Shower records showed only four showers in a 30-day period, and there was no documentation of refusals in the progress notes. Another resident reported inconsistent assistance with bathing and hygiene, stating that some staff were helpful while others were not, and that there were staffing shortages on certain shifts. The care plan called for staff assistance with showers twice weekly and as needed, but again lacked individualized scheduling or documentation of resident preferences. Shower records indicated missed showers on specific days, with no documented refusals. A third resident expressed dissatisfaction with receiving only quick bed washes instead of showers, which he did not like. The care plan included staff assistance for showers and instructions to reapproach and document refusals, but only two showers were recorded in a 30-day period, and no refusals were documented in the progress notes.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities to meet the needs of a resident, resulting in complaints of boredom and having nothing to do. Observations revealed that the resident was often found resting in bed with the television on but with the volume off and the remote out of reach. The resident expressed feeling bored and stated there was nothing to do. Interviews with the Activity Director indicated that while some one-on-one activities and food-related group activities were offered, there was no activity cart available to provide a variety of in-room activity choices. Documentation showed that only four activities were provided in the past 30 days, and the resident's care plan indicated a preference for self-directed and independent activities, as well as board games and country music, but there was little evidence these preferences were being met. The resident had diagnoses including dementia, dysphagia, and depression, required assistance with activities of daily living, and had impaired cognition. Despite these needs, the resident's care plan interventions, such as providing materials of interest and assistance to activity functions, were not consistently implemented. Multiple observations confirmed that the resident's environment lacked accessible activities, and basic needs such as access to the television and glasses were not addressed, contributing to the resident's ongoing complaints of boredom.
Failure to Provide Supervision and Assistance with Toileting and Ambulation
Penalty
Summary
The facility failed to follow care-planned interventions and provide adequate supervision and assistance with toileting for a resident with severe cognitive impairment, a history of falls, and multiple comorbidities including dementia, visual loss, and chronic kidney disease. Observations revealed that the resident was left unsupervised in their room, stood up from their wheelchair without locking the brakes, and ambulated independently to their closet and bathroom on multiple occasions. The resident was also observed to change their socks and slippers and propel themselves in the wheelchair without staff assistance. During one incident, the resident exposed themselves to the hallway while attempting to use the bathroom unassisted, and the wheelchair rolled and struck the bathroom door, creating a potential hazard. Record review indicated that the resident had several unwitnessed falls in recent months and required staff assistance for activities of daily living, including ambulation, transfers, and toileting, as documented in their care plan. Despite these interventions being in place, staff did not consistently provide the required supervision or assistance, resulting in the resident performing activities independently that should have been assisted. Interviews with staff confirmed the resident's poor safety awareness and cognitive impairment, further emphasizing the need for adherence to care-planned interventions.
Failure to Maintain Clean CPAP Equipment for Resident
Penalty
Summary
A resident with diagnoses including obstructive sleep apnea, heart failure, and chronic obstructive pulmonary disease was observed with visibly soiled CPAP equipment over multiple days. The CPAP nasal mask, tubing, and head strap all had significant brown buildup, and the resident reported that nobody cleaned the equipment. The resident required assistance with activities of daily living and had impaired cognition. Despite physician orders specifying weekly cleaning of the CPAP tubing and documentation indicating the cleaning was completed, the equipment remained dirty upon repeated observations. Record review confirmed that the treatment administration record was marked as completed for the required weekly cleaning, yet the equipment was still visibly soiled. Staff acknowledged the presence of brown buildup and that the equipment was dirty, indicating a failure to provide safe and appropriate respiratory care as ordered. The deficiency was identified through direct observation, resident interview, and review of medical and treatment records.
Failure to Provide Palatable and Timely Meals per Resident Preferences
Penalty
Summary
The facility failed to provide palatable, appetizing, and per-preference meals at safe and appropriate temperatures for multiple residents. One resident, who is bed bound, alert, and dependent on staff for all ADLs, reported receiving cold and unappetizing food, missing items on her meal tray, and not receiving her preferred or required foods, such as oatmeal and caffeine-free beverages. She also reported receiving food with egg shells and experiencing significant delays in meal delivery, sometimes receiving meals hours late. Review of her care plans indicated she had specific dietary needs and preferences, which were not consistently honored by the facility. Another resident, who is thin and has missing teeth, reported that his meals were usually cold and tasteless, and he did not regularly receive fresh water, prompting him to keep bottled water at his bedside. Observations confirmed that his meal trays were cold and flavorless, and that he relied on bottled water due to inconsistent water delivery. During a Resident Council meeting, multiple residents unanimously expressed dissatisfaction with the food, citing issues such as poor taste, lack of variety, untimely meal delivery, unfulfilled menu preferences, and staff not respecting resident choices. These findings were corroborated by interviews with staff and direct observation of meal service.
