Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Grand Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective system to reconcile and verify methadone doses supplied by external opioid treatment programs, resulting in multiple residents with opioid use disorder receiving methadone under conditions where physician orders did not match the dosages on clinic-labeled bottles. Despite existing policies for controlled substances and medication administration, there was no specific policy, procedure, or formal agreement governing methadone from outside clinics, and staff did not receive or use clinic documentation to confirm current dosages. Nurses reported relying mainly on resident names on bottles and did not routinely compare bottle dosages to physician orders, while physicians and the consultant pharmacist described processes in which methadone orders were entered or signed based on bottle labels without independent verification. These systemic gaps led to repeated discrepancies between ordered and labeled methadone doses for numerous residents.
The facility failed to ensure methadone was administered according to physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Policy required nurses to use the eMAR as the source for medication administration and to verify the five rights, but methadone bottles for several residents carried doses that did not match the physician orders entered in the electronic record, despite daily administration being documented. Nursing staff reported either not cross-checking bottle dosages against orders or relying solely on the bottle label or resident familiarity, and they often did not notice discrepancies. The attending physician, DON, and medical director described a process in which the methadone clinic determined doses, nurses transcribed bottle labels or clinic information into the electronic record, and physicians signed orders without independent verification or direct clinic documentation, contributing to inconsistent and inaccurate methadone dosing information.
The medical director failed to provide adequate oversight of methadone medication management, including the development and implementation of procedures to safely reconcile and verify methadone received from external opioid treatment programs. Facility policy assigned the medical director responsibility for oversight of medical care practices and clinical standards, yet the medical director did not know how methadone was delivered, relied on methadone clinic reports entered by nursing staff into the EMR, and electronically signed orders without reviewing the source documentation. An attending physician reported having residents on methadone maintenance but was unsure of each resident’s correct dosage and stated that nurses administered the dose on the methadone bottle even when it did not match the physician’s order, demonstrating a lack of coordinated, standardized processes for methadone prescribing and administration.
Failure to Assess and Report Unexplained Facial Bruising: A resident with dementia, DM, atherosclerotic heart disease, and daily aspirin therapy was observed with bruising on the forehead/temple and under the eye, but staff had not identified it, documented an assessment, completed neuro checks, notified the MD, or investigated a possible fall or injury. The RN, LPN, CNA, and DON all stated they were unaware of the bruise until the surveyor asked about it.
A resident with severe cognitive impairment was found unable to stand and was later diagnosed with a hip fracture of unknown origin. The facility did not report this injury of unknown source to the State Department of Health within the required timeframe, resulting in a delay of ten days before notification.
Lack of Qualified Dietitian and Food Service Director: The facility failed to employ a qualified RD or clinically qualified nutrition professional, including a food service director, after the prior RD/FSD left. A non-registered dietician was working part to full time and handled resident dietary assessments, allergy checks, diet recommendations, and weight monitoring, but did not perform administrative duties such as staff supervision or policy review. Interviews confirmed the facility had no RD in place and was relying on interim arrangements.
Unlabeled and expired food was found in the kitchen walk-in refrigerator and a pantry refrigerator. The walk-in contained cooked beans, raw seasoned pork, and multiple defrosting meats that were unlabeled and undated, while the pantry refrigerator contained resident food that was expired, undated, and unlabeled. Facility policy required food items to be clearly labeled with product name and dates, including thawing foods and outside food stored for later use.
Administration failed to oversee facility operations effectively, with widespread and repeated deficiencies cited across food and nutrition services, administration, infection control, physical environment, and training requirements. The facility knew its licensed dietitian had resigned, knew the second-floor call system was not functioning as intended, and the Administrator was unaware that drug regimen review reports were not readily available. The DON was aware of the infection control issue and that there was no documented evidence CNAs received the required 12 hours of in-service training.
QAPI program lacked governance and leadership oversight, with widespread deficiencies in food and nutrition services, administration, infection control, physical environment, and training requirements. The facility also had repeated prior survey deficiencies with no documented evidence that accepted POCs were implemented or sustained. The Medical Director said the medical dept was working on infection control issues, while the Administrator said they were unaware of an infection control problem, the QAPI committee needed to identify who handled vaccine records, antibiotic stewardship needed recommendations, and since the RD left, refrigerators had not been audited, meal trackers were not being updated, and there was no RD.
Failure to Monitor Antibiotic Use: The facility had an Antibiotic Stewardship Program policy, but there was no system to track antibiotic use or resistance data and no evidence of staff education on antibiotic stewardship. Record review showed residents receiving antibiotics for a UTI and malignant otitis externa, while interviews with the ADON/IP, DON, and Medical Director confirmed that antibiotic use had not been monitored and reports had stopped after a nurse resigned.
Dishwasher Failed to Maintain Required Sanitizing Temperatures: The facility’s mechanical dishwasher was observed operating below the required wash temperature, and temperature logs showed repeated low readings. An equipment invoice documented a leaking booster in extremely poor condition that should be shut down, and interviews confirmed the dishwasher had been malfunctioning and was not consistently reaching adequate temperatures.
A resident with severe cognitive impairment and a history of falls was repeatedly observed without required fall prevention interventions, including floor mats and a bed in the lowest position, despite these being specified in the care plan. Staff interviews confirmed that these interventions were not consistently implemented.
No documented physician evaluation after a resident fall. A resident with DM, HTN, and depression fell from a chair in the day room and had scant nasal bleeding, but the chart contained no physician assessment or progress note related to the incident. Nursing notes said the MD was notified, while the NP and MD later did not recall the event or notification. The DON and Medical Director stated residents are to be seen by the medical provider after a fall and the assessment must be documented.
Medical records were not maintained in an easily retrievable manner when drug regimen review reports for five sampled residents were not available for surveyor review upon request. The consultant pharmacist emailed the reports to the DON, but staff did not know where the copies were kept, and the DON later found missing reports in the Medical Director’s office. The Medical Director kept a copy of the recommendations in the office, and the Administrator stated documents were printed and given to the DON for filing.
Failure to document influenza and pneumococcal immunization offers: Surveyors found missing records for several residents showing they were offered, educated on, received, or declined flu and pneumococcal vaccines. Residents included people with diagnoses such as schizophrenia, dementia, Alzheimer’s disease, diabetes, COPD, and stroke, and some had intact cognition while others had severely impaired cognition. The IP and DON stated immunization folders had been deleted from the computer and records could not be found in the EMR or binders.
Failure to Document and Offer COVID-19 Immunizations: The facility did not ensure that all sampled residents were offered the COVID-19 vaccine or that screening, education, consent/declination, and administration were documented. Four residents had records showing their COVID-19 status was not up to date, including residents with intact cognition and residents with severely impaired cognition, but the facility could not provide complete evidence that the vaccine was offered or received. The IP stated immunization files were deleted from the computer, and the DON could not explain why the records were missing from the EMR or binders.
A facility failed to maintain a working call bell system in the bathrooms and bathing areas for all second-floor rooms. Testing showed the call lights illuminated but did not sound at the corridor or nursing station, and residents were given hand bells instead. Staff reported the call bells on the second floor had been broken for a long time, while the Maintenance Director and Administrator stated the system was antiquated and parts were difficult to obtain.
Facility records showed that five CNAs had no documented evidence of receiving the required 12 hours of annual in-service training. The ADON stated only 4 hours of in-service had been provided since starting, while the HR Director said education records were kept in the nursing office and the DON stated prior staff education paperwork was taken by the former ADON after termination.
Failure to Provide Written Transfer/Discharge Notice: A resident with intact cognition, anxiety disorder, bipolar disorder, and COPD was transferred to the hospital, but the facility did not complete or provide a written transfer/discharge notice in a language and manner the resident could understand. Record review found no notice in the chart, and interviews showed the SWD, DON, and Administrator were aware of the notification process but could not confirm the resident received it.
A resident with Osteomyelitis and MRSA had physician-ordered Contact Isolation and nursing documentation showing contact precautions were maintained, but there was no documented comprehensive care plan for infection-related needs, including MRSA, Bacteremia, or contact precautions. Interviews with the Nursing Supervisor, MDS Coordinator, and DON confirmed the resident had no care plan for these issues and that the admission MDS items should have had corresponding care plans.
Resident served pork despite documented no-pork preference. A resident with intact cognition and a regular diet had care plan preferences for chicken and fish, with beef and pork listed as dislikes, yet a lunch tray contained pork even though the ticket said no beef or pork. The resident reported this happened repeatedly, and staff interviews showed tray checks were inconsistent, with dietary and nursing staff relying on the kitchen and unit distribution process rather than consistently verifying that the meal matched the ticket.
