Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Delmar Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Staff did not demonstrate required competency in infection control precautions and insulin administration. A resident with herpes zoster eye disease had precaution signage posted, but a CNA entered and exited the room without proper hand hygiene or PPE and said they did not know the difference between Contact Precautions and EBP. An LPN could not identify which resident was on EBP or explain the difference between precautions, and another LPN was unable to demonstrate insulin KwikPen priming or describe shortened medication expiration dates.
A resident with severe cognitive impairment was left slumped in a wheelchair in a common area without staff interaction, and another resident needing toileting assistance reported that a CNA told them to urinate in their pants and soil themselves. Staff also were observed sitting off to the side of the dining room talking among themselves and using phones while residents ate, which the DON and an Activities Director described as disrespectful and a dignity concern.
PRN psychotropic medication order lacked required end date. A resident with schizophrenia, CKD, and iron deficiency anemia had a lorazepam order for anxiety without an end date, despite facility policy limiting PRN psychotropic orders to 14 days. The DON stated nurses should recognize the end-date requirement and correct pending orders, and the MD stated they relied on nurses to cue needed order changes.
Incomplete and Non-Individualized Care Plans: The facility failed to develop fully individualized care plans for three residents. One resident with dementia had an impaired cognition plan that lacked person-centered details and was not fully reflected on the Kardex. A resident with schizophrenia had a behavior plan that did not capture key behaviors such as yelling and screaming or include individualized approaches like male caregivers, lip balm, or specific preferred activities. Another resident with dysphagia and a history of aspiration pneumonia did not have an aspiration-related care plan, and staff assisting with meals were not aware of the resident’s aspiration history or feeding instructions.
Failure to Provide Ordered ADL Assistance: A resident with dysphagia and vision difficulty was not consistently given the feeding help documented in the care plan, another resident with aspiration history was left in bed for meals and staff did not know the resident’s feeding precautions, and a dependent resident was told to urinate or soil themselves instead of receiving timely toileting assistance. Observations, chart review, and staff interviews showed that the residents’ documented ADL needs were not followed as planned.
Failure to provide resident-specific activities: one resident with depression and severe cognitive impairment was not consistently offered or documented as receiving meaningful activities aligned with preferences, despite a care plan calling for bingo, coloring, crafts, and discussions. Another resident with cerebral palsy, developmental disorder, adult failure to thrive, and severe cognitive impairment had no activity care plan and no documented evidence of offered or provided activities; staff interviews and blank tracking records showed no routine one-to-one sensory programming, while activities were mainly held in the dining room and not on the units.
A resident with CHF, chronic respiratory failure with hypoxia, and pleural effusion was receiving continuous oxygen at 4 L/min by NC, but the portable oxygen tank was repeatedly found in the red empty zone during observations. The resident was seen with a non-productive cough, and an LPN replaced the tank only after the surveyor asked her to check it. The care plan called for monitoring for respiratory distress, and the facility policy required checking oxygen equipment and observing tolerance.
A resident with schizophrenia, CKD, and anemia had PRN narcotic orders for tramadol and morphine without end dates. The facility policy limited PRN psychotropic medications to 14 days, and the DON stated nurses should recognize and correct missing end dates in pending orders; the MD said they depended on nursing staff to cue them on needed order changes.
Medication labeling and controlled substance storage deficiencies were identified on two med carts and in one med room. Surveyors found multiple eye drops, inhalers, insulin pens, and an open lidocaine vial without open or expiration dates, and observed one narcotic lock box left open and another with a broken outer lock leaving the door ajar. An LPN said the open lock was left that way in a rush, while the DON stated shortened expiration dates were covered in orientation and should be posted in the med room.
Staff did not consistently follow posted Contact Precaution and EBP signage, perform proper hand hygiene, or understand the difference between the two precaution types. An LPN entered a room on EBP without PPE, CNAs entered and exited rooms without required PPE or hand hygiene, and staff used sanitizer when soap and water were indicated on signage. Residents with ESBL, C. difficile, herpes zoster, MRSA, and conjunctivitis were involved, and interviews showed confusion among nursing leadership and direct care staff about precaution status and infection control responsibilities.
The facility failed to meet the required staffing levels, leading to delays in resident care. From January 12 to January 17, 2025, the facility did not have enough RNs, LPNs, or CNAs to provide the mandated hours of care per resident. Residents and family members reported long wait times for assistance, particularly at night and on weekends. Staff interviews revealed struggles with inadequate staffing, and the facility faced challenges in recruiting due to pay structure issues.
A deficiency in nurse staffing was identified, with a resident experiencing delays in assistance due to insufficient nighttime staff. Discrepancies in reported staffing hours and reliance on agency staff were noted. The facility faces challenges in maintaining adequate staffing levels despite recruitment efforts.
The facility failed to maintain a safe environment to prevent infections, with staff not adhering to PPE and hand hygiene protocols. Observations included residents' medical equipment lying on the floor and shared personal care items not labeled. Interviews revealed inadequate staff education and monitoring of infection control practices.
The facility failed to uphold resident dignity and care standards, as evidenced by incidents involving four residents. A resident was unable to attend activities due to wheelchair access issues, while another felt like a burden due to staff unprofessionalism. A third resident experienced poor hygiene and delayed assistance, and a fourth had an uncovered urinary catheter drainage bag, violating privacy policies.
The facility failed to assess two residents for their ability to safely self-administer medications, as required by policy. Both residents were observed with inhalers on their overbed tables without documented assessments or physician orders. Interviews revealed that the inhalers were used under nurse supervision, but proper procedures for assessment and documentation were not followed.
The facility failed to maintain a safe and clean environment across all resident units, with issues such as scuffed handrails, insufficient hot water, and unclean bathrooms. Interviews revealed dissatisfaction with housekeeping and maintenance processes, and staff acknowledged the need for more consistent inspections. Despite ongoing projects to upgrade lighting and heating, immediate maintenance issues were not addressed, contributing to the deficiencies observed.
The facility failed to provide a means for residents to submit grievances anonymously, as required by regulations. Observations and interviews revealed no secured location for anonymous submissions, and staff were unaware of the process. Residents expressed fear of retaliation and difficulty in maintaining confidentiality. The facility's grievance policy was not effectively implemented, leading to a deficiency in honoring residents' rights.
A resident with a history of seizure disorder, morbid obesity, and bipolar disorder fell and sustained a serious injury while being assisted by a single CNA, contrary to their care plan requiring two staff members. The incident was not reported to the Department of Health as required by state regulations. Interviews revealed a lack of clarity and adherence to the reporting process, with the Administrator only reporting substantiated allegations, contrary to the regulation requiring all allegations to be reported within two hours.
A resident with a femur fracture and polysubstance abuse was discharged without proper planning or education. The facility failed to provide a discharge planning meeting, adequate education, or written notice of appeal rights. The discharge was due to insurance payment discontinuation, but the resident was not informed of their rights or the appeal process, leading to a deficiency in discharge procedures.
The facility failed to complete the required PASARR screenings for several residents with mental health diagnoses prior to admission. Incomplete or incorrect PASARR forms were found for residents with conditions such as major depressive disorder, PTSD, bipolar disorder, and schizophrenia. Staff interviews revealed a misunderstanding of the PASARR process, with some believing Level II evaluations were unnecessary based on admission reasons or corporate guidance.
The facility failed to develop comprehensive care plans for several residents, neglecting to include measurable objectives and timeframes for their medical and psychosocial needs. For example, a resident with benign prostatic hyperplasia and another with epilepsy lacked appropriate care plans. Interviews revealed that staff were not adequately trained in updating care plans, contributing to these deficiencies.
A resident with a history of falls and muscle weakness experienced multiple falls over several months, but the facility failed to update the resident's care plan to reflect these incidents. Despite the facility's policy requiring care plan revisions after significant changes, the care plan was not updated following the falls, as confirmed by the DON.
The facility failed to provide meaningful activities for two residents, impacting their quality of life. One resident, who enjoyed crocheting, did not receive requested supplies, while another found the offered activities demeaning and felt isolated. The facility's activity program lacked oversight, with the Activities Director resigning without notice and interim support in place.