Failure to Assess, Monitor, and Treat Surgical Wounds
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and intervention for wounds in three residents with recent amputations or surgical wounds. One resident was admitted with a right below the knee amputation (RBKA) and had no documented assessment or monitoring of the surgical site for 14 days after admission, despite hospital discharge instructions requiring daily inspection. The initial skin assessment did not mention the surgical wound, and subsequent assessments lacked details such as measurements, presence of staples or sutures, and peri-wound condition. There were no physician orders or care plan interventions addressing wound monitoring until two weeks post-admission, by which time the wound had dehisced and become infected, ultimately requiring further surgery. Another resident with a right above the knee amputation (AKA) did not have the surgical site assessed or monitored until three days after admission, and wound monitoring orders were not initiated until the fourth day. The admission skin assessment failed to mention the surgical site, and the care plan did not include specific interventions from the hospital discharge instructions, such as the use of a stump shrinker or showering guidelines. The resident reported that nurses checked the incision every other day, but documentation and orders did not reflect consistent monitoring from admission. A third resident with a left great toe amputation had an open wound that was not consistently assessed or treated according to physician orders. The skin assessment was completed four days after admission, and there was no order for wound dressing or treatment for the left great toe, despite wound care being observed and the resident expressing concern about inconsistent dressing changes. Documentation showed only weekly measurements by the wound nurse, and the care plan lacked specific interventions for the wound. Interviews with staff confirmed that wound assessment and monitoring were not routinely performed as required, and there was confusion regarding wound care orders.
Failure to Assess and Monitor PEG Tube Site and Timely Obtain Admission Weight
Penalty
Summary
A deficiency occurred when a resident with a percutaneous endoscopic gastrostomy (PEG) tube did not receive proper assessment and monitoring of the tube insertion site. During an observation, the resident was found with a reddened, raised area at the PEG site, which had gone unnoticed by nursing staff. The family reported that they had placed a dressing on the site themselves after noticing the area looked sore, and expressed concerns that nurses were not checking the site. The dressing was undated, and the resident indicated pain when the area was examined. Record review revealed that there were no physician orders for PEG site care upon admission, and no documentation of assessments or care of the PEG site in the resident's medical record. The facility's policy required daily checks and documentation of the enteral retention device and surrounding skin, but this was not followed. Additionally, the resident's admission weight was not obtained until five days after admission, despite policy requiring weights to be taken upon admission. The registered dietician and DON confirmed the delay in obtaining the weight and the lack of documentation for PEG site care. Further review showed that enteral nutrition orders were not in place until 24 hours after admission, and the resident received a different enteral formula than what was indicated on the hospital discharge summary until the correct product arrived. The DON acknowledged that the nurse failed to enter the tube feeding order on the day of admission and that documentation of PEG site assessments was missing. The facility's documentation practices did not capture the required ongoing assessment of the PEG site, and the initial nursing admission assessment did not include a skin assessment of the PEG insertion site.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed and Late Medications
Penalty
Summary
The facility failed to provide timely pharmaceutical services for one resident, resulting in late and missed medication doses. The resident, who was admitted with diagnoses including aphasia following a stroke, right-sided hemiplegia, and gastrostomy status, required extensive assistance with activities of daily living but had intact cognition. Record reviews revealed multiple instances where medications were either documented as not given, left blank, or marked with a '9' on the medication administration record. Specific medications affected included atorvastatin, amantadine, famotidine, metoprolol, and heparin, with several doses either missed or not properly documented as administered. Interviews with the DON revealed that medication orders not submitted before a certain time would not be included in the next delivery, and the contracted pharmacy did not provide emergency drops for new admissions. The DON also stated that medications should be available in the backup supply, but was unable to provide a backup medication list when requested. Additionally, the DON indicated that the facility did not obtain medications from local pharmacies while waiting for deliveries from the contracted pharmacy. The pharmacy contract reviewed by surveyors required 24-hour emergency delivery for new or changed prescriptions, but this was not consistently followed, leading to the deficiency.