Improper Handling of a Pillow After Contact With the Floor: A CNA picked up a resident’s pillow from the floor and placed it back under the resident’s head without changing the pillowcase. The facility’s linen handling and infection control policy required safe and sanitary handling of linens, and an LPN and the DON both stated the pillowcase should have been changed because the floor is dirty.
Survey results were not readily accessible to residents or family members. Although signage directed people to the location in the lobby elevator area, the bin was empty and the results were not posted there. The DON provided only a binder with complaint survey results, stated residents tear up the surveys, and the Administrator said the binder is where the surveys should be kept but did not know why the binder was empty.
Facility Assessment listed hospice as a provided service even though the facility had no hospice contract and only offered palliative care. A resident was admitted for hospice care, and the family reported that the hospital discharge planner and facility website both documented hospice as available, but they later learned hospice was not offered. The DON confirmed there was no hospice contract, and the Administrator said the contract had been terminated years earlier and the listing remained by oversight.
The facility did not report allegations of staff borrowing money from residents and failing to repay within required timeframes, and failed to submit follow-up investigation reports within five business days. In each case, the initial or follow-up reporting was delayed, and investigations could not substantiate the allegations due to inconsistent statements or lack of evidence. Leadership interviews revealed a lack of awareness of reporting requirements.
A resident with significant medical needs reported being threatened by two CNAs, but the allegation was not immediately communicated to supervisory staff as required by facility policy. The Director of Recreation documented the report but failed to notify the DON or Administrator directly, resulting in a delayed investigation and lack of immediate protective measures.
The facility did not transfer the personal funds of two deceased residents to the probate jurisdiction within the required 30-day period, as confirmed by record review and staff interviews. The Payable Coordinator and Administrator acknowledged the delay but could not explain why the transfers were not completed on time.
A resident with multiple complex diagnoses exhibited restlessness, a stuffy nose, and a low-grade fever. Despite these changes, staff did not document notifying the physician or performing a follow-up assessment after administering acetaminophen. The resident later expired from cardiac arrest, and the physician was only notified post-mortem. This failure to follow assessment and notification protocols resulted in actual harm.
A resident with severe cognitive impairment and multiple medical conditions became restless and developed a low-grade fever. Staff documented the symptoms, notified the RN Supervisor, and administered Tylenol, but did not inform the resident's representative or physician of the change in condition, as required by policy. Interviews confirmed the family was not notified, and there was no evidence of reassessment after treatment.
The facility did not maintain required temperature levels, with all sampled resident rooms and common areas found below regulatory standards, some as low as 40 to 53°F. Multiple residents filed complaints and grievances about cold conditions, and maintenance logs documented ongoing heating issues. The Administrator and Medical Director were unaware of the extent of the problem, and the facility lacked proper maintenance contracts and failed to address vendor recommendations for boiler repairs, resulting in Immediate Jeopardy and Substandard Quality of Care.
The facility did not ensure safe and comfortable temperatures in resident rooms and common areas due to lack of heat, with all sampled areas below regulatory requirements. The Administrator was unaware of the issue, and there was no evidence of routine maintenance for boiler and PTAC units. The Director of Maintenance was unable to secure vendor services due to unpaid balances, and the Administrator denied receiving vendor communications about necessary repairs. These failures resulted in Immediate Jeopardy.
The facility failed to maintain its boiler system, resulting in malfunctioning heating equipment and temperatures in resident rooms and common areas falling below regulatory requirements. Despite multiple vendor proposals and reports of insufficient heat, the facility did not act to address the boiler deficiencies, and only a portion of the boilers were operational. Staff interviews revealed that maintenance requests were hindered by unpaid bills and lack of administrative approval, and the Administrator was unaware of the extent of the heating problem.
Two residents were involved in an altercation due to inadequate supervision, resulting in one resident sustaining head lacerations. Despite known behavioral issues, the facility failed to update care plans or ensure proper monitoring, leading to the incident.
A facility failed to review and revise comprehensive care plans for three residents after significant events. A resident's care plan for an indwelling catheter was not updated after an ER visit for urinary retention. Another resident's care plan for behavior and victimization was not revised after a physical abuse incident, lacking evidence of required monitoring. A third resident's care plan was not reviewed following a physical altercation. The DON acknowledged the oversight in care plan updates.
The facility failed to provide sufficient nursing staff, particularly CNAs, leading to delays in resident care, especially during evenings and weekends. Residents reported long wait times for assistance with personal care, and staffing schedules consistently showed fewer CNAs than required. Staff interviews confirmed the challenges in maintaining adequate care due to staffing shortages, with agency staff often not showing up for work.
The facility failed to conduct annual performance reviews for CNAs, as required by their policy. A review of personnel files showed no evidence of such reviews for five CNAs. Interviews revealed that the responsibility for these evaluations fell through the cracks due to personnel changes, leading to the deficiency noted by surveyors.
The facility failed to administer resources effectively, leading to repeated deficiencies in staffing, infection control, and care quality. The administration and Director of Nursing were aware of staffing issues but did not adequately address them, resulting in unmet resident needs and unmonitored previous citations. The Director of Nursing was unaware of specific care issues, including infection control and care plan updates.
The facility lacked an active governing body to implement management policies, leading to deficiencies in resident care. Inconsistent communication between the Administrator and Governing Body hindered effective management. Residents reported delayed call light responses and insufficient staffing, especially on weekends, with no prompt action or follow-up on their concerns.
The facility's QAPI program failed to identify and prioritize issues, resulting in widespread deficiencies in Nursing Services, Administration, and Infection Control. Repeated deficiencies from past surveys were noted, and the facility lacked documented evidence of corrective actions. Interviews revealed a lack of awareness and oversight by the Director of Nursing, Administrator, and Operator/Owner, contributing to the ongoing issues.
The facility failed to maintain infection control practices during medication administration. An LPN did not sanitize the blood pressure machine and cuff after using them on multiple residents. Similarly, an RN did not sanitize the glucometer after finger stick blood sugar tests and failed to perform hand hygiene. Another LPN also neglected to sanitize the blood pressure equipment after use. Despite receiving education on these practices, staff did not adhere to the facility's policy requiring equipment cleaning between uses.
Two residents in an LTC facility did not receive regular showers as per their care plans, leading to a deficiency. One resident, with Cerebral Palsy and Depression, preferred showers at a later time, but this was not accommodated, resulting in missed showers. Another resident, with Non-Alzheimer's Dementia and Bipolar Disorder, also did not receive showers according to the schedule. Staff interviews revealed communication gaps and lack of awareness about the residents' preferences and care needs.
A resident with a history of healed pressure ulcers and a care plan for a pressure ulcer relieving device was found with a deflated air mattress on multiple occasions. Despite the resident's complaints of pain, the facility staff failed to address the issue, and there was no documentation of the use of pressure relieving devices. Interviews revealed a lack of awareness and communication among staff regarding the mattress issue.
A resident with behavioral issues, including stealing and involvement in altercations, did not receive necessary behavioral health care and services. The facility failed to evaluate intervention effectiveness, update care plans, and ensure consistent monitoring. Staff interviews revealed a lack of coordination and awareness in managing the resident's behavior.
The facility failed to store insulin pens properly, as observed during a survey. Insulin pens for four residents were stored together in a medication cart, contrary to the facility's policy requiring separate storage to ensure sanitation. A nurse admitted the oversight, while the DON stated there was no requirement for individual storage, indicating a lack of consistent policy implementation.
A resident with cerebral palsy and depression did not have their bathing preferences honored, as the facility failed to provide scheduled showers and instead gave bed baths without documented refusal. The resident preferred evening showers, but this was not communicated or reflected in their care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's preferences, contributing to the deficiency.
The facility failed to ensure accurate documentation in the MDS assessments for three residents, leading to discrepancies in their recorded statuses. A resident's discharge status was inaccurately documented, another's Schizophrenia diagnosis was omitted, and a third resident's behavioral symptoms were not recorded despite a physical altercation. The MDS Coordinator acknowledged these oversights, reflecting a failure to adhere to the facility's policy for comprehensive assessments.
The facility did not submit the required direct care staffing information for Quarter 3 of 2024 on time, as required by CMS. The Director of Human Resources and the Administrator were responsible for ensuring the submission, but an oversight led to the failure to meet the deadline.
The facility failed to maintain adequate staffing levels, leading to compromised resident care. Staffing schedules showed consistent shortages of LPNs and CNAs, particularly on weekends. Staff and residents reported delayed care, with Registered Nurse Supervisors covering LPN duties and residents experiencing delayed medication and inadequate incontinence care. The Assistant Administrator acknowledged the issue but was unclear on staffing adjustments, and the Director of Nursing did not provide further clarification.