Two residents in an LTC facility did not receive care according to professional standards. A resident with a surgical wound did not have daily dressing changes as ordered, and an LPN documented a change that was not performed. Another resident was ordered to self-perform oral suctioning, but the facility lacked guidelines for this, and there was no evidence of vital sign monitoring during the procedure.
The facility failed to maintain proper nutritional and hydration care for two residents. One resident experienced significant weight fluctuations and vomiting due to improper tube feeding management, while another did not receive adequate fluids, leading to signs of dehydration. Staff interviews revealed issues with communication, staffing, and adherence to care plans, contributing to these deficiencies.
The facility failed to administer oxygen therapy correctly for two residents. One resident received oxygen at 2.5 liters per minute instead of the prescribed 3 liters, and their oxygen saturation was not checked every shift. Another resident was given oxygen at 3 liters per minute instead of the ordered 2 liters. Nursing staff were unclear about monitoring responsibilities, leading to inconsistent checks and adjustments.
The facility did not ensure an RN was on duty for at least eight consecutive hours daily, as required. On several occasions, staffing records showed insufficient RN coverage, with no waivers in place. Interviews with staff highlighted ongoing staffing challenges and attempts to adjust schedules, but specific reasons for the deficiencies were not provided.
A facility's medication error rate reached 22.22% when a nurse crushed and administered medications to a resident without a physician's order. The resident, with conditions including dementia, received medications that should not have been altered, according to manufacturer guidelines. Miscommunication among nursing staff led to the error, despite facility policies requiring proper medication administration checks.
The facility failed to properly label and store medications, with multiple medication carts and rooms containing drugs without open or expiration dates, and expired or discontinued medications present. Personal items were improperly stored in medication areas, and narcotic boxes were not double locked. Staff interviews revealed a lack of awareness about medication expiration dates, despite training and competency checks.
The facility failed to maintain food safety and cleanliness standards in the main kitchen and resident unit nutrition rooms. Inspections revealed debris on kitchen equipment, broken seals on coolers, and ice build-up in the freezer. Nutrition rooms had rusted equipment, broken cabinets, and dirty surfaces. Interviews indicated unclear cleaning responsibilities and a need for improved diligence.
The facility failed to properly dispose of garbage and refuse, with two trash bins not being pest and rodent-proof due to unsecured doors and a missing drain plug. Despite daily clean-up efforts, garbage waste was found around the dumpsters. The Director of Maintenance acknowledged the issues and had contacted the vendor to address the missing drain plug, but a follow-up observation showed the problem persisted.
The facility was found to be inadequately administered, failing to effectively use its resources to ensure residents' well-being. Deficiencies included failures in maintaining resident dignity, assessing medication self-administration, and ensuring a safe environment. Issues with staffing, nursing services, care planning, and medication management were identified, along with infection control and food safety concerns. The facility also lacked a robust quality assurance program, potentially compromising resident health and safety.
A resident with a history of abdominal surgery had incomplete medical records due to a failure in documenting dressing changes accurately. The resident expressed concerns about the monitoring of their incision, and it was found that an LPN marked a dressing change as completed without performing it, due to being called away for an emergency.
The facility failed to maintain a QAPI committee with all required members, including the Medical Director and Infection Preventionist, who were absent from meetings. The Director of Nursing was also serving as the Nurse Educator and was unaware that the Infection Preventionist role could not be combined with their position. The Administrator admitted to oversight regarding the Medical Director's attendance. These issues hindered the committee's ability to coordinate and evaluate performance improvement projects effectively.
The facility did not designate a qualified Infection Preventionist from October 2024 to January 2025, leading to insufficient infection control practices. The Director of Nursing, also serving as the Nurse Educator, assumed the role but was unable to manage all responsibilities effectively due to multiple roles.
The facility did not ensure survey results were accessible to residents, as they were kept in an unmarked binder near the entrance with incomplete documentation. Residents were unaware of the location, and staff interviews confirmed the absence of proper signage and documentation.
A resident with multiple health conditions fell and broke their leg due to a Certified Nurse Aide not following the care plan, which required assistance from two or more staff members. The incident was not promptly reported, revealing gaps in the facility's incident documentation and reporting processes.
A facility failed to provide a written notice of the bed-hold policy to a resident and their representative during a hospital transfer. The resident, who was transferred due to respiratory distress, did not receive the required documentation, as confirmed by interviews with staff. The facility's policy mandates written notice at the time of transfer, but this was not documented, leading to a deficiency.
A resident with respiratory conditions was found with unsupervised medications in their shared room, contrary to the facility's policy requiring secure storage. The resident's inhalers were left accessible on the bedside table, despite the facility's rule against self-administration of medications.
A resident was prescribed Estrace Vaginal Cream without a documented indication for use, contrary to facility policy and professional standards. Interviews with staff revealed that medication orders should include the reason for use, but the provider and Medical Director indicated that this information was in clinical notes, not on the order itself.
A resident experienced significant medication errors when Alprazolam was administered at incorrect times, contrary to physician orders. The resident reported that a nurse left medication unattended, and records showed multiple instances of improper timing. Staff interviews revealed a lack of awareness and failure to notify the physician, leading to the deficiency.
A facility failed to ensure the safe storage of food brought by visitors, leading to a deficiency. A resident with multiple medical conditions had outside food improperly stored in their room. Staff interviews revealed a lack of adherence to the facility's policy, with family members not educated on safe food handling and staff unaware of the food's presence. The DON was unfamiliar with the policy specifics, expecting staff to address any food-related issues.
A resident with multiple medical conditions sustained a skin tear on their hand after returning to the facility late at night. Although the wound was treated and documented by nursing staff, there was no evidence of a thorough investigation into how the resident exited and re-entered the building or whether proper leave procedures were followed. Staff interviews confirmed that required investigative steps were not taken, resulting in a deficiency for failure to investigate the incident.
Staff Lacked Competency in Infection Control and Insulin Administration
Penalty
Summary
Licensed nurses and nurse aides were not consistently competent in infection control practices and medication administration. The facility assessment stated the resident population included dementia, diabetes, COPD, and CHF, and the facility policy required staff to receive in-service training on infection control, including standard and transmission-based precautions. The report also stated the facility had been without a nurse educator and that its tracking system for training was poor and did not capture who attended training or when it occurred. For Resident #63, who was admitted with rhabdomyolysis, herpes zoster eye disease, and COPD, the Minimum Data Set documented moderate cognitive impairment. During observations, a Contact Precaution sign was posted outside the resident’s room, and a CNA entered the room, delivered a meal tray, and exited without hand hygiene before going to another resident’s room. The CNA later stated they did not know the difference between Contact Precautions and Enhanced Barrier Precautions and had not followed the steps listed on the signage. In another observation, the CNA entered and exited the room labeled Contact Precautions without PPE and used hand sanitizer even though the signage indicated soap and water after contact with residents. The report also documented that staff did not understand precaution requirements and medication procedures. An LPN was unable to identify which resident in a shared room was on Enhanced Barrier Precautions and could not explain the difference between Contact Precautions and Enhanced Barrier Precautions. Multiple CNAs stated they did not know the difference between the two precautions, and one CNA was unsure whether infection control education was included in orientation. Another LPN was unaware of shortened medication expiration dates and could not demonstrate insulin KwikPen administration, stating they had never primed insulin pens and did not know about shortened expiration dates. The DON stated insulin administration and shortened expiration dates were reviewed during orientation, but the staff interviews and observations showed staff did not consistently demonstrate that knowledge.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for two residents. One resident with cerebral palsy, developmental disorder of scholastic skills, adult failure to thrive, and severe cognitive impairment was observed in a common area slumped over in a wheelchair and dozing for over 45 minutes without any staff interaction. The same resident was later observed lying in bed in a dark room, awake and chewing on a toy. A cognitively intact resident with diagnoses including a right acetabular fracture, type 2 diabetes, and cerebral infarction was documented as needing substantial to maximal assistance with toileting hygiene and assistance with toilet transfers. The resident stated that a CNA told them to urinate in their pants on more than one occasion, and the resident said this made them feel like a little kid because they knew when they needed to urinate and should not have to soil themselves. A family member also reported that the same CNA told the resident to soil themselves again over the weekend. During interviews, the CNA stated they told the resident they would come back and change them once they were finished with what they were doing rather than assisting at that time. An LPN stated that telling a resident to soil themselves would be unacceptable and a dignity concern. The DON stated the facility had received complaints about staff telling residents to soil themselves and that such statements made residents feel terrible and unimportant. In addition, during lunch observations, staff were seen talking among themselves and using their phones off to the side of the dining room while residents were eating, and no staff were observed sitting with residents during some meals.