Failure to Document Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to properly assess and monitor a resident with pressure ulcers upon admission, leading to a deficiency in documenting these ulcers. The resident, a 56-year-old female with multiple health conditions including necrotizing fasciitis, end-stage renal disease, and bilateral above-knee amputations, was admitted with pressure ulcers that were not identified by the facility staff. Despite a progress note from the hospital indicating the presence of pressure ulcers on the coccyx and right ischium, the facility's initial skin assessment did not document these conditions. Further review revealed discrepancies in the facility's documentation and assessment of the resident's skin condition. The Unit Manager noted only a bruise and self-inflicted scratches during the initial assessment, missing the pressure ulcers that were later identified by hospital staff when the resident was sent to the ER. The facility's policy on wound prevention emphasizes the need for evidence-based interventions for residents at risk of pressure injuries, but this was not adequately followed in this case, resulting in a failure to document and address the resident's pressure ulcers upon admission.
Failure to Provide Timely Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, resulting in the resident being discharged to the emergency room with hallucinations and confusion. The resident, a 56-year-old female with end-stage renal disease and other significant health issues, was admitted to the facility with orders to receive hemodialysis three times a week. However, upon admission, the facility encountered difficulties arranging dialysis appointments due to the resident's previous non-attendance at the dialysis center, leading to a lack of available chair time. Despite attempts to coordinate dialysis, the facility did not succeed in securing treatment for the resident during her stay from September 12 to September 17. Interviews with facility staff revealed a lack of follow-up and monitoring, as the resident did not receive any dialysis treatments during this period. The Director of Nursing and other staff members acknowledged the oversight, noting that the resident's cognitive state did not initially appear to change, which contributed to the delay in sending her to the emergency room. The resident's condition deteriorated, leading to hallucinations and confusion, prompting the facility to eventually send her to the emergency room on September 17. The emergency room visit was necessitated by the resident not having received dialysis for five days, as confirmed by the nephrologist. The facility's policy required ongoing monitoring and medical management if dialysis was postponed, but this was not adequately implemented, as evidenced by the lack of weight monitoring and lab work to assess kidney function during the resident's stay.
Failure to Maintain Resident Safety Leads to Suicide Attempts
Penalty
Summary
The facility failed to maintain the safety of a resident who had a history of mental health issues, resulting in two suicide attempts by strangulation. The resident, diagnosed with Alcoholic Cirrhosis of the Liver, Paranoid Personality Disorder, and Alcohol-induced persisting Dementia, was admitted to the facility and required close supervision due to his mental health condition. Despite this, the facility did not provide adequate supervision, as evidenced by the absence of a designated 1:1 sitter on certain shifts, which contributed to the resident's ability to attempt suicide twice. The first suicide attempt occurred when the resident was found with strings tied tightly around his neck, which had to be cut off by a nurse. Despite being sent to the emergency room for evaluation, the resident returned to the facility without new orders and was placed on 1:1 supervision. However, the facility failed to ensure continuous 1:1 supervision, as there was no specified sitter for the resident on the 2nd and 3rd shifts on a subsequent day. This lack of supervision allowed the resident to attempt suicide again by wrapping a phone charger cord around his neck. Interviews with staff revealed confusion and miscommunication regarding the assignment of 1:1 sitters, and a lack of a clear policy to address suicidality and subsequent procedures. The facility's failure to implement and maintain appropriate interventions and supervision for the resident's safety led to the citation of past non-compliance.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent the deterioration of wounds for three residents, leading to significant health issues. Resident #74, who was admitted with a pressure ulcer on the coccyx, did not receive the prescribed wound care treatment consistently. The treatment orders were not followed, and there was confusion between two different wound care treatments. The wound care practitioner had ordered Triad cream, but the facility also had an order for Allevyn, which was not completed on several occasions. This inconsistency and lack of proper wound care led to the worsening of Resident #74's wound, resulting in infection and sepsis. Resident #290 had a dressing on the right foot that was not dated or initialed, which is against nursing standards of practice. The dressing was observed to be dried onto the wound, indicating that it was not changed as required. This oversight in wound care documentation and management could potentially lead to further complications for the resident. Resident #292 had bilateral foot dressings that were not dated or initialed, and the resident was not wearing heel protectant boots as ordered. The care plan indicated the need to elevate heels, but the specific order for heel protectant boots was not included in the care plan or Kardex. This lack of adherence to physician orders and care plan documentation contributed to inadequate wound care management for Resident #292.