The facility failed to properly dispose of garbage, with surveyors observing uncovered and overflowing dumpsters, scattered trash, and flies. Interviews revealed unclear responsibility for maintaining the garbage area, with the Director of Housekeeping and Administrator unaware of the issues.
The facility failed to provide consistent hot water for bathing and hygiene across all units, with water temperatures significantly below the required level and some areas lacking water flow. Residents reported being washed with cold water for months, and maintenance logs confirmed ongoing issues. Despite temporary measures like providing wipes, the deficiency persisted, indicating inadequate response.
Failure to Reconcile and Verify Methadone Doses from External Opioid Treatment Programs
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain a system to accurately reconcile, verify, and oversee methadone medications received from external opioid treatment programs. Facility policies on controlled substance handling, medication administration, and consultant pharmacist services required accurate receipt, logging, and administration of controlled drugs, as well as verification of the five rights of medication administration using the electronic MAR and prescription labels. However, the facility had no policy or procedure specific to methadone received from opioid treatment programs and could not provide any documented agreement outlining coordination with those programs. Surveyors identified 10 residents, all diagnosed with opioid use disorder and various comorbidities such as endocarditis, heart failure, anemia, asthma, coronary artery disease, diabetes, hypertension, cerebral infarction, schizophrenia, benign prostatic hypertrophy, and viral hepatitis, whose methadone administration records showed discrepancies between physician orders and the dosages labeled on methadone bottles. In several cases, the physician’s order reflected a lower dose than the bottle label (for example, 60 mg ordered vs. 70 mg labeled, 115 mg ordered vs. 125 mg labeled, 80 mg ordered vs. 90 mg labeled, 120 mg ordered vs. 130 mg labeled, and 280 mg ordered vs. 295 mg labeled), while in other cases the physician’s order reflected a higher dose than the bottle label (for example, 40 mg ordered vs. 30 mg labeled, 95 mg ordered vs. 85 mg labeled, 30 mg ordered vs. 24 mg labeled, 20 mg ordered vs. 30 mg labeled, and 90 mg ordered vs. 80 mg labeled). Despite these discrepancies, the MARs documented administration of the physician-ordered doses, and controlled drug accountability records, when present, reflected the physician-ordered doses rather than the doses indicated on the clinic-supplied bottles. Interviews with nursing staff and medical providers revealed that methadone from the external clinics was handled without systematic reconciliation against physician orders or clinic documentation. Nurses reported that residents were escorted to methadone clinics, and the escort returned with labeled methadone bottles that were handed to the unit nurse, who logged only the number of bottles in the controlled drug record and stored them in a locked box. Nurses stated they did not receive paperwork from the clinics to verify dosage or changes, did not cross-check the dosage on the bottle against the physician’s order, and often relied only on the resident’s name on the bottle or familiarity with the resident. The attending physician stated that orders were entered by nurses based on the bottle labels and then signed, that they did not receive physical or electronic orders from the clinics, and that they were unsure of the correct methadone dosages but believed residents must receive the dosage indicated on the bottle and that the physician’s order and bottle label did not necessarily need to match. The consultant pharmacist reported that regimen reviews were limited to medications dispensed from the linked pharmacy and that there was no way to verify the correctness of methadone orders from the clinics. The Medical Director acknowledged not knowing the delivery process, stated that clinic reports were signed without review, and later characterized the situation as a system failure. The Administrator stated that nurses were responsible for reconciling physician orders with methadone regimens on the bottles and that attending physicians should have performed monthly record reviews to identify discrepancies. This combination of missing policies, lack of formal agreements, and staff practices resulted in methadone dosages that were inconsistent between physician orders and clinic-labeled bottles for multiple residents. The situation was determined to have caused no actual harm but posed a likelihood for serious harm that constituted Immediate Jeopardy to residents receiving methadone maintenance therapy.
Removal Plan
- The Director of Nursing reviewed all residents receiving methadone from an external opioid treatment program, confirmed residents with dosage discrepancies, and clinically assessed those residents with no signs/symptoms of toxicity or adverse reactions.
- The Director of Nursing contacted each methadone clinic to confirm the current prescribed methadone dose and frequency.
- The Director of Nursing contacted the Medical Director and obtained telephone orders to ensure the physician orders correspond with the doses on the methadone bottles.
- The Pharmacy Consultant completed a regimen review of residents prescribed methadone and confirmed discrepancies were corrected and no other discrepancies were identified.
- The facility created and implemented a new policy and procedure for methadone administration, order verification, reconciliation, and chain of custody, including use of a Reconciliation and Chain of Custody Receipt Form completed by the methadone clinic, reconciliation by the receiving licensed nurse against the facility physician order, escalation/verification steps for discrepancies, documentation in nursing progress notes, and retention of forms in a binder in the nursing office.
- All licensed nurses, attending physicians, the pharmacy consultant, and facility escorts received in-service training on the new policy.
Methadone Dosing Discrepancies and Failure to Verify Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure methadone was administered in accordance with physician orders, resulting in significant medication errors for multiple residents on methadone maintenance therapy. Facility policy required that medication administration and documentation be timely and accurate, that the eMAR serve as the source for pouring and administering medications, and that licensed nurses verify the five rights by comparing the medication name, strength, route, and dosage schedule on the MAR against the prescription label. Despite this, a review of methadone administration records for 23 residents on methadone identified 10 residents whose methadone bottles were labeled with doses that did not match the physician’s orders entered in the electronic medical record. For these 10 residents, the physician’s orders and bottle labels showed consistent discrepancies in methadone dosages, although the eMARs documented administration of the ordered doses. Examples included residents with diagnoses such as endocarditis, heart failure, anemia, asthma, coronary artery disease, schizophrenia, viral hepatitis, and opioid use disorder. One resident had a physician’s order for 60 mg daily while the bottle was labeled 70 mg; another had an order for 115 mg while the bottle was labeled 125 mg; another had an order for 80 mg with a bottle labeled 90 mg. Additional residents had orders for 40 mg with a bottle labeled 30 mg, 95 mg with a bottle labeled 85 mg, 30 mg with a bottle labeled 24 mg, 20 mg with a bottle labeled 30 mg, 120 mg with a bottle labeled 130 mg, 280 mg with a bottle labeled 295 mg, and 90 mg with a bottle labeled 80 mg. All of these residents had methadone orders documented in the eMAR and received daily methadone doses as charted, but the labeled bottle doses did not match the physician orders. Interviews with nursing staff and medical leadership revealed systemic process failures and inconsistent practices in verifying methadone doses. An LPN stated that when administering methadone, they checked the physician’s order in the electronic record and then administered methadone labeled with the resident’s name, but did not cross-check the dosage on the bottle against the physician’s order and had not noticed discrepancies. An RN reported only checking the resident’s name on the bottle and not the physician’s order or dosage, explaining that they were familiar with the residents, despite acknowledging they were supposed to ensure the bottle dosage matched the order. Other RNs stated they followed the dosage on the bottle without comparing it to the physician’s order and had not noticed differences. Interviews with the attending physician, DON, and medical director further described a lack of clear communication and documentation processes between the facility and the methadone clinic. The attending physician stated that the methadone clinic prescribed the dosage and frequency, that they did not receive physical or electronic orders from the clinic, and that nurses entered orders into the electronic record from the bottle labels, which the physician then signed without knowing the intended methadone dose for each resident. The attending physician also stated that the physician’s order and the bottle dosage did not necessarily need to match for nurses to administer the medication. The DON reported that residents went to the methadone clinic to pick up medication, returned it to the unit nurse, and that the nurse called the attending physician with the dosage and entered the order, with no receipt or paperwork from the clinic. The medical director stated that the clinic sent a report with dosages and frequencies, that nurses entered this into the electronic record, and that they signed orders without reviewing the report, later characterizing the situation as a system failure due to lack of established processes and communication.
Failure of Medical Director Oversight for Methadone Medication Management
Penalty
Summary
The deficiency involves the failure of the medical director to collaborate with the facility to develop and implement procedures for the safe and accurate provision of methadone medications received from external opioid treatment programs. The facility’s policy on Physician Visits and Physician Delegation stated that the medical director’s role is to provide oversight of medical care practices, regulatory compliance programs, and clinical standards. Despite this, the medical director did not ensure that current standards of practice were followed for reconciling, verifying, and overseeing methadone medications from methadone clinics. Surveyor interviews revealed that an attending physician acknowledged having residents on methadone maintenance programs but stated they were unsure of the methadone dosage each resident was supposed to receive and that nurses were to administer the dosage indicated on the methadone bottle, even if it did not match the physician’s order. The medical director stated they did not know the process by which methadone was delivered to the facility and that the methadone dosage was determined by the methadone clinic, which sent a report to the facility. The medical director reported that nurses entered this information into the EMR as physician orders, which the medical director electronically signed without reviewing the clinic report, and that their only responsibility was to assess residents and renew orders. In a follow-up interview, the medical director characterized the lack of established processes and communication between the facility and the methadone clinic as a system failure.