PRN psychotropic medication order lacked required end date
Penalty
Summary
The facility did not ensure that an as needed psychotropic medication had an end date for one resident reviewed for unnecessary medications. Resident #10, who was admitted with schizophrenia, chronic kidney disease, and iron deficiency anemia, had a Minimum Data Set dated 2/9/2026 that documented the resident was understood, could understand others, and was cognitively intact. The physician's order dated 02/20/2026 documented lorazepam 2 milligrams per milliliter, give 0.5 milliliters by mouth every six hours as needed for anxiety, and the order did not include an end date. The facility policy titled Psychotropic Medications, reviewed 12/2025, stated that as needed orders for psychotropic medications, including anti-anxiety medications, are limited to 14 days. During interview, the DON stated nurses should be aware that as needed psychotropic and narcotic medications required a 14-day end date and that pending orders should be checked and corrected with the provider if necessary. The MD stated they depended on nurses to cue them for order changes and trusted nurses to know about required end dates for medications.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility did not ensure that comprehensive care plans were developed and implemented for three residents according to professional standards. The report states that the facility policy required individualized comprehensive care plans with measurable objectives, timetables, identified problem areas, risk factors, resident strengths, and interventions that reflected recognized standards of practice. Survey findings showed that the care plans for Residents #2, #6, and #111 did not fully reflect those requirements. Resident #2 had diagnoses including dementia, depression, and hip fracture, and the MDS documented severe cognitive impairment. The resident’s care plan for impaired cognition identified impaired cognition related to dementia and included interventions such as communicating with the resident or representative, engaging the resident in simple structured activities, presenting one thought or direction at a time, and providing a safe, clutter-free environment. However, the care plan did not identify what the structured activities were, and the interventions were not person-centered. The Kardex only documented the safe, clutter-free environment intervention, while the other listed interventions were not included. Resident #6 had diagnoses including schizophrenia, depression, and anxiety, and the MDS documented moderate cognitive impairment. The behavior care plan described symptoms including hallucinations, delusions, paranoia, anxiety, depressed mood, difficulty sleeping, agitation, displacement of anger, accusatorial comments, homicidal ideations, homicidal threats, and racial slurs. Interventions included psychoactive medications, snacks or drinks, preferred activities, psychiatric and psychology evaluations, redirection, preferred television shows, reorientation, calm staff approach, and emotional support. During observations, the resident was heard yelling, screaming, and using derogatory language, and staff noted the behavior calmed briefly when staff entered the room. The care plan did not include the resident’s yelling and screaming or the disruption to the environment, and it did not include the resident’s preference for male caregivers, use of lip balm as a redirection tool, or what the preferred activities and television shows were. Resident #111 had diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and encephalopathy, and the MDS documented the resident was cognitively intact. The resident’s care plans addressed self-care, mobility, and ADLs, including alternating solids and liquids, getting out of bed for meals, remaining upright after meals, and monitoring oxygen during oral intake. However, there was no documented aspiration-related care plan despite the resident’s history of aspiration pneumonia and aspiration precautions. During a meal observation, the resident remained in bed while being fed lunch, and the CNA assisting the resident was not aware of the resident’s aspiration history or feeding directives such as alternating liquids and solids.
Failure to Provide Ordered ADL Assistance
Penalty
Summary
The facility did not ensure that residents who were unable to perform activities of daily living received the necessary assistance with eating, positioning for meals, and toileting. The deficiency involved three residents who were dependent on staff for care and whose care plans included specific interventions for feeding, meal positioning, or toileting assistance. Survey observations, record review, and staff interviews showed that the documented care needs were not consistently carried out. Resident #4 had diagnoses including cerebral infarction, left-sided hemiplegia/hemiparesis, and dysphagia. The resident’s care plan documented dependence on staff for daily ADLs and included eating assistance. During one observation, the resident was in bed attempting to feed himself, but the breakfast tray was not directly in front of him and he was too shaky to use the fork effectively. During another observation, the resident was in bed with the tray in front of him, had eaten only part of the meal, and stated he had difficulty seeing. Staff entered the room to check whether he was finished, but no staff were observed providing cues or assistance during the observation period. Interviews with staff reflected conflicting understanding of the resident’s feeding needs, while the care plan and rehabilitation documentation indicated supervision/touching assistance or substantial assistance for eating. Resident #111 had diagnoses including pneumonitis due to inhalation of food and vomit, dysphagia, and encephalopathy. The resident’s care plan directed staff to encourage the resident out of bed for meals, keep the resident upright after meals, and provide dependent assistance with eating. Observations showed the resident eating lunch and dinner in bed, with the bed not fully upright during one meal and the resident slightly slouched during another. Staff assisting the resident stated they did not know the resident’s care plan details, including aspiration-related feeding interventions such as alternating solids and liquids, and one CNA stated they were not aware of any reason the resident needed to be out of bed for meals. Resident #130 had diagnoses including fracture of the right acetabulum, type 2 diabetes, and cerebral infarction, and was documented as dependent for toileting hygiene. A complaint and interviews described a CNA telling the resident to urinate or soil themselves because the staff member did not have time to assist with toileting. The resident and family member reported the statements made them feel degraded, and staff interviews confirmed that the resident should have been assisted with toileting rather than told to wait and soil themselves.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility did not ensure ongoing activities were provided to support residents’ interests and choices for two residents reviewed. The facility policy stated residents were to receive an ongoing program of group, individual, and independent activities based on comprehensive assessment, care plan, and preferences. However, the record and interviews showed that one resident with major depressive disorder, type 2 diabetes, and severe cognitive impairment was not consistently offered or provided meaningful activities aligned with stated interests, and another resident with cerebral palsy, developmental disorder of scholastic skills, adult failure to thrive, and severe cognitive impairment had no documented activity care plan and no documented evidence of offered or provided activities. For the first resident, the activity care plan stated the resident could express recreation and leisure preferences, enjoyed being around others, and was shy about initiating conversation. The plan included attending programs such as bingo, coloring, arts and crafts, and discussions, with interventions to assist with finding programs, introduce peers, escort to activities, and provide calendars. The only documented one-to-one visit was a progress note describing a brief visit with shared laughs and memories. After that, there was no documented evidence of activities attended or provided. Observations on multiple dates showed the resident sitting in common areas where no activities were present, and staff interviews indicated activities were usually held in the main dining room, with little or no activity offered on the unit. For the second resident, the record contained no comprehensive activity care plan and no documented evidence of activity participation. The resident was observed dozing in a wheelchair in a common area without staff interaction and later lying in bed while group activities were being prepared elsewhere. The Activities Director stated the resident had sensory visits two to three times per week, but the activity tracking record for the resident was blank, and the director stated there was no routine of sensory visits and that visits were provided ad-lib. Activity aides stated they had not done one-to-one sensory activities with the resident and were not aware of who did. The DON also stated the activities program had challenges and that more activities on the units were needed for residents who could not or did not go to the main dining room.