Inadequate Supervision and Documentation Lead to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and post-fall assessments for two residents, leading to significant injuries. Resident #84, who was an active exit seeker and oriented only to self, attempted to leave the building unauthorized. During this attempt, he was startled by a staff member, tripped, and sustained a head injury that required emergency medical treatment, including stitches. Despite the facility's policy requiring neurological assessments post-fall, no such evaluations were documented for Resident #84 following his return from the hospital. Resident #17, who had a history of dementia and severely impaired cognition, sustained fractures to the third and fourth metacarpals of his right hand after a fall. The incident occurred while Resident #17 was visiting another resident in her room, contrary to the facility's guidance to visit in more public areas. The Director of Nursing confirmed that there were no witness statements from staff regarding the incident, and the care plan for Resident #17 did not include increased supervision or measures to prevent him from entering other residents' rooms. The facility's failure to adhere to its fall management policy and ensure proper documentation and supervision contributed to the injuries sustained by both residents. The lack of a comprehensive post-fall assessment for Resident #84 and the absence of preventive measures in Resident #17's care plan highlight deficiencies in the facility's management of resident safety and accident prevention.
Inaccurate Infection Control Program and Outdated Policies
Penalty
Summary
The facility failed to maintain an accurate infection control program, as evidenced by inconsistencies in tracking infections within the resident population. In January 2024, there were discrepancies between the number of infections highlighted on the mapping, the line listing, and the summary, with some infections not meeting antibiotic criteria yet being treated with antibiotics. Similar inconsistencies were noted in February, March, and April 2024, with infections being placed on antibiotics without meeting criteria and discrepancies in infection counts across different records. Additionally, the facility's infection control policies were outdated, with some not having been revised since 2016 or 2018, and there was a lack of education provided to staff regarding infection control procedures. Interviews with the infection preventionist and the Director of Nursing (DON) revealed a lack of awareness and action regarding the increase in infections, particularly urinary tract infections (UTIs). The infection preventionist, who had recently taken over the role, was not aware of the need for education in response to the infection increase. The DON confirmed that the infection control policies were not current and that there were no audits or education on antibiotic stewardship. The mapping, line listing, and summaries did not match due to the absence of a consistent infection preventionist, as the previous one had been incapacitated, leading to a piecemeal approach to infection control management by the DON and regional consultant nurses.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents, leading to a deficiency in the care of activities of daily living (ADL). Resident #8, who has a self-care deficit due to morbid obesity and a below-the-knee amputation, did not receive scheduled showers on two occasions, with no documentation explaining the missed showers. Similarly, Resident #51, who requires assistance due to physical limitations and cerebral palsy, reported missing a scheduled shower, attributing it to staff shortages. The task list and progress notes for Resident #51 also lacked documentation for missed showers on two scheduled days. Resident #17 and Resident #20 both refused showers on multiple occasions, but there was no documentation of alternative bathing options being offered. Resident #17's care plan required staff assistance for showers twice a week, yet there was no record of why the resident refused or if alternatives were provided. Resident #20 also refused showers on several days, and the facility did not offer a bed bath or alternative day, as indicated by the shower sheet documentation. The facility's ADL policy states that care and services should be provided to prevent deterioration in residents' abilities, but the lack of adherence to scheduled bathing routines indicates a failure to meet this standard.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed for a resident, resulting in an 8% error rate. The errors were identified during a medication administration observation involving a Licensed Practical Nurse (LPN) and a resident. The LPN noted that the medications pantoprazole (Protonix) 40mg and Entresto 24-26mg were not available in the facility's medication dispensing machine, despite having ordered them the previous day. The LPN mentioned that the pharmacy typically delivers medications at night and confirmed that the order had been placed, but the medications were still unavailable. The resident's Medication Administration Record (MAR) indicated that pantoprazole was to be administered once daily for acid reflux, and Entresto was to be given twice daily for heart failure, both starting from earlier in the month. The MAR entries for the date in question directed to see progress notes, which confirmed the unavailability of both medications. This lack of medication availability and administration as prescribed contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, leading to several deficiencies. During an observation, a medication cart was found unlocked and unattended in the hallway, with a half-eaten sandwich and a bottle of water on top. The drawers of the cart were accessible, except for the narcotic drawer, and contained loose medications. A Licensed Practical Nurse (LPN) admitted to leaving the cart to inform management of the state surveyor's presence. Additionally, another LPN identified loose tablets in a different medication cart, and there were no antibacterial wipes available for cleaning the glucometer, which was placed back into the cart after use. Further observations revealed expired and undated medications in the facility. In the East med room, a bottle of Tuberculin was found opened without a date, and a resident's latanoprost eye drops were undated and half full. On the North Hall medication cart, several medications, including Timolol and Brimonidine eye drops, and insulin vials, were either expired or lacked open and use-by dates. The facility's policies on medication storage and administration were not adhered to, as medications were not properly labeled or stored, increasing the risk of decreased efficacy and potential drug diversion.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness risks for all residents consuming food from the kitchen. Observations revealed that the kitchen staff did not adhere to proper hygiene practices, such as wearing hair and beard nets, as required by the facility's policies. Specifically, a dietary aide refused to wear the necessary hair and beard nets and was subsequently sent home. Additionally, the kitchen floors were observed to have food droppings and debris, and the griddle had burnt-on food residue from previous meals. The dishwasher room was also noted to have debris on the floors and overflowing trash cans. The facility's food storage practices were found to be inadequate, with improperly labeled and stored food items in the coolers. An opened box of apple juice without an open date and a container of tea past its expiration date were found in the refrigerator. The kitchen's cleaning schedule was not consistently followed, as evidenced by the presence of unswept floors and dirty countertops, despite staff signing off on completed cleaning tasks. The kitchen manager acknowledged that the cleaning procedures were not being followed by the newer, younger staff, and that there was a significant buildup of lime on the dishwasher surfaces. Further observations highlighted improper glove use by kitchen staff during meal preparation and service. A cook was seen using the same pair of gloves for multiple tasks without washing hands in between, including handling food and opening storage areas. Additionally, structural issues were noted, such as an unfinished kitchen doorway with exposed drywall and metal, and an open drain under the sink without a cover. These deficiencies indicate a lack of adherence to professional standards for food safety and sanitation, posing a risk to the health and safety of the residents.
Deficiency in Vaccination Program
Penalty
Summary
The facility failed to maintain an effective vaccination program for four residents, as identified during a survey. Resident #59 had a signed consent for a pneumococcal vaccination, but the vaccine was never administered. Additionally, the consent form indicating refusal of the Pneumovax-23 vaccine lacked a date. Resident #72's records showed no consent or administration of influenza and pneumococcal vaccines. Resident #74 had consents signed for pneumococcal, influenza, and COVID-19 vaccinations, but none were administered. Resident #86's records lacked both immunization consents and any administered vaccines. Interviews with facility staff revealed gaps in the vaccination process. The Director of Nursing (DON) acknowledged that the infection preventionist did not have access to the State Agency Vaccination Database, which hindered the vaccination process. The DON admitted that immunizations should be offered upon admission and consents obtained at that time. An LPN was unable to explain why Resident #74 did not receive vaccinations despite signed consents. The facility's policies on influenza and pneumococcal vaccines were outdated, lacking current CDC recommendations, which contributed to the deficiencies.
Deficient Equipment Maintenance in Resident Rooms
Penalty
Summary
The facility failed to maintain essential resident equipment in safe operating condition, affecting multiple residents. In one instance, a resident in room 42A reported nearly falling due to a bed that did not lock properly, which had been an ongoing issue for weeks. The resident had previously fallen and bruised her shoulder due to the bed's instability. Despite the resident and her family notifying the staff, the issue remained unresolved until the surveyor's intervention. Additionally, another resident in the same room experienced frustration as their bed would not adjust up or down due to a malfunctioning remote control, which was not addressed until the surveyor's report. In room 63A, a resident's wheelchair was found to have loose wheels, which the resident had reported but remained unfixed until the surveyor's involvement. The resident expressed distress over the situation, and the staff was unaware of the issue until it was brought to their attention by the surveyor. Similarly, in room 3B, an overhead light fixture was cracked, posing a potential hazard, and had been in this condition for over a month without being addressed, despite the resident's report to the staff. The facility's maintenance staff and administration were unaware of these equipment issues, as there was no record of maintenance requests for the affected rooms. The Maintenance Director, who had been in the position for only two weeks, confirmed that they were not informed of these concerns until the surveyor's report. The Director of Nursing was also unaware of the equipment issues contributing to a resident's fall, as the fall report did not mention any bed-related problems. The Nursing Home Administrator could not provide an equipment policy, indicating a lack of systematic checks and communication regarding equipment maintenance.