Failure to Assess and Report Unexplained Facial Bruising
Penalty
Summary
The facility failed to ensure timely assessment and evaluation of a resident’s change in condition when a bruise was found on the top of the left eyebrow extending toward the temple and a red linear bruise under the left eye. The resident had diagnoses of dementia, diabetes mellitus, and atherosclerotic heart disease, and the quarterly MDS documented severely impaired cognition with substantial to maximal assistance needed for activities of daily living, transfers, and ambulation. The resident also had an active order for aspirin 81 mg daily and a care plan noting risk for easy bruising related to aspirin use. The bruise was observed by the State Surveyor while the resident was sitting in the dining room, but the medical record contained no documented assessment of the bruising, no investigation for a possible fall or injury, no neurological checks or other monitoring, no physician notification, and no care plan update related to the injury. Staff interviewed after the observation stated they were not aware of the facial bruises or of any fall or injury during their shifts. The RN who administered morning medications stated they noticed a slight discoloration on the forehead only after the surveyor asked about it and did not identify it as a bruise. The attending physician stated they had not been informed of any injury or facial bruise and indicated that, for any head injury, neurological checks or CT imaging would have been ordered. The DON stated the bruise had not been reported and therefore was not investigated. The Administrator stated staff are to notify the nurse if they observe any bruise or discoloration during care so the nurse can assess the resident and notify nursing leadership for investigation.
Delayed Reporting of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving injury of unknown source were reported immediately, as required by policy and regulation. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including dementia and diabetes, was found unable to stand on their left leg and was transferred to the hospital, where a closed left hip fracture was diagnosed. The resident was unable to explain how the injury occurred, and there was no documentation of a fall or traumatic event. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the New York State Department of Health until ten days after the change in the resident's condition was observed. Record review and interviews revealed that the delay in reporting was due to a lack of immediate notification to the Director of Nursing by the nursing supervisor. The Director of Nursing only became aware of the fracture after the resident was readmitted from the hospital and subsequently reported the injury. The facility's investigation did not find evidence of abuse, mistreatment, or neglect, and there was no documentation that the fracture was pathological. However, the failure to report the injury of unknown source within the required timeframe constituted a deficiency.
Lack of Qualified Dietitian and Food Service Director
Penalty
Summary
The facility failed to ensure that a qualified dietitian or another clinically qualified nutrition professional, including a director of food and nutrition services, was employed part-time, full-time, or as a consultant. The report states that the facility had employed a non-registered dietician as the full-time dietician and food service director without oversight from a registered dietitian or certified food service director since September 2025. The undated Food Service Management policy required the department head to meet New York State Department of Health requirements for food service manager and to plan, organize, supervise, and direct all administrative and operational activities of the Food and Nutrition Services Department. Record review showed the Facility Survey Report, New York State Department of Health Form 1550, was signed by the facility operator and principal partner and dated 12/01/2025, and it listed the previous registered dietician as the Registered Dietician and Food Service Director without naming any other staff in that role. During interviews, Facility Dietician #2 stated they were not a registered dietitian, had been working per diem since 2022, and were now hired part to full time because there had not been a full-time registered dietitian or food service director since September 2025. They stated they completed resident-focused tasks such as dietary assessments, allergy checks, diet recommendations, and weight monitoring, but did not perform administrative duties such as meetings, staff supervision, or policy review. The Medical Director stated they had been told the registered dietitian was terminated in October 2025 and that they were expecting an immediate replacement, while the Administrator stated the facility currently did not have a registered dietitian employed and had not had one since the previous food service director resigned at the end of September 2025.
Unlabeled and expired food found in kitchen and pantry refrigerators
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation in the kitchen, the walk-in refrigerator contained one unlabeled quarter pan of cooked beans dated 11/26/2025, one unlabeled and undated full pan of raw seasoned pork, and multiple unlabeled and undated defrosting meats, including two whole turkey breasts, two two-pound packages of sliced ham, three two-to-three-pound packages of sliced bologna, and three whole pork loins. The Dietary Supervisor stated that all food items should be labeled with the product name and relevant dates, and that unlabeled and undated items should be discarded immediately. During an observation of the Sixth Floor pantry refrigerator, two plastic bags labeled with a resident's name were found. One bag contained two one-pound open packages of Swiss cheese with a sell-by date, and the other contained resident food that was expired, undated, and unlabeled. Facility policy required prepared, opened, repackaged, and thawing foods to be clearly labeled with the product name and dates, and required pantry refrigerator foods older than three days to be discarded.
Failure to Administer Facility Resources and Oversight
Penalty
Summary
Administration failed to manage the facility in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The deficiency was identified during review of Food and Nutrition Services, Administration, Infection Control, Physical Environment, and Training Requirements, and was tied to widespread deficiencies and repetition of deficiencies cited on previous recertification surveys. The facility’s administration was aware that the licensed dietitian had resigned and that a qualified dietitian was needed to oversee food and nutrition services, and they were also aware that the call system was not functioning as intended on the second floor. The Administrator was unaware that the drug regimen review reports were not readily available. In addition, the DON was aware of the extent of the infection control issue and was aware that there was no documented evidence that CNAs received the required 12 hours of in-service training. The report also states that the Administrator acknowledged the facility was a Special Focus Facility with multiple issues to resolve and said they believed they had made progress, but the concerns cited on this survey were not the same as those found on previous surveys.
QAPI Program Lacked Oversight and Follow-Through
Penalty
Summary
The facility failed to maintain a comprehensive QAPI program and plan with governance and leadership oversight. Survey findings identified widespread deficiencies in Food and Nutrition Services, Administration, Infection Control, Physical Environment, and Training Requirements, and the facility also had repeated deficiencies from prior recertification surveys, including F656, F711, F801, F812, F835, F865, and F880, that had been previously cited with accepted plans of correction but had no documented evidence of implementation or maintained outcomes. The facility policy titled Quality Assurance and Performance Improvement Plan, last updated in 01/2025, stated that the QAPI committee meets at least monthly and includes the Administrator, DON, Medical Director, department heads, and residents and/or family members as appropriate, with data reviewed on resident outcomes, satisfaction surveys, staff performance, and compliance trends. During interviews, the Medical Director stated that the medical department was working to address infection control issues. The Administrator stated they were unaware of any infection control problem, that the QAPI committee would need to identify who handles vaccine records, and that recommendations would be made regarding antibiotic stewardship. The Administrator also stated that since the RD left in September 2025, refrigerators had not been audited, meal trackers were not being updated, and the facility had no RD. The Administrator further stated that the potential deficiencies were not the same issues raised on previous surveys.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The Infection Control Task found that there was no system in place to monitor antibiotic use, and there were no reports related to antibiotic usage or resistance data. Although the facility had a policy titled Antibiotic Stewardship Program, reviewed in 06/2024, documenting that the Infection Preventionist, under the oversight of the DON, coordinates the program with support from the Medical Director and Consultant Pharmacist, the facility had no documented evidence that antibiotic usage and resistance data were being monitored. Record review showed that Resident #1 had a diagnosis of UTI and was ordered Macrobid 100 mg by mouth twice daily for 7 days, and Resident #7 had a diagnosis of malignant otitis externa and was ordered Augmentin 500 mg by mouth every 12 hours for 10 days. Interviews confirmed the lack of monitoring: the ADON, who also served as the Infection Preventionist, stated they had not been tracking antibiotic use since starting in the facility in October 2025; the DON stated they had been overseeing the program after the prior Infection Preventionist was terminated in July 2025 until the new Infection Preventionist was hired; and the Medical Director stated they had not been tracking antibiotic use because there were not many infections and that reports had stopped after the nurse who provided them resigned.