Empty Oxygen Tanks Not Monitored for Resident on Continuous Oxygen
Penalty
Summary
The facility did not ensure safe and appropriate respiratory care for Resident #43, who was admitted with unspecified diastolic congestive heart failure, chronic respiratory failure with hypoxia, and pleural effusion elsewhere classified. The resident’s Minimum Data Set dated 1/26/2026 documented that the resident usually could be understood and understood others with intact cognition. The facility policy on Oxygen Administration revised 5/2025 directed staff to check oxygen equipment to ensure it was in good working order and securely fastened, and to observe the resident upon setup and periodically thereafter to be sure oxygen was tolerated. During observations on 3/4/2026, Resident #43’s portable oxygen tank was noted to be in the red empty zone at 8:30 AM, and the resident was noted to have a non-productive cough. Later that day at 12:37 PM, the resident was in the dining room with the oxygen tank still in the red empty zone. On 3/8/2026 at 1:15 PM, the resident’s tank was again empty while the resident sat in a wheelchair in the common area, and an LPN replaced the tank after the surveyor asked her to check it. The MAR documented supplemental oxygen at 4 liters per minute via nasal cannula continuously, and on 3/8/2026 a new order was entered to check the oxygen tank level and replace the tank if less than 25% full every 2 hours for oxygen dependence. The care plan documented supplemental oxygen therapy and monitoring for signs and symptoms of respiratory distress.
PRN narcotic orders lacked required end dates
Penalty
Summary
The facility did not ensure that as needed psychoactive medications had an end date for one resident reviewed for unnecessary medications. For Resident #10, the record showed diagnoses of schizophrenia, chronic kidney disease, and iron deficiency anemia, and the Minimum Data Set dated 2/9/2026 documented the resident was understood, could understand others, and was cognitively intact. The facility policy titled Psychotropic Medications stated that as needed orders for psychotropic medications, including anti-psychotic, anti-anxiety, anti-depressant, and hypnotic medications, are limited to 14 days. The physician's order dated 02/18/2026 documented tramadol HCl 25 mg by mouth every 12 hours as needed for pain with no end date, and the physician's order dated 02/20/2026 documented morphine sulfate solution 20 mg/mL, 0.25 mL sublingually every two hours as needed for pain with no end date. During interview, the DON stated nurses should be aware that as needed psychotropic and narcotic medications required a 14-day end date and should check pending orders and correct them with the provider if necessary. The MD stated they depended on the nurses to cue them for any order changes and trusted the nurses to know about required end dates for medications.
Medication Labeling and Controlled Substance Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles on two medication carts and in one medication room. On the Sunflower Unit Medication Cart A, surveyors observed one bottle of Artificial Tears, one bottle of Brimonidine 1% eye drops, and one Albuterol HFA inhaler without open or expiration dates. On the [NAME] Unit Cart B, surveyors observed one Lantus insulin pen, one open Lidocaine vial, one Liraglutide insulin pen, and one fluticasone inhaler without open or expiration dates. The facility’s Medication Storage policy stated that injectable multi-dose vial preparations must be dated and initialed upon opening and that open vials without dates must be discarded. In the Sunflower/Daffodil AD unit medication room, one outer lock of a narcotic lock box was left open and another narcotic lock box outer lock was broken, leaving the door ajar. During interviews, an LPN stated the open narcotic box lock had been left open because they were in a rush, and another LPN stated maintenance had previously been contacted about the broken lock. A DON stated insulin administration and shortened expiration dates were covered during nurse orientation and that the list of medications with shortened expiration dates should be posted in the medication room.
Infection control precautions and hand hygiene were not consistently followed
Penalty
Summary
The facility did not maintain an infection prevention and control program that ensured staff followed posted Contact Precaution and Enhanced Barrier Precaution signage, performed appropriate hand hygiene, and understood the differences between the two precaution types. The report identified five residents affected by these issues: residents with ESBL, C. difficile infection, herpes zoster of the eye, MRSA, and conjunctivitis, along with associated care plans and precaution orders that were not consistently followed by staff. For one resident with ESBL and diabetes, a Contact Precaution sign was posted even though the resident was intended to be on Enhanced Barrier Precautions. An LPN entered the room without PPE while setting up the tray and assisting with the television, and stated the resident was on Enhanced Barrier Precautions and that the posted sign had not been noticed. For another resident with C. difficile, the care plan documented Contact Precautions, but an Enhanced Barrier Precaution sign was posted outside the room. The unit manager stated the resident was no longer infectious and that the physician orders and care plan should have been updated to reflect the current precaution status. For a resident with herpes zoster of the eye and an active wound, a CNA entered the room, delivered a meal tray, and exited without hand hygiene; the CNA later entered and exited the room labeled Contact Precautions without PPE and used hand sanitizer instead of soap and water despite the posted instructions. For a resident with MRSA and a colostomy on Enhanced Barrier Precautions, an LPN and a CNA provided colostomy care, exited the room wearing gloves, and did not perform hand hygiene; the LPN stated they had not been educated on the difference between Contact Precautions and Enhanced Barrier Precautions. For a resident with conjunctivitis on Contact Precautions, a CNA entered the room, used hand sanitizer, delivered a meal tray, exited, removed gloves, and again used hand sanitizer without wearing the additional PPE indicated on the signage, stating precautions were only required during direct care. Additional interviews showed multiple staff members, including CNAs, housekeeping leadership, the infection control nurse, the DON, and the administrator, gave inconsistent or uncertain descriptions of precaution requirements and infection control oversight.
Staffing Deficiency in Nursing Home
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as required by New York State Public Health Law and Regulations. From January 12, 2025, to January 17, 2025, the facility did not meet the minimum staffing standards, which require 3.5 hours of care per resident per day, with at least 2.2 hours provided by a certified nurse aide and 1.1 hours by a licensed nurse. The facility's staffing records showed that the required number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) were not scheduled on several days, and the number of Certified Nurse Aides (CNAs) was consistently below the required levels. Observations and interviews during the survey revealed that residents experienced delays in receiving care, particularly during nighttime and weekends. Residents reported that call lights could take up to an hour to be answered, and family members expressed concerns about the lack of staff, leading them to provide personal care themselves. Staff interviews indicated that the facility struggled with staffing, with some staff members working alone and unable to complete their duties effectively. The facility's staffing coordinator and Director of Nursing acknowledged the staffing challenges, citing issues such as inadequate pay structures and difficulties in recruiting staff. The facility attempted to address these issues by using travel nurses and borrowing staff from other corporate facilities, but these measures were insufficient to meet the required staffing levels. The facility's administrator also noted efforts to recruit staff, with corporate assistance beginning in January 2025.