Deficiencies in Resident Dignity and Call Light Response
Penalty
Summary
The facility failed to ensure resident rights pertaining to dignified care for several residents, resulting in multiple deficiencies. One resident, who was cognitively intact, reported being left wet due to untimely call light responses and the call light being out of reach. The resident expressed frustration over the situation, which was confirmed by a Licensed Practical Nurse who observed the call light was not properly placed. Another resident, also cognitively intact, reported waiting two to three hours for call light responses, which was particularly distressing due to their dependency on staff for mobility and personal care needs. Additional residents reported similar issues with call light response times, leading to prolonged periods of incontinence and frustration. One resident described waiting for hours to be assisted with a bedpan, while another reported that staff would turn off the call light at night and not return. The facility's failure to ensure timely call light responses was further highlighted during a confidential group meeting, where multiple residents shared experiences of extended wait times and feelings of neglect. The facility also failed to maintain privacy and dignity for a resident with severe cognitive impairment. This resident was observed exposed in their room with the door open, while staff attended to a roommate behind a curtain. The lack of privacy was not addressed until several minutes later when a staff member covered the resident. Additionally, a resident was observed being denied timely assistance for a change before a meal, with a CNA expressing frustration and refusing to assist, citing workload as a reason. These incidents collectively demonstrate a significant lapse in maintaining resident dignity and timely care.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medication for a resident, resulting in discrepancies in the documentation of controlled substances. During an inspection of the North Hall medication cart, a discrepancy was found in the controlled substance log for a resident's Tramadol 50 MG. The facility was dispensed 30 pills, but the count was inaccurate, with one pill unaccounted for. The controlled substance form showed inconsistencies in the number of pills remaining, particularly on 5/17/2024, when the count decreased by two pills instead of one. This discrepancy was not caught during the routine narcotic count conducted at the beginning and end of each shift. Further review of the Medication Administration Record (MAR) from 5/15/2024 to 5/21/2024 revealed that Tramadol was documented as administered only three times, while the narcotic sheet indicated it was given eight times. This inconsistency suggests that facility nurses were not accurately documenting medication administration. The Director of Nursing (DON) confirmed that the MAR and narcotic sheet should match, but the investigation revealed that the missing Tramadol pill was still unaccounted for, and there was no documentation of it being wasted. The facility's policies on controlled substances and medication administration require accurate documentation and reconciliation of medications at each shift change. However, the failure to adhere to these policies led to the misappropriation of a resident's medication and inaccuracies in the controlled substance log. The nurse involved in the discrepancy was identified and suspended pending further investigation, highlighting the need for improved oversight and adherence to established procedures.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the State Agency for a resident, resulting in a potential for undetected abuse or neglect. The incident involved a resident who was assisted to the Central unit by another nurse after visiting another resident and experiencing a fall. The resident was found sitting in a wheelchair with an ice-wrapped right hand, and the tip of the right finger was bent upward. The resident was transferred to the emergency room, and upon return to the facility, X-ray results indicated fractures to the third and fourth metacarpals, with a cast noted on the right hand up to the arm. An interview with the Director of Nursing confirmed that the injury was not reported to the State Agency, as required by the facility's Abuse Prevention Program, which mandates immediate notification of such incidents to the appropriate authorities.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation for an injury of unknown origin involving a resident with dementia and severely impaired cognition. The resident was admitted with diagnoses including dementia with other behavioral disturbances and had a BIMS score indicating severe cognitive impairment. On a specific date, the resident was found with an injury to the right hand after visiting another resident. The injury was severe enough to require an emergency room visit, where fractures to the third and fourth metacarpals were diagnosed, and a cast was applied. The Director of Nursing confirmed that the investigation into the incident did not include witness statements from staff, despite the presence of staff who could have provided information. The facility's policies on abuse prevention and investigation require comprehensive steps, including interviews with involved staff and witnesses, which were not followed. This oversight resulted in a deficient practice with the potential for undetected abuse or neglect and unmet care needs for the resident.