Dishwasher Failed to Maintain Required Sanitizing Temperatures
Penalty
Summary
The facility did not maintain the mechanical dishwasher in safe operating condition during the recertification survey. During observation of the dishwashing task, the dishwasher was measured at 120 degrees Fahrenheit, below the required minimum wash temperature of 150 degrees Fahrenheit. Review of the December 2025 dishwasher temperature log showed additional instances where the breakfast wash temperature was documented below the required level, including 124 degrees Fahrenheit and 120 degrees Fahrenheit on separate days. Record review showed a Kitchen Equipment invoice dated 11/06/2025 stating that the dishwasher booster had a leak on the tank, was leaking onto electrical components, and was in extremely poor condition and should be shut down. The invoice also showed no payments or credits toward repair. Interviews with the Dietary Supervisor and Administrator confirmed that the dishwasher had been malfunctioning and not consistently maintaining adequate temperatures, and that a replacement booster had been ordered, but no repair completion date was available.
Failure to Provide Required Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident identified as being at risk for falls received adequate supervision and assistive devices as outlined in their care plan. Specifically, the resident, who had diagnoses including schizoaffective disorder, dementia, and anxiety disorder, was assessed as having severely impaired cognition and significant functional limitations. The resident's care plan required the bed to be maintained in the lowest position and the use of bilateral floor mats to prevent falls. Despite these interventions being documented, multiple observations showed the resident's bed was in the highest position and no floor mats were present. These observations occurred on more than one occasion, and staff confirmed that floor mats were not in use in the resident's room. The resident had a documented history of multiple falls, with incidents occurring both on and off the floor mats, and was known to be non-compliant and to get up independently. The facility's policies required individualized fall prevention interventions and regular monitoring by nursing supervisors to ensure compliance with care plans. However, interviews with staff, including a CNA and the DON, revealed that the required interventions were not consistently implemented, resulting in the resident being left without the necessary fall prevention measures as specified in their care plan.
No Documented Physician Evaluation After Resident Fall
Penalty
Summary
The facility failed to ensure the physician reviewed the resident's total program of care for one resident who was involved in a fall. Resident #8 was admitted with diagnoses including diabetes mellitus, hypertension, and depression, and the MDS dated 10/23/2025 documented intact cognition and independence in bed mobility, transfers, and toilet use. On 07/30/2025, a nurse documented that the resident was sitting in the day room, fell from a chair while asleep, and had a scant amount of blood noted on the left nostril that was cleaned with no further bleeding observed. The note stated that Physician #1 was notified. A later nursing note documented that the resident was observed on the floor in the day room, stated they fell asleep while sitting in the chair, had a scant amount of blood in the left nostril, no visible injury, and denied pain. The interdisciplinary progress notes from 07/30/2025 through 08/05/2025 contained no documented evidence that a physician assessed or evaluated the resident related to the fall. During interviews, the RN stated the physician was notified, the NP did not recall being notified, and the physician did not recall whether they were notified or whether the resident fell. The DON stated physicians are to evaluate residents within 24 to 48 hours after a fall, and the Medical Director stated residents must be seen by the medical provider and that the assessment must be documented in a progress note even when there is no injury.
Medical Records Not Readily Accessible for Drug Regimen Review Reports
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices because drug regimen review reports were not systematically organized or readily accessible. This was identified for five of five sampled residents reviewed for unnecessary medications: Residents 4, 7, 56, 68, and 88. The facility’s policy required the consultant pharmacist to complete monthly medication regimen reviews and provide written recommendations with prescriber responses, with copies maintained in an easily retrievable location for surveyor review upon request. During record review, copies of the drug regimen review reports with prescriber responses for the five residents were not available when requested by State Surveyors and were not provided until several working days later. Staff interviews showed the pharmacy consultant emailed the reports to the DON, and the DON stated the reports were kept in a binder in the nursing office, but the reports for residents covered by the Medical Director were missing. The DON later found those missing reports in the Medical Director’s office. The Medical Director stated they kept a copy of the recommendations in the Medical Director’s office, and the Administrator stated they printed necessary documents and gave them to the DON for filing.
Failure to Document Resident Influenza and Pneumococcal Immunization Offers
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal and influenza immunizations, as required by its policies. During the recertification survey, surveyors found no documented evidence that Residents #25, #88, and #202 were offered, educated, received, or declined the influenza immunization, and no documented evidence that Residents #25, #88, #99, #153, and #202 were offered, educated, received, or declined the pneumococcal immunization. Resident #25 was admitted with diagnoses including paranoid schizophrenia, cerebral infarction, and type 2 diabetes mellitus, and the Quarterly MDS documented intact cognition. The record showed the resident’s pneumococcal immunization status was not up to date because it was not offered, and the facility could not provide documentation that the resident was offered and educated on either the pneumococcal or influenza immunization. Resident #88 was admitted with diabetes mellitus, schizophrenia, and Alzheimer’s disease, and the Significant Change MDS documented severely impaired cognition. The record showed pneumococcal immunization status was not up to date because it was not offered; the facility had documentation that the resident’s representative was offered, educated, and authorized both immunizations, but could not provide evidence that the immunizations were actually received. Resident #99 was admitted with paranoid schizophrenia, dementia, and anemia, and the Quarterly MDS documented severely impaired cognition. The record showed pneumococcal immunization status was not up to date because it was not offered; the facility had documentation that the representative was offered and educated on the pneumococcal immunization, but the form did not document whether it was authorized or declined, and there was no evidence it was received. Resident #153 was admitted with bipolar disorder, anemia, and COPD, and the Discharge MDS documented intact cognition; the facility could not provide documentation that the resident was offered and educated on the pneumococcal immunization. Resident #202 was admitted with cerebellar stroke syndrome, behavioral disturbance, and dementia, and the Quarterly MDS documented severely impaired cognition; the record showed pneumococcal immunization status was not up to date because it was offered and declined, but the facility could not provide documentation that the pneumococcal immunization was offered, that education was provided, or that the resident declined it, and there was also no documentation that the influenza immunization was offered and educated.
Failure to Document and Offer COVID-19 Immunizations
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 immunization and failed to maintain documented evidence of screening, administration or declination, and education for four residents sampled for immunizations. Resident #25 had diagnoses including paranoid schizophrenia, cerebral infarction, and type 2 diabetes mellitus, and the Quarterly MDS documented intact cognition and that the resident’s COVID-19 immunization status was not up to date, but the facility could not provide documentation that the resident was offered or educated on the vaccine. Resident #153 had diagnoses including bipolar disorder, anemia, and COPD, and the Discharge MDS documented intact cognition and that the resident’s COVID-19 immunization status was not up to date, but there was no documented evidence that the resident was offered or educated on the immunization. Resident #99 had diagnoses including paranoid schizophrenia, dementia, and anemia, and the Quarterly MDS documented severely impaired cognition and that the resident’s COVID-19 immunization status was not up to date. The facility provided evidence that the resident’s representative was offered, educated, and authorized the immunization, but the form did not document whether the vaccine was accepted or declined, and the facility could not provide evidence that the resident received it. Resident #202 had diagnoses including cerebellar stroke syndrome, behavioral disturbance, and dementia, and the Quarterly MDS documented severely impaired cognition and that the resident’s COVID-19 immunization status was not up to date, but the facility could not provide documented evidence that the resident was offered or educated on the vaccine. During interviews, the Infection Preventionist stated the folder containing resident immunizations was deleted from the computer and that residents or representatives had to be contacted a second time for authorizations or declinations. The DON stated the facility offers COVID-19, influenza, pneumococcal, and RSV immunizations, but could not explain why the immunization records were not found in the EMR or immunization binders.
Nonfunctioning Call Bell System on Second Floor
Penalty
Summary
The facility failed to ensure that a working call system was available in residents’ bathrooms and bathing areas on the second floor. During observation and testing, the call light indicator would illuminate when pressed, but there was no audible bell sound in the north corridor or at the nursing station, and later testing showed that the lights above the doorway lit up but none of the call bells in any room emitted a sound. This condition was identified for 25 out of 25 rooms on the second floor. Interviews confirmed that residents were being given hand bells because the call bell system was not functioning properly. A resident in one room stated the facility had provided a hand bell because the call bells were broken, and another resident said they also had a hand bell and still pressed the call bell even though it did not make a sound because the light usually attracted staff after some time. A CNA stated the call bells on the second floor had always been broken during the two years they had worked there, and an RN stated the call bells had never been properly working in all rooms on the second floor during the year they had worked there. The Maintenance Director stated the system was very old, that parts were difficult to obtain, and that a contractor had identified it as antiquated. The Administrator stated some parts were no longer manufactured and that the facility was waiting for a contractor proposal to replace the system.