Staffing Deficiency and Delayed Resident Assistance
Penalty
Summary
The report highlights a deficiency in sufficient and competent nurse staffing at the facility. An incident was noted where a resident's oxygen cannula was not properly placed in their nose, and the resident experienced delays in receiving assistance, particularly at night when only one staff member was on duty. This situation indicates a lack of adequate staffing to meet the needs of residents, especially during nighttime hours. Additionally, there were issues with the accuracy of reported staffing hours, as discrepancies were found between the hours reported and the actual hours worked by staff, including instances where no Registered Nurse (RN) was present. The staffing coordinator, Deprincess Golden, has been proactive in scheduling and coordinating staff to meet the required hours, but challenges remain. The facility relies on a mix of local and out-of-state agency staff, as well as travelers, to fill staffing gaps. Despite efforts to recruit and retain staff, including offering sign-on and referral bonuses and attending job fairs, the facility continues to face difficulties in maintaining consistent and adequate staffing levels. The Director of Nursing (DON) occasionally takes on assignments, which is not ideal, and there is a reliance on borrowing staff from sister facilities as a last resort.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable diseases and infections. Observations revealed that staff did not consistently adhere to infection prevention and control practices, such as putting on and taking off personal protective equipment (PPE) or practicing hand hygiene when entering and exiting residents' rooms with transmission and enhanced barrier precautions. Additionally, personal care items in shared bathrooms were not labeled or designated for specific residents, increasing the risk of cross-contamination. Specific incidents included Resident #218's oxygen tubing lying on the floor and not being labeled, and Resident #17's urinary catheter drainage bag was observed lying on the floor. Resident #364's urinary catheter care was not maintained as ordered, with the catheter bag also lying on the floor. These observations indicate a lack of adherence to the facility's infection prevention and control policies, which require that catheter drainage bags not touch the floor and that standard precautions be followed when handling or manipulating drainage systems. Interviews with staff and residents further highlighted deficiencies in infection control practices. Resident #364 reported that staff did not wear PPE when checking their catheter and that they were not educated on how to clean it. Certified Nurse Aides were observed not performing hand hygiene or wearing PPE when required, and a Licensed Practical Nurse was seen wearing an N95 mask incorrectly. The Director of Nursing acknowledged the need for handwashing and PPE use but admitted that re-education was informal and not documented, relying on unit managers and supervisors to monitor compliance.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by several incidents involving four residents. Resident #13 was unable to attend activities of their choice because their wheelchair could not fit through the interior doorways to the activities room, leading to feelings of exclusion. Despite expressing a desire to participate in activities like bingo, the resident was only able to access the activities room through an exterior route, which was not feasible in poor weather conditions. This situation was acknowledged by staff, who noted the difficulty in maneuvering the wheelchair through a 'rut' on the path. Resident #17 reported feeling like a burden due to staff unprofessionalism, which made them uncomfortable asking for assistance with bowel movements. The resident also noted that staff often discussed personal matters inappropriately, indicating a need for in-service training on professionalism and dignity. The facility primarily employed agency staff, and there was uncertainty about the orientation process for these staff members. Resident #62 was observed with matted, greasy hair and a malodorous presence, and expressed frustration over the delayed removal of meal trays. The resident also experienced an incident where they were locked out of a shared bathroom, resulting in incontinence while waiting for staff assistance. This incident highlighted issues with call light response times and staff attitudes, as one CNA expressed that residents should be grateful for the care provided. Additionally, Resident #364's urinary catheter drainage bag was not covered with a privacy pouch, contrary to facility policy, and was observed lying on the floor, raising concerns about adherence to dignity and privacy standards.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medication when clinically appropriate. This deficiency was identified during a recertification survey for two residents who were observed with inhalers on their overbed tables without documented assessments or physician orders for self-administration. The facility's policy requires an assessment of residents' mental and physical capabilities to self-administer medications, but this was not followed for the residents in question. Resident #13, who has diagnoses including acute and chronic respiratory failure, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, was observed with Albuterol and Trelegy inhalers on their overbed table. Despite being cognitively intact and able to communicate effectively, there was no documented evidence of an assessment for self-administration capability or a physician order allowing self-administration. Interviews with the resident and nursing staff revealed that the inhalers were left at the bedside and used under nurse supervision, contrary to facility policy. Similarly, Resident #22, with diagnoses of diabetes mellitus, chronic obstructive pulmonary disease, and anxiety disorder, was observed with an Albuterol inhaler on their overbed table. The resident reported using the inhaler as needed, with the nurse providing it from the medication cart. However, there was no documented assessment or physician order for self-administration. Interviews with nursing staff and the Director of Nursing confirmed that no residents were officially allowed to self-administer medications, and proper procedures for assessment and documentation were not followed.
Deficiencies in Facility Maintenance and Housekeeping
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across all five resident units, as observed during a recertification survey. Handrails throughout Units A, B, C, D, and G were found to be scuffed, nicked, and scraped, exposing untreated wood. In Unit A, there was insufficient hot water in residents' rooms, and a bathroom light was dimly working. Additionally, a door handle was sticking, preventing easy access. In Unit B, residents reported difficulty regulating room temperature, and in Unit C, shared bathrooms had significant buildup around toilets and in corners. Unit D had a room that was cluttered with equipment and had sticky floors, while Unit G had a valance coming off the window holder and exposed radiator tubing. Interviews with staff and family members highlighted further issues. A family representative noted persistent odors from bags left in hallways and expressed dissatisfaction with the cleanliness of floors. The Director of Housekeeping claimed that rooms were cleaned daily, focusing on high-touch areas, but acknowledged the need for more consistent spot inspections. The Director of Maintenance explained that damage to handrails and other areas was due to residents' actions and that no work orders had been received for these issues. They also mentioned ongoing projects to replace lighting and heating units but admitted that some problems, like exposed radiator piping, had not been addressed. The facility's policy required staff to complete maintenance and housekeeping work orders when issues were identified, but this process was not effectively implemented. The Director of Maintenance was aware of the handrail damage but had not taken corrective action. Additionally, the facility was working with an outside contractor to upgrade lighting, but this had not yet reached resident rooms. The lack of immediate action and communication regarding maintenance issues contributed to the deficiencies observed during the survey.
Deficiency in Grievance Process for Anonymous Submissions
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal, as required by regulations. During a recertification survey, it was observed that there was no designated location for residents to submit grievances anonymously, such as a secured box or drop area. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse, revealed a lack of awareness about the process for submitting anonymous grievances. The Director of Social Work, who serves as the Grievance Officer, confirmed that while grievance forms were available, there was no mechanism for anonymous submission. Residents expressed concerns during a Resident Council meeting, indicating fear of retaliation and difficulty in maintaining confidentiality when filing grievances. The Administrator acknowledged that there was no formal process for anonymous grievances, suggesting informal methods such as slipping forms under doors. The facility's grievance policy, although documented, was not effectively implemented to allow for anonymous submissions, leading to a deficiency in honoring residents' rights to voice grievances without fear.
Failure to Report Resident Fall and Injury
Penalty
Summary
The facility failed to report an incident involving Resident #40, who fell and sustained a serious injury, in accordance with state regulations. Resident #40, who has a history of seizure disorder, morbid obesity, and bipolar disorder, required assistance from two or more staff members for personal care tasks as per their Comprehensive Care Plan. However, during an incident on October 1, 2024, the resident fell out of bed while being assisted by a single Certified Nurse Aide, resulting in a right distal femur fracture. The incident was not reported to the Department of Health as required by the facility's policy and state regulations. The facility's policy mandates that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, must be reported immediately, but not later than two hours after the allegation if it involves abuse or results in serious bodily injury. Despite this, there was no documented evidence that the incident involving Resident #40 was reported to the Department of Health. Interviews with staff revealed a lack of clarity and adherence to the reporting process, with some staff members unaware of the requirement to document incidents in the medical chart or report them to the Department of Health. The Director of Nursing and the Administrator were identified as the individuals responsible for investigating and reporting such incidents. However, interviews indicated that the Administrator only reported allegations of abuse if they were substantiated within two hours, which contradicts the regulation that requires all allegations to be reported within that timeframe. This failure to report the incident involving Resident #40 highlights a significant deficiency in the facility's adherence to state regulations and its own policies regarding the reporting of abuse, neglect, and mistreatment.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure an appropriate and safe discharge for a resident, identified as Resident #362, who was admitted with a fracture of the femur, polysubstance abuse, and unspecified osteoarthritis. The resident was cognitively intact and required skilled physical therapy to improve functional mobility and safety. Despite reaching maximum potential in physical therapy, the resident expressed feeling unprepared for discharge and did not receive adequate discharge education or written notice of their rights to appeal the decision. The facility's policy required coordination of necessary services for a safe transition to the community, including providing written notice of discharge and appeal rights. However, the resident did not have a discharge planning meeting with Social Work, and there was no documented evidence of education or notification of the appeal process. The resident was informed by a nurse that leaving the facility would result in signing out Against Medical Advice, potentially affecting insurance coverage. The Social Worker later informed the resident of the discharge, but no appeal information was documented. Interviews revealed that the discharge was prompted by a notice of discontinuation of payment from the resident's insurance, which was not communicated effectively to the resident. The Social Work Director confirmed the insurance issue as the reason for discharge, but did not report offering an appeal. The resident signed the discharge notice without understanding their rights or the appeal process, leading to a deficiency in the facility's discharge procedures.