Deficient PICC Line Management in LTC Facility
Penalty
Summary
The facility failed to provide care and services according to its policy and standards of clinical practice for two residents with Peripheral Inserted Central Catheter (PICC) lines. For Resident #290, the PICC line dressing was observed to be non-occlusive and dated 5/8, despite the resident being admitted on 5/10. The dressing had not been changed during the resident's stay, contrary to the facility's policy of weekly dressing changes. Additionally, there were no initial measurements of the PICC line upon admission, and the orders for PICC line monitoring and dressing changes were delayed by several days. Similarly, Resident #292's PICC line dressing was also non-occlusive, and flex tape was used in an attempt to secure it. The resident's medical records lacked documentation of initial measurements upon admission, and the dressing was not changed despite its condition. The facility's policy requires weekly dressing changes and initial measurements of arm circumference and catheter length upon admission, which were not adhered to in these cases. The discrepancies in documentation and untimely monitoring and dressing change orders were acknowledged by the facility's management.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, leading to the administration of potentially unnecessary medications. Resident #60 was administered Paliperidone, an antipsychotic medication, for eight weeks without proper consent from her court-appointed guardian. Although verbal consent was reportedly obtained, there was no documentation to support this claim, and the consent form was not completed until eight weeks after the medication was ordered. The facility's policy on psychotropic management did not address the requirement for informed consents, contributing to the oversight. Resident #84 was administered multiple psychotropic medications, including two antipsychotics, an antidepressant, and Alzheimer's medication, without any signed consents. The resident was admitted to the facility from a hospital and was noted to be alert and oriented to self only. Despite the facility's efforts to work with the resident's daughter to obtain guardianship, no consents were documented for the medications administered. This lack of documentation and consent raises concerns about the appropriateness of the drug regimen and the potential for adverse side effects.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer and document medications per professional standards of practice for two residents, resulting in a discrepancy with narcotic medication and erroneous medication documentation. For Resident #58, a discrepancy was found in the controlled substance log for Tramadol, where one pill was unaccounted for. The log indicated that two pills were deducted on a specific date, although only one was administered. This discrepancy was confirmed by a count of the remaining pills, and the Director of Nursing (DON) acknowledged that the medication was still unaccounted for after an investigation. For Resident #293, the issue involved the attempted administration of Melatonin without a proper order. The resident refused the medication, and it was later discovered that the nurse involved had backdated entries in the medical record to justify the administration. The Medication Administration Record (MAR) showed discrepancies in the timing of the medication order and administration, and the nurse's documentation did not align with the actual events. The DON confirmed that the nurse had attempted to backdate the MAR entry and had documented the medication as given on an incorrect date. The facility's internal investigation revealed that the nurse involved, Nurse V, had a history of medication administration violations, including gross negligence and administering medication without proper orders. Despite being deemed competent in medication administration, Nurse V continued to demonstrate a lack of adherence to professional standards. The facility's policies on administering medications and documentation in medical records were not followed, leading to inaccurate and untimely documentation of medication administration.
Failure to Complete Yearly PASSAR and Level II Evaluations
Penalty
Summary
The facility failed to complete yearly PASSAR and Level II evaluations for three residents, resulting in a lack of yearly follow-up and documentation. Resident #602, admitted with diagnoses including Depression and Anxiety, had a comprehensive Level II evaluation due by March 11, 2022, but the most recent documentation was from May 17, 2023, without any other correspondence for 2023. Resident #604, with diagnoses including Dementia and Depression, had a PASSAR dated March 15, 2021, but no corresponding SAR (78) document. The Social Work Director (SWD) and Director of Nursing (DON) acknowledged the lack of up-to-date documentation and mentioned issues with access to the OBRA system as a contributing factor. Resident #603, with diagnoses including Major Depressive Disorder and Schizophrenia, had a PASSAR/Level II assessment dated October 28, 2022, but no documentation for 2023 and 2024. The SWD confirmed the absence of up-to-date assessments for this resident as well. The facility's PASSAR/Level II Screening Policy was requested but not provided during the exit interview.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 260 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Flushing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kith Haven | 4.8 mi | ★★★★★ | 15 | 0 |
| Villa At Beecher Place | 5.1 mi | ★★★★★ | 13 | 1 |
| Willowbrook Manor | 5.1 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Montrose Inc | 7.6 mi | ★★★★★ | 28 | 0 |
| Briarwood Nursing And Rehabilitation | 9.7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.