Missing Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nurse aides were provided the required 12 hours of annual in-service training. During the recertification survey, record review showed that Certified Nursing Assistants #14, 15, 16, 17, and 18, all currently employed by the facility, had no documented evidence of receiving the required annual in-service education. The deficiency was identified based on review of the facility’s Employee Education Inservice Policy and the Facility-wide Assessment, both of which stated that the facility maintains an ongoing in-service education program and that nurse aide in-service training must include no less than 12 hours per year. Interviews with facility leadership showed that the Assistant Director of Nursing had been hired on 06/16/2025 and stated they were responsible for staff education, but had only arranged and provided four hours of in-service training since starting. The Assistant Director of Nursing also stated that prior staff in-service records were taken by the former Assistant Director of Nursing when that person was terminated. The Human Resources Director stated that staff education records were not kept in HR and were maintained in the nursing office, while the Director of Nursing stated that the previous Assistant Director of Nursing was terminated and took all paperwork, including staff education records, due to a grudge against the facility.
Failure to Provide Written Transfer/Discharge Notice
Penalty
Summary
The facility failed to ensure that a resident was notified in writing, in a language and manner they could understand, of the transfer or discharge and the reasons for the move when the resident was sent to the hospital. Resident #153 was admitted with diagnoses including anxiety disorder, bipolar disorder, and COPD. The Quarterly MDS documented that the resident’s cognition was intact, the resident used oxygen, and the resident participated in assessment and goal setting. Review of the medical record for the hospitalization period showed no evidence that a Notice of Transfer or Discharge form was completed or provided to the resident or the resident’s representative. The facility’s policy stated that when the facility initiates a transfer or discharge, notice will be provided to the resident and representative in a manner they can understand. During interviews, the Social Worker Director stated the resident was transferred to the hospital and did not receive discharge notification because they were just hospitalized, and also stated that the Ombudsman receives transfer and discharge notifications monthly. The DON stated it was the social workers’ responsibility to provide the discharge notice upon transfer, and the Administrator stated they would need to audit discharges to ensure proper notifications were made.
Missing Care Plan for Infection Precautions
Penalty
Summary
A comprehensive person-centered care plan was not developed and implemented for Resident #142 to address infection-related needs, including Contact Isolation, MRSA, and Osteomyelitis. Resident #142 was admitted with diagnoses including Osteomyelitis of the vertebrae and MRSA, and the admission MDS documented intact cognition. The physician order initiated on 11/06/2025 and renewed on 12/04/2025 required Contact Isolation for Bacteremia/MRSA, and a nurse's progress note on 11/18/2025 documented that contact precautions were maintained due to MRSA/Bacteremia. Despite these findings, there was no documented evidence of a comprehensive care plan related to Contact Precautions, MRSA, or Osteomyelitis. During interviews, the Nursing Supervisor stated that Resident #142 had no care plan developed for contact precautions related to infections and said care plans should have been created upon admission. The MDS Coordinator stated nursing supervisors review admission and readmission orders and initiate appropriate care plans, and the DON stated the Nursing Supervisor is responsible for initiating care plans on new admissions and that everything coded in the admission MDS must have a corresponding care plan.
Resident Served Pork Despite Documented No-Pork Preference
Penalty
Summary
The facility failed to ensure that a resident received food that matched documented preferences and meal ticket instructions. Resident #35 had intact cognition, was independent with eating, and had care plan preferences documented for chicken and fish, with beef and pork listed as dislikes. The care plan also directed that food preferences be met within diet guidelines, and the resident was on a regular diet with thin liquids. During meal observation, the resident’s lunch tray contained pork even though the tray ticket documented no beef or pork. The resident stated that most of the time the meal ticket did not match what was served and that the facility kept serving pork and beef despite repeated complaints. The resident also stated that when they asked for an alternate item, staff told them they would be given whatever was available in the kitchen. Staff interviews showed that the tray was prepared in the kitchen and sent to the unit, but the tray line process was not consistently ensuring that the food matched the ticket. Dietary staff stated they were only doing spot checks and that the loader was now checking tray accuracy, while nursing staff stated they generally did not check trays when distributing them. The Dietary Supervisor and Administrator both acknowledged that the facility did not have a Food Service Director at the time and could not explain why the resident continued to receive pork despite the documented preference against it.
Improper Handling of a Pillow After Contact With the Floor
Penalty
Summary
The facility failed to maintain infection control practices and procedures for one unit when Certified Nursing Assistant #5 picked up Resident #152’s pillow from the floor and placed it under the resident’s head without changing the pillowcase. The report states the facility policy titled Linen Handling and Infection Control, reviewed 12/2024, required safe and sanitary handling of clean and soiled linens and resident clothing to prevent the spread of infection, including linens contaminated by contact precautions, blood, body fluids, or wound drainage. During an observation on 12/01/2025 at 10:07 AM, Resident #152 was seated in a reclining wheelchair in the hallway with a pillow on the floor next to them. CNA #5 picked up the pillow from the floor and placed it under the resident’s head without changing the pillowcase. In an interview moments later, CNA #5 stated they were supposed to change the pillowcase before placing the pillow under the resident’s head and said they made a mistake. An LPN later stated the pillowcase should have been changed because the floor is dirty, and the DON stated CNAs should know to change the pillowcase when a pillow falls on the floor.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that residents could examine the results of the most recent state survey or that those results were posted in a place readily accessible to residents and family members. The facility’s policy, Survey Results, with a review date of 06/2025, stated that the most recent standard annual survey results and any subsequent complaint survey results were to be posted in an area available to residents, families, visitors, and surveyors. During the Resident Council Meeting on 12/02/2025, 11 residents stated they did not have access to the survey results, and Resident #35 stated that signage directed people to the location where the results were supposed to be posted. Observations on 12/01/2025 and 12/02/2025 confirmed that signage was posted in the lobby elevator area indicating where the survey results could be found, but the bin at that location was empty and the results were not posted anywhere else there. On 12/02/2025, the DON provided a white binder containing only the results of a complaint survey conducted on 05/29/2025. The DON stated that the results could not be kept in the binder because residents take them and tear them up. The Administrator later stated that the surveys are kept in the binder in the bin and that they place them there, but do not personally check to see if they remain in place; when shown the empty binder, the Administrator stated they did not know why the results were not in it.
Facility Assessment Listed Hospice as a Service Despite No Contract
Penalty
Summary
The facility failed to ensure that its Facility-wide Assessment accurately reflected the services it provided. The assessment, last reviewed in 09/2025, stated that it would be completed annually and updated when significant changes occurred, and it listed Hospice Care as a special treatment and condition even though it also noted that 0 residents were on hospice. During an interview, a family member of Resident #88 stated that the resident had been admitted for hospice care and that both the hospital discharge planner and the facility website documented hospice as an offered service, but the family later learned that hospice was not available and only palliative care was provided. The DON confirmed that the facility had no hospice contract and provided palliative care but not hospice care, and the Administrator stated that the hospice contract had been terminated in 2021 and that continuing to list hospice as an offered service was an oversight.
Failure to Timely Report and Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure timely reporting and follow-up of alleged misappropriation of resident property to the State Survey Agency as required by regulations. In three cases involving residents with intact cognition and various medical diagnoses, allegations were made that staff members borrowed money from residents and did not repay it. The facility did not report one of these allegations to the New York State Department of Health within the required 24-hour timeframe, and in all cases, failed to submit the required Follow-Up Investigation Reports within five business days of the incidents. For one resident with depression and opioid abuse, an allegation was made that a patient care assistant borrowed money several months prior and did not repay it. The initial report to the state was delayed, and the follow-up investigation report was also submitted late. The facility's investigation could not substantiate the allegation due to inconsistent statements and lack of corroborating evidence. Another resident with cerebral palsy, anxiety disorder, and hypertension reported a similar incident involving a certified nursing assistant. While the initial report was timely, the follow-up investigation report was again submitted late, with the investigation unable to confirm the allegation due to lack of witnesses and denial by the staff member involved. Interviews with facility leadership revealed a lack of awareness regarding the specific reporting timelines for both initial and follow-up reports. The Director of Nursing and the Administrator both indicated they were either unaware of the requirements or the late submissions, and delays were attributed to the need for additional information and difficulty contacting involved staff. Facility policy and state guidance both require immediate reporting and timely completion of investigations, which were not followed in these cases.
Failure to Immediately Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with multiple medical conditions, including Multiple Sclerosis, Hemiplegia, and Adjustment Disorder. The resident, who had intact cognition and required assistance with activities of daily living, reported to the Director of Recreation and a nursing supervisor that two Certified Nursing Assistants had threatened to slap them if they pressed the call bell again. The Director of Recreation documented the allegation but did not immediately report it to the appropriate supervisory staff, citing a lack of specific details such as the staff member's name or the date of the incident. Instead, the written statement was placed in the mailboxes of the Social Worker and, purportedly, the Director of Nursing, but was not directly communicated to them. As a result, the Social Worker and Director of Nursing were not made aware of the allegation until several days later, delaying the initiation of an internal investigation. The facility's policy required immediate reporting and prompt initiation of investigations into abuse allegations, but this process was not followed. There was no documented evidence that an investigation was started until days after the initial report, and no immediate measures were put in place to protect the resident from further potential abuse.