Incomplete PASARR Screening for Residents
Penalty
Summary
The facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission, as required by the Preadmission Screening and Resident Review (PASARR) process. Specifically, the PASARR forms for seven residents were incomplete, with missing or incorrect information regarding their mental health diagnoses. For instance, Resident #17, who was diagnosed with major depressive disorder, PTSD, and anxiety disorder, had a Level I PASARR form that incorrectly documented no serious mental illness and lacked a Level II referral. Similarly, Resident #40's PASARR form was incomplete, with unanswered questions regarding mental illness and developmental disability. Resident #60, who had diagnoses of bipolar disorder, schizophrenia, and dementia, also had a Level I PASARR form that incorrectly documented no serious mental illness and lacked a Level II referral. The Director of Social Work stated that a Level II form was not required for Resident #60 because they were admitted for rehabilitation, despite the surveyor pointing out that the resident could potentially qualify for a Level II evaluation based on their diagnoses. The facility's Corporate Social Worker had advised that a Level II evaluation was unnecessary, which was echoed by the Corporate Registered Nurse, who stated that the residents did not have a qualifying stay for mental illness. Interviews with facility staff revealed a lack of understanding and compliance with the PASARR process. The Director of Social Work and the Corporate Registered Nurse both indicated that they believed Level II evaluations were not required based on the residents' admission reasons or corporate guidance. However, the Minimum Data Set Coordinator stated that a Level II evaluation should be conducted whenever there is a qualifying mental illness diagnosis. This discrepancy in understanding and execution of the PASARR process led to the deficiency identified during the survey.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for several residents, as identified during a recertification survey and an abbreviated survey. Specifically, the care plans for seven residents did not address their medical, nursing, and psychosocial needs. For instance, one resident with diagnoses of benign prostatic hyperplasia, obstructive uropathy, tremors, generalized anxiety disorder, and constipation did not have a care plan that included these conditions. Another resident with epilepsy and seizures also lacked a care plan addressing these diagnoses. The report highlights that the facility's policy required comprehensive care plans to be developed within seven days of completing the Minimum Data Assessment, incorporating measurable objectives and timeframes. However, this was not adhered to, as evidenced by the lack of care plans for specific medical conditions and treatments. For example, a resident who was prescribed hormone cream and another who required thigh-high stockings for deep vein thrombosis prevention did not have corresponding care plans. Interviews with facility staff revealed gaps in the care planning process. A registered nurse admitted to participating in care plan meetings but was not familiar with updating care plans. The Director of Nursing stated that registered nurses were responsible for updating or creating care plans, but there was a lack of clarity and training on how to do so effectively. This lack of training and oversight contributed to the deficiencies observed in the care planning process.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised based on changing needs for a resident who experienced multiple falls. Specifically, the care plan for a resident with diagnoses of muscle weakness, pain, and a history of falls was not updated following several incidents of falls in October, November, and December 2024. Despite the resident being cognitively intact and able to communicate effectively, the care plan was not revised to reflect the falls documented in the incident reports. The facility's policy required that care plans be updated when there was a significant change in a resident's condition, such as falls. However, the care plan for the resident was only revised on 10/30/2024 and did not include updates for the subsequent falls. During an interview, the Director of Nursing stated that falls were reviewed the day after they occurred to ensure appropriate interventions were implemented, but this was not reflected in the care plan updates.
Deficiency in Resident Activity Provision
Penalty
Summary
The facility failed to ensure the provision of meaningful and accommodating activities for two residents, which impacted their quality of life. Resident #22, who was cognitively intact and diagnosed with diabetes mellitus, chronic obstructive pulmonary disease, and anxiety disorder, expressed disinterest in the activities offered and reported feeling bored. Despite requesting yarn for crocheting, an activity they enjoyed, the supplies were not provided, leading to dissatisfaction and a lack of engagement in activities. Resident #75, also cognitively intact and diagnosed with cerebral infarction, bipolar disorder, and morbid obesity, expressed feelings of loneliness and isolation. Their care plan included interventions to encourage social engagement and participation in activities, but they reported that the activities offered, such as coloring, felt demeaning. The resident's mood was affected by the recent death of their cat, and they preferred playing games on their computer, which was not adequately addressed by the facility's activity program. The facility's policy required an ongoing program to support residents' choices of activities, but the Corporate Recreation Director was unaware of Resident #22's request for yarn and could not provide documentation of activity attendance or one-on-one activities. The Activities Director had resigned without notice, and interim support was being provided, indicating a lack of continuity and oversight in the activities program.
Deficiencies in Resident Care and Treatment Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents. Resident #34, who was admitted with a disrupted surgical wound, did not receive daily dressing changes as ordered by the physician. Observations revealed that the dressing was not changed for several days, and the resident expressed concerns about the lack of monitoring by the nursing staff. The Treatment Administration Record indicated that a dressing change was documented as completed by an LPN, but the dressing was not actually changed, leading to a discrepancy in care. Resident #211, diagnosed with cardiomyopathy and cancer, was ordered to self-perform oral suctioning for excessive oral mucus. However, the facility's policy did not include guidelines for self-performed oral suctioning, and there was no documented evidence that the resident's vital signs and respiratory status were monitored during the procedure. The Director of Nursing acknowledged that residents permitted to self-suction should have a doctor's order and be assessed by nursing staff, with intermittent monitoring to ensure proper procedure. The deficiencies highlight a lack of adherence to physician orders and professional standards of practice, resulting in inadequate care for the residents. The facility's failure to ensure proper documentation and monitoring of treatments contributed to the deficiencies observed during the survey.
Deficiencies in Nutritional and Hydration Care for Residents
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and hydration for two residents, leading to deficiencies in their care. Resident #51, who was admitted with diagnoses including gastrostomy malfunction and protein-calorie malnutrition, experienced significant weight fluctuations and episodes of vomiting due to improper monitoring and adjustment of tube feedings. The facility did not consistently document weekly weights as ordered, and there was a lack of communication and follow-up between the dietitian and nursing staff regarding the resident's nutritional needs and symptoms. Resident #364, admitted with conditions such as influenza virus A and acidosis, did not receive adequate fluid intake to maintain proper hydration. Despite the facility's policy on hydration, there was no clear documentation of the resident's specific fluid needs, and staff interviews revealed a lack of awareness and adherence to providing extra fluids as required. The resident reported having to repeatedly request fluids, and observations noted signs of dehydration, such as dry skin and mucous membranes. The deficiencies in care for both residents were compounded by inadequate staffing and communication issues within the facility. Staff interviews indicated that weights and fluid monitoring were not consistently prioritized, and there was a disconnect between dietary assessments and the implementation of care plans. These failures contributed to the residents' compromised nutritional and hydration status, highlighting significant lapses in the facility's ability to meet their care needs.
Inadequate Oxygen Therapy Administration for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during the Recertification Survey. Resident #13, who was admitted with acute and chronic respiratory failure, was found to have their oxygen therapy administered incorrectly. The physician's order specified that the resident should receive oxygen at 3 liters per minute, but observations revealed that the oxygen was set at 2.5 liters per minute. Additionally, the oxygen saturation levels were not consistently checked every shift as required, with several dates missing the necessary checks. Resident #22, who was admitted with chronic obstructive pulmonary disease and other conditions, also experienced improper administration of oxygen therapy. The physician's order indicated that the resident should receive oxygen at 2 liters per minute, but observations showed that the oxygen was set at 3 liters per minute. The resident reported that they had always been on 3 liters per minute, and the Physical Therapy Aide confirmed this setting during a session. However, the Licensed Practical Nurse later identified the discrepancy and noted that the oxygen should have been set at 2 liters per minute. Interviews with nursing staff revealed a lack of consistent monitoring and adjustment of oxygen levels according to physician orders. Licensed Practical Nurses and Registered Nurses were responsible for checking and adjusting oxygen levels, but there was confusion about the frequency of these checks. The Director of Nursing confirmed that oxygen saturation should be checked every shift, but the records indicated that this was not consistently done for Resident #13. Similarly, the Director of Rehabilitation acknowledged that oxygen should be applied by nursing staff, but the Physical Therapy Aide had adjusted the oxygen settings for Resident #22.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required by regulations. Specifically, the facility's staffing records revealed that on multiple occasions between July 4, 2024, and September 28, 2024, there was no RN scheduled for the required eight consecutive hours. On July 4, 2024, an RN was present for only 7.5 hours, and on July 14, 2024, there was no RN scheduled for the full eight hours. On September 20, 2024, an RN was present for 6.75 hours, but the Director of Nursing (DON) was also in the facility for eight hours that day. The facility did not have any staffing waivers in place to justify these deficiencies. Interviews with facility staff revealed that the staffing coordinator was aware of the scheduling issues and attempted to address them by adjusting staff hours. However, the coordinator could not provide explanations for the specific dates when the RN coverage was insufficient. The Director of Nursing, who was not in the position during the time of the deficiencies, acknowledged the ongoing staffing challenges. The facility administrator also confirmed the difficulties in maintaining adequate staffing levels but was unable to provide details about the specific incidents of non-compliance. The facility's failure to maintain the required RN coverage was not addressed by any corrective actions or waivers at the time of the survey.
Medication Error Rate Exceeds 5% Due to Improper Administration
Penalty
Summary
The facility failed to ensure its medication error rate did not exceed 5%, resulting in a 22.22% error rate during a medication pass observation. This deficiency was identified when a registered nurse crushed and administered medications to a resident without a physician's order to do so. The resident, who was admitted with diagnoses including muscle weakness, depression, and dementia, was observed receiving crushed medications that were not supposed to be altered, according to manufacturer recommendations. The medications included Eliquis, Metoprolol Tartrate, Lotrel, Calcium Vitamin D3, Omeprazole, and Tradjenta, none of which had orders to be crushed in the Medication Administration Record. The error occurred despite the facility's policy requiring medications to be administered as per orders and checked three times for accuracy. Interviews revealed a miscommunication between nursing staff regarding the administration route, with one nurse advising another to crush the medications, contrary to the facility's policy and the manufacturer's instructions. The Director of Nursing confirmed that there should have been a physician's order for crushing medications and that medications not suitable for crushing should not have been prescribed without an alternative order.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that multiple medication carts and rooms contained medications without open or expiration dates, including albuterol inhalers, insulin vials, and nasal sprays. Additionally, expired and discontinued medications were found in the medication carts and refrigerators. Personal items such as a telephone charger and clothing were improperly stored in medication areas, and narcotic boxes were not double locked as required. Interviews with nursing staff revealed a lack of awareness regarding the labeling and expiration of medications after opening. A Registered Nurse and a Licensed Practical Nurse admitted to being unaware of the shortened expiration dates for certain medications. The Director of Nursing stated that it was the responsibility of the medication nurse to maintain the cleanliness and orderliness of the medication cart, and that all nurses received training and competency checks for medication administration. However, the survey findings indicated that these procedures were not consistently followed, leading to the observed deficiencies.
Food Safety and Cleanliness Deficiencies in Kitchen and Nutrition Rooms
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in multiple areas, including the main kitchen and resident unit nutrition rooms. During the initial inspection, several issues were observed, such as a rolling toaster and meat slicer with significant debris, broken seals on coolers, and a walk-in freezer with ice build-up preventing the door from closing properly. Additionally, the kitchen floor was dirty, and the Accutemp steamer had dirt and debris. Follow-up inspections revealed persistent issues, including wet and improperly stored pots and pans, a rolling toaster with debris, and a meat slicer with debris. The chemical sanitizer concentration in the three-sink system was also found to be higher than the recommended range. In the resident unit nutrition rooms, further deficiencies were noted. The G unit nutrition room had an out-of-service ice machine that was rusted and potentially hazardous, with broken cabinet doors and dirty counters. The B/C unit's nutrition room had similar issues with broken cabinet doors and dirty counters, while the A/D unit's nutrition room had dirty counters and door seals on the refrigerator and freezer. Interviews with the Director of Food Services and the Director of Housekeeping revealed a lack of clarity regarding cleaning responsibilities and acknowledgment of the need for improved diligence in maintaining cleanliness and equipment functionality.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed during a recertification survey. Two out of three trash bins were not pest and rodent-proof, with the doors not fully closed and the drain plug unsecured. Specifically, garbage waste was found around the dumpsters, with the right dumpster missing a drain plug and the left dumpster's side door left open. During an interview, the Director of Maintenance acknowledged responsibility for the dumpsters and the surrounding area, noting that despite daily clean-up efforts, refuse continued to litter the ground. They also confirmed awareness of the missing drain plug and had contacted the vendor to address it. A follow-up observation revealed the side door of the dumpster was still open, which the Director of Maintenance had to close manually, indicating a need for better awareness among staff to ensure the doors are closed after disposing of garbage.
Inadequate Administration and Resource Utilization
Penalty
Summary
The facility was found to be inadequately administered, failing to effectively use its resources to ensure the highest practicable well-being of its residents. This was determined during a recertification survey, which included observations, interviews, and reviews of various records and reports. The administration's lack of effective oversight and planning was evident in multiple areas, affecting all 39 residents sampled. These deficiencies included failures in maintaining resident dignity, assessing residents' ability to self-administer medications, and ensuring a safe, clean, and homelike environment. The survey identified numerous specific regulatory failures, such as the facility's inability to provide sufficient staffing, competent nursing services, and a comprehensive person-centered care plan for each resident. Additionally, the facility failed to ensure residents were free from abuse and neglect, report injuries from unknown sources, and provide safe and appropriate discharges. There were also significant issues with medication management, including unnecessary medications, medication errors, and improper storage of drugs and biologicals. Further deficiencies were noted in the facility's infection control practices, food service safety standards, and the completeness and accuracy of medical records. The facility also lacked a robust quality assurance program, as evidenced by the administrator's admission of system failures and attempts to correct them. These widespread deficiencies highlight the facility's failure to meet professional standards and regulatory requirements, potentially compromising the health and safety of all residents.
Incomplete Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for a resident, as evidenced by an incomplete Treatment Administration Record. The resident, who was cognitively intact, had a history of abdominal surgery with complications and expressed concerns about the monitoring of their incision. An observation revealed that the resident's abdominal dressing had not been changed as per the documented schedule, with the dressing dated two days prior to the observation. The deficiency was further highlighted during interviews, where it was revealed that a Licensed Practical Nurse (LPN) had documented the completion of the dressing change on a specific date, but the procedure was not performed. The LPN admitted to marking the treatment as done with the intention of returning to complete it, but was called away for an emergency. The Director of Nursing confirmed the discrepancy and took disciplinary action against the LPN upon discovering the issue.
Failure to Maintain Required QAPI Committee Members
Penalty
Summary
The facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee with the participation of all required members, including the Director of Nursing, Medical Director or designee, Administrator, and Infection Preventionist. The facility's QAPI plan outlined that the committee should meet monthly and include various key personnel, but a review of meeting attendance records from July 2024 through December 2024 revealed that the Medical Director or designee did not attend any meetings, and the Infection Preventionist was absent from all meetings. This lack of participation hindered the committee's ability to coordinate and evaluate performance improvement projects effectively. Interviews with facility staff revealed further issues contributing to the deficiency. The Director of Nursing, who was also serving as the Nurse Educator, stated that there had been no one available to fulfill the role of Infection Preventionist, and they were attempting to promote a nurse to the Assistant Director of Nursing role, assuming the nurse had the necessary certification. The Administrator admitted to being unaware that the Infection Preventionist role could not be combined with the Director of Nursing role and acknowledged that the Medical Director's absence from the meetings was due to a failure to sign in, despite attending. These oversights and misunderstandings contributed to the facility's failure to maintain a properly functioning QAPI committee, as required by regulations.