Failure to Timely Transfer Deceased Residents' Personal Funds
Penalty
Summary
The facility failed to transfer the personal funds of two deceased residents to the probate jurisdiction administering their estates within the required 30-day period. According to the facility's admission agreement, refunds for the balance in a resident's personal account, after deducting any amounts owed to the facility, are to be made to the resident after discharge or, in the case of death, to the probate jurisdiction or by a New York small estate affidavit, unless otherwise claimed by the Department of Social Services. Record review showed that for two residents who had expired, there was no disbursement of their remaining funds or final accounting sent to the Public Administrator within the required timeframe. Interviews with facility staff revealed that the Payable Coordinator is responsible for reviewing monthly reports to identify residents who have been discharged or have expired and who have a balance left in their accounts. The Payable Coordinator acknowledged that the funds for the two deceased residents were not transferred within 30 days but could not provide an explanation for the delay. The Administrator confirmed the process for transferring funds after a resident's death but also indicated that the required transfer did not occur within the specified period for these cases.
Failure to Assess and Notify Physician After Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure a comprehensive clinical assessment was performed to identify changes in a resident's condition and did not provide treatment and care in accordance with professional standards. The resident, who had a history of severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, traumatic brain injury with epilepsy, and incontinence, was observed with symptoms including a stuffy nose, low-grade fever of 100.5°F, and restlessness. Despite these changes, there was no documented evidence that the medical doctor was notified of the resident's elevated temperature and restlessness. Additionally, after acetaminophen was administered for the fever, there was no documentation of a follow-up assessment to evaluate the resident's response to the medication. Multiple staff interviews confirmed that the resident appeared weaker and was experiencing changes in condition, but the required notifications and assessments were not consistently documented or performed. The medical doctor was only informed after the resident had expired due to cardiac arrest secondary to coronary artery disease. The facility's policy required timely identification, documentation, and response to significant changes in a resident's condition, but these procedures were not followed, resulting in actual harm to the resident.
Failure to Notify Representative and Physician of Resident Condition Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's designated representative and physician of significant changes in the resident's condition. The resident, who was severely cognitively impaired and had multiple diagnoses including epilepsy, non-Alzheimer's dementia, depression with schizophrenia, traumatic brain injury, and incontinence, exhibited restlessness and developed a low-grade fever of 100.5°F. Certified Nursing Assistant observed the resident appearing weaker and reported this to the LPN, who documented the symptoms and administered Tylenol. The Registered Nurse Supervisor was notified and attempted to contact the medical doctor without success. However, there was no documentation that the resident's representative or family was informed of these changes, as required by facility policy and state regulation. Interviews with staff confirmed that the family was not notified because the resident was not perceived to be in distress, and there was no evidence of reassessment after Tylenol administration. The Director of Nursing acknowledged that both the physician and family should have been notified when the resident exhibited fever and restlessness. The lack of notification and documentation constituted a failure to comply with the facility's policy and regulatory requirements for informing representatives of significant changes in a resident's condition.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable temperature levels throughout the building, as required by federal and state regulations. Observations during the survey revealed that all sampled resident rooms, corridors, and stairwells on five resident floors had temperatures below the required range, with some areas as low as 40 to 53 degrees Fahrenheit. Multiple complaints and grievances were filed by residents regarding the loss of heat over a period of time, and maintenance logbooks documented ongoing heating issues in 23 resident rooms. Despite these reports, there was no documented evidence that the facility had identified or addressed unsafe room temperatures. The Administrator was unaware of the loss of heat or that room temperatures had dropped below regulatory standards, and stated that the PTAC units were not necessary because the boiler was supposed to provide heat. However, maintenance records and vendor invoices indicated that the boiler system was not functioning properly, with only 5 of 13 boilers operational at one point, and that the facility had not maintained an active service contract for preventive maintenance. Vendor communications documented repeated recommendations and proposals for repairs and maintenance that were not addressed by the facility. Staff interviews confirmed that the heating issues were discussed in meetings and that activities staff were called in to distribute hot drinks due to the cold conditions. The Medical Director was not aware of the heat-related issues, and temperature logs maintained by the facility were incomplete, lacking specific room or corridor information. The facility's failure to maintain adequate heating resulted in Immediate Jeopardy and Substandard Quality of Care, affecting all residents in the building.
Removal Plan
- Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs revealed temperatures within acceptable ranges.
- Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas.
- The Administrator provided a vendor contract to provide annual maintenance to boilers, and for the maintenance of Packaged Terminal Air Conditioner units.
- The facility completed staff training on identifying and addressing temperature related issues, procedures for reporting issues, deploying emergency measures, and ensuring resident comfort. All staff received the in-service.
- Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the temperature.
- The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues.
Failure to Maintain Safe Temperatures and Boiler Maintenance
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels in residents' rooms and common areas, as required by State and Federal regulations. Six resident grievances were filed over several days regarding lack of heat, and observations confirmed that temperatures in all sampled rooms, corridors, and stairwells were below required ranges. The Administrator was not aware of the loss of heat in the building during this period. Additionally, there was no documented evidence that the boiler room equipment and Packaged Terminal Air Conditioner (PTAC) units were routinely maintained. The PTAC units were found to be incorrectly connected and not providing heat, and the boilers were not functioning adequately due to lack of maintenance. The Director of Maintenance reported that attempts to have the boilers serviced were unsuccessful because the vendor refused to come due to overdue unpaid balances, and all requests for materials or services required prior approval from the Administrator. The vendor confirmed that the boilers had significant issues from lack of maintenance and were operating at only 40% capacity, with proposals for repairs sent to both the Administrator and Director of Maintenance. Despite this, the Administrator denied receiving any such communications. These failures resulted in Immediate Jeopardy due to the likelihood of more than minimal harm to all residents.
Removal Plan
- The Administrator is conducting meetings with department heads to review any issues.
- Staff have been in-serviced, a policy was created on how agency staff will also be in-serviced.
- Morning meetings attended by all department heads are being conducted.
- Resident council meeting was rescheduled.
- The Administrator provided documentation of regular rounds.
- A binder of Vendor Documents was created and placed at the Security Desk by the elevators.
- Emergency Preparedness plan for loss of heating was revised and discussed at the QAPI meeting, the Administrator is the Acting Director of Maintenance.
Failure to Maintain Boiler System Results in Inadequate Heating
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically neglecting routine maintenance of the boiler system. The annual service contract for the boilers had expired, and the facility did not have a current contract in place. Multiple proposals and quotes from vendors to address identified boiler deficiencies and to provide ongoing maintenance were not acted upon by the facility. Invoices and service records showed repeated reports of insufficient heat and hot water, with only a fraction of the boilers functioning at any given time. The lack of maintenance led to the heating system malfunctioning, resulting in inadequate heating throughout the building. Observations during the survey revealed that temperatures in resident rooms, corridors, and stairwells were below the required state and federal ranges, with some areas measured as low as 40 degrees Fahrenheit. Resident rooms closest to the stairwells had the lowest temperatures. There was no documented evidence that the facility staff were inspecting or maintaining the heating system equipment, including the boilers and Packaged Terminal Air Conditioner (PTAC) units. The Director of Maintenance confirmed that the PTAC units were not blowing hot air due to incorrect connections and that the Administrator had been made aware of the issue. Interviews with the Director of Maintenance, the Administrator, and the boiler vendor revealed that the vendor had stopped servicing the facility due to unpaid bills, and that the Director of Maintenance was not permitted to order services or materials without prior approval from the Administrator. The Administrator was unaware of the extent of the heating issues and the low temperatures in resident rooms. The vendor reported that the boilers were operating at only about 40% capacity due to lack of maintenance, which contributed to the insufficient heat and hot water throughout the building.
Removal Plan
- Packaged Terminal Air Conditioner units were deployed to all affected areas. Residents were relocated to warmer areas of the facility and temperature checks of all residents' rooms were conducted by the facility. A review of the temperature logs revealed temperatures within acceptable ranges.
- Extra blankets and clothing were distributed to the residents by Housekeeping and Activities staff, hot beverages were provided, and residents had the option of staying in the warmer common areas.
- The Administrator provided a vendor contract for annual boiler maintenance and the maintenance of Packaged Terminal Air Conditioner units.
- The facility completed staff training on identifying and addressing temperature-related issues, procedures for reporting problems, deploying emergency measures, and ensuring resident comfort. 100% of staff received the in-service.
- A Quality Assurance meeting was held to discuss the findings of the Immediate Jeopardy. Wall thermometers have been installed in residents' rooms and staff were given in-service education on reading the thermometers.
- The Emergency Preparedness plan for Loss of Heat was revised to include immediate deployment of portable units and proactive monitoring and escalation processes for heating issues.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, as evidenced by an incident involving two residents. Resident #118, who had a history of stealing and involvement in physical altercations, was not adequately supervised or monitored despite staff awareness of their behavior. On August 2, 2024, Resident #118 snatched a $20 bill from Resident #151's hand in an elevator, leading to Resident #151 hitting Resident #118 on the head with a cane. This altercation resulted in Resident #118 sustaining head lacerations that required emergency medical intervention, including 14 staples. The facility's policy on Abuse Prohibition and Prevention, which was reviewed in May 2023, mandates a zero-tolerance approach to abuse and requires the provision of a safe environment for all residents. However, the facility's investigation into the incident revealed that there was cause to believe resident abuse had occurred. Despite the policy's requirements, there was no documented evidence that the care plans for either resident were reviewed or updated following the incident. Resident #151 had a care plan for victimization, but it lacked evidence of evaluation or revision after the altercation. Similarly, Resident #118's care plan, which included interventions for behavior monitoring and safety, was not updated, and there was no evidence of the required close observation or 1:1 monitoring. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, highlighted a lack of consistent monitoring and supervision of Resident #118, particularly when they left their assigned unit. Staff members were aware of Resident #118's behavior issues, such as stealing and wandering to other units, but there was no clear protocol for monitoring the resident's movements or ensuring their safety. The Director of Social Services acknowledged the altercation but indicated that the responsibility for monitoring and intervention lay with the nursing department. The Director of Nursing confirmed awareness of Resident #118's behavioral issues but did not provide a clear response on how the resident was monitored when leaving their unit.
Failure to Review and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised periodically and after each assessment, including both comprehensive and quarterly review assessments. This deficiency was evident in the cases of three residents. Resident #84's care plan for an indwelling catheter was not reviewed and revised after returning from an emergency room visit due to urinary retention and pain at the catheter insertion site. Additionally, the care plan was not updated after quarterly assessments and the annual assessment. Resident #118's care plan interventions for behavior and victimization were not reviewed and evaluated after a resident-to-resident physical abuse incident. The care plan lacked updates following the incident where Resident #118 was hit in the head by another resident. Furthermore, there was no documented evidence of close observation or 1:1 monitoring as stated in the care plan interventions. Resident #151's care plan interventions were not reviewed and evaluated following a resident-to-resident physical altercation. The care plan for victimization was not updated after the incident, and there was no evidence of the interventions being reviewed. The Director of Nursing acknowledged that the nurse supervisor is responsible for updating the care plans, but the oversight was not addressed.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents, as evidenced by observations, record reviews, and interviews conducted during the Recertification and Abbreviated Survey. Several residents reported a shortage of Certified Nursing Assistants (CNAs), particularly during evenings and weekends, leading to delays in assistance with toileting, bathing, and personal care. The facility's staffing schedules from July to November 2024 consistently showed fewer CNAs than required, with some shifts having only one CNA for units with up to 45 residents. Interviews with residents revealed significant delays in response times to call bells, with some residents waiting up to four hours for assistance. Residents expressed frustration over the lack of timely help, which sometimes resulted in missed showers and inadequate personal care. Staff interviews corroborated these findings, with CNAs and nurses acknowledging the staffing shortages and the resulting challenges in providing adequate care. The facility's staffing plan indicated a need for 4 CNAs per unit during day and evening shifts and 3 during night shifts. However, actual staffing often fell short of these numbers, with agency staff frequently not showing up for work. The Director of Nursing and the Administrator acknowledged the staffing issues, citing challenges in hiring and retaining staff, particularly due to better pay offered by staffing agencies. Despite efforts to improve staffing, the facility continued to struggle with maintaining adequate levels of care.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews for Certified Nursing Assistants (CNAs) were conducted at least once every 12 months, as required by their policy. This deficiency was identified during a Recertification Survey conducted from November 13 to November 21, 2024. The facility's policy, dated June 2024, mandates annual performance reviews for nurse aides, but a review of personnel files for five CNAs showed no documented evidence of such reviews. Interviews with the Director of Human Resources and the Director of Nursing revealed that the CNAs were hired years ago, and no performance reviews could be located in their files. The Director of Nursing could not explain the absence of these reviews. The Administrator acknowledged that the Nursing Department is responsible for conducting these evaluations and attributed the oversight to personnel changes within the facility, which led to the responsibility of performance reviews being neglected. The facility's assessment tool, dated October 2024, indicated that performance reviews should provide structured feedback and identify areas for improvement, but it did not specify the frequency of these reviews. This lack of adherence to policy and oversight resulted in the deficiency noted by the surveyors.
Inadequate Administration and Staffing Deficiencies
Penalty
Summary
The facility was found to be inadequately administered, failing to use its resources effectively and efficiently to ensure the highest practicable well-being of its residents. The administration did not maintain sufficient staffing levels to meet residents' needs, and there was a lack of monitoring and enhancement of care quality, as evidenced by repeated deficiencies from previous surveys. These deficiencies included issues with activities of daily living, medication storage, infection control, and performance evaluations for nursing assistants. The administration was aware of the staffing issues but did not provide evidence of efforts to retain staff or monitor previous citations to prevent recurrence. The Director of Nursing was also aware of the staffing issues but did not understand the extent of their impact on resident care and services. During interviews, the Director of Nursing admitted to being unaware of several issues, including infection control problems, deflated mattresses, and outdated care plans. The Director of Nursing also could not explain how residents with behavioral issues were supervised when off the unit. The Administrator acknowledged the repeated staffing deficiency and mentioned contracting staffing agencies to fill positions, but was unaware of the newly identified issues, considering them isolated incidents.
Lack of Active Governing Body and Inadequate Resident Care
Penalty
Summary
The facility was found to lack an active governing body responsible for establishing and implementing management policies, as evidenced by multiple deficiencies identified during the Recertification and Complaint Survey. There was inconsistent communication between the facility Administrator and the Governing Body, which hindered effective management and regulatory compliance. The facility's policy on Quality Assurance and Performance Improvement (QAPI) indicated that the Governing Body is accountable for the program, including identifying and prioritizing problems and ensuring corrective actions are effective. However, the Operator/Owner of the facility admitted to attending QAPI meetings only once a year, relying on the Administrator to submit monthly reports, which suggests a lack of active oversight. During a Special Resident's Council Meeting, residents reported that call lights were not answered promptly, especially on weekends, and they were often left in bed due to insufficient staffing. These concerns were previously raised in an August 2024 Resident Council meeting, where issues such as staff using cell phones, poor customer service, and room cleanliness were also noted. The residents expressed that the facility did not act promptly on their concerns, and there was no follow-up from the staff, indicating a failure in addressing and resolving resident issues effectively.
Inadequate QAPI Program and Oversight Lead to Widespread Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program effectively identified and prioritized problems and opportunities for improvement. This was evident during the Recertification and Complaint Survey, where widespread deficiencies were noted in Nursing Services, Administration, and Infection Control. The facility also had repeated deficiencies from previous surveys, indicating a lack of effective corrective action. The QAPI plan, last revised in May 2023, was intended to guide the facility in improving the quality of care and resident life, but the facility could not provide documented evidence of systems and reports for identifying, reporting, investigating, analyzing, and correcting these deficiencies. Interviews with facility staff revealed a lack of awareness and oversight regarding the deficiencies. The Director of Nursing was unaware of the infection control issue, attributing it to an isolated incident and new staff. The Administrator acknowledged awareness of staffing issues but claimed other issues were isolated and not previously known. The Operator/Owner attended QAPI meetings only once a year and relied on the Administrator for compliance, indicating insufficient oversight by the governing body. This lack of effective governance and oversight contributed to the facility's failure to address and rectify ongoing deficiencies.
Infection Control Deficiency in Equipment Sanitization
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed during the recertification survey. Specifically, Licensed Practical Nurse #4 did not sanitize the blood pressure machine and cuff after using them on Residents #69, #47, and #92. This oversight occurred despite the facility's policy requiring equipment shared between residents to be cleaned and disinfected after each use to prevent cross-contamination. Licensed Practical Nurse #4 acknowledged forgetting to sanitize the equipment after