Failure to Designate Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the Infection Prevention and Control Program from October 2024 to January 2025. This deficiency was identified during a recertification survey, where it was observed that the facility did not have a designated individual fulfilling the role of Infection Preventionist. The Director of Nursing, who was also serving as the Nurse Educator, stated that they had assumed the role of Infection Preventionist but were unable to effectively manage all responsibilities due to their multiple roles. This lack of a dedicated Infection Preventionist led to insufficient infection control practices among the staff. The facility's policy on Antibiotic Stewardship, revised in July 2024, indicated that the Infection Preventionist should oversee the program with input from the Medical Director, Consultant Pharmacist, Director of Nurses, and Administrator. However, the absence of a designated Infection Preventionist meant that these responsibilities were not adequately fulfilled. The Director of Nursing acknowledged the challenge of managing infection control duties alongside their other responsibilities, indicating a gap in the facility's infection prevention and control measures.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent Federal/State survey were posted in a location that was easily accessible to residents, visitors, and other individuals. During a resident council meeting, four residents expressed that they were unaware of where the Department of Health Survey results were located. An observation revealed that the survey results were kept in a black binder near the entrance area, but there was no prominent sign indicating the contents of the binder. Additionally, the binder contained incomplete documentation regarding survey results from the past three years. Interviews with facility staff further highlighted the deficiency. A receptionist stated that reports regarding survey results were sent directly to the Administrator and were not kept at the front desk. The receptionist was unaware of the location of the survey results and confirmed the absence of a sign indicating their availability. The Administrator acknowledged that a sign indicating the availability of survey results had been removed and stated that they would replace it. The Administrator also admitted that the binder lacked survey results for specific dates, which they intended to rectify.
Neglect Leads to Resident Injury Due to Care Plan Violation
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall and injury. A Certified Nurse Aide did not adhere to the resident's comprehensive care plan while providing personal care, leading to the resident falling from their bed and sustaining a broken leg. The resident, who had a history of seizure disorder, morbid obesity, and bipolar disorder, required significant assistance with activities of daily living and was dependent on two or more staff members for tasks such as rolling in bed and personal hygiene. The incident occurred when the resident was being assisted by a single Certified Nurse Aide, contrary to the care plan's requirement for assistance from two or more staff members. During the care, the resident rolled too close to the edge of the bed and fell, resulting in a right distal femur fracture. The resident was on a blood thinner, Eliquis, and had additional injuries, including a head strike and a bleeding toe laceration, necessitating hospital evaluation. Interviews with facility staff revealed gaps in incident reporting and documentation. The Director of Nursing and Administrator were responsible for reporting incidents to the Department of Health, but there was inconsistency in how incidents were documented and reported. Staff were educated on abuse and neglect annually, but the incident highlighted a failure to follow the care plan and report the incident promptly, as required by facility policy and regulations.
Failure to Provide Written Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident and their representative during a transfer to the hospital. Specifically, the deficiency involved a resident who was transferred to the hospital due to respiratory distress. The facility's policy required that a written notice specifying the duration of the bed-hold policy be provided at the time of transfer, but there was no documented evidence that this notice was given to the resident or their representative. During interviews, it was revealed that the nurse responsible for the transfer did not follow up on the bed-hold issue after notifying the family verbally. The Director of Nursing outlined the expected procedures for hospital transfers, which included notifying the family and providing necessary paperwork, but the written notice of the bed-hold policy was not part of the documented process. This oversight led to the deficiency as the facility did not comply with the regulatory requirement to inform the resident and their representative in writing about the bed-hold policy.
Medication Storage Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for a resident, identified as Resident #13, who was observed with medications unsupervised in their room. Resident #13, who shared a room with another resident, had an Albuterol inhaler and a Trelegy inhaler left on their bedside table, accessible to both themselves and their roommate. This was contrary to the facility's policy, which required medications to be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. Resident #13 was cognitively intact and had diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. Despite the resident's ability to understand and communicate, the facility's Director of Nursing confirmed that no residents were permitted to self-administer medications. The inhalers were left on the bedside table throughout the day and were sometimes stored on the medication cart at night, indicating a lapse in adherence to the facility's medication storage policy.
Failure to Document Indication for Medication Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, as evidenced by the lack of an indication for the use of Estrace Vaginal Cream prescribed to Resident #27. The resident, who was admitted with diagnoses including urinary tract infection, unspecified dementia, and major depressive disorder, had a physician order for Estrace Vaginal Cream without a documented indication for its use. The facility's policy required that medication orders include a clinical indication, and the consultant pharmacist's review did not identify this omission as an irregularity. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, revealed that medication orders should include the reason for use, and if missing, staff should contact the provider to obtain it. However, the provider and Medical Director indicated that the indication for use was documented in clinical notes rather than on the order itself. This discrepancy led to the deficiency, as the medication was administered without a documented indication, contrary to professional standards and facility policy.
Significant Medication Errors in Alprazolam Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Alprazolam, a medication used to treat anxiety. The resident, who had intact cognition and could communicate effectively, reported that the night nurse administered Alprazolam at incorrect times and left medication unattended, instructing the resident to take it or not. The Medication Administration Record and physician's orders indicated that Alprazolam was to be given three times a day at specific times, but there were multiple instances where the medication was administered either late, early, or too close to the previous dose, violating the prescribed schedule. Interviews with the Director of Nursing and Licensed Practical Nurses revealed that the facility's policy required medications to be administered according to the physician's orders and that any deviations should be reported to the physician. However, the staff involved were unaware of the errors in administering Alprazolam, and there was no documented evidence that the physician was notified or that the resident was monitored for side effects. This lack of adherence to medication administration protocols led to the deficiency identified during the recertification survey.
Deficiency in Safe Storage of Outside Food for Resident
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of foods brought to residents by families and other visitors, leading to a deficiency in preventing food-borne illness. Specifically, Resident #52, who was cognitively intact and had medical conditions including a unilateral inguinal hernia with obstruction, hepatomegaly, and type 2 diabetes mellitus, had food brought from outside that was not labeled or discarded according to the facility's policy. During an observation, it was noted that Resident #52 had raw hotdogs in their dresser and a Tupperware container with rice at their bedside, which had been brought by a family member earlier that day. Interviews with staff and family members revealed a lack of adherence to the facility's policy regarding the handling of outside food. Family Member #1 reported that staff on the G unit did not ask to place the food in the refrigerator, unlike the previous D unit. Additionally, the family member had not received any education on the facility's policy for safe storage of outside food. Licensed Practical Nurse #1 was unaware of the food in the resident's room, and Registered Nurse #1 stated that staff were expected to inspect and store outside food properly. The Director of Nursing admitted to not knowing the specifics of the policy and expected staff to notify supervision if there were any problems with food in residents' rooms.
Failure to Investigate Resident Injury and Unsupervised Exit
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of a thorough investigation into an alleged incident involving a resident who sustained a skin tear on their right hand. The resident, who had diagnoses including type 2 diabetes mellitus, nicotine dependence, and schizophrenia, was cognitively intact and able to communicate effectively. On the night of the incident, the resident reported injuring their hand on the front door while returning to the facility at 11:00 PM. Documentation by nursing staff confirmed the presence of a new skin tear, and the wound was treated and reported to the provider. Despite the facility's policy requiring all accidents and incidents to be thoroughly investigated, including completion of an incident/accident report with detailed circumstances, there was no documented evidence that a comprehensive investigation was conducted. Staff interviews revealed that neither the supervisor nor the nurse who treated the resident inquired about how the resident exited or re-entered the building, nor did they determine whether the required Out on Pass Agreement was completed. The supervisor acknowledged not starting an investigation and only completed the incident form and skin assessment. Further interviews with the Director of Nursing and other staff confirmed that the expected protocol of immediate investigation was not followed. The resident could not recall who allowed them to leave or re-enter the facility, and staff were unaware of who facilitated the resident's movements. The lack of a documented investigation into the circumstances of the incident and the resident's unsupervised exit and re-entry constituted the deficiency.
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What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 5 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Delmar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Margarets Center | 1.9 mi | ★★★★★ | 0 | 0 |
| St Peters Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 2 | 0 |
| Eddy Village Green At Beverwyck | 2.8 mi | ★★★★★ | 2 | 0 |
| Hudson Park Rehabilitation And Nursing Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Daughters Of Sarah Nursing Center | 4.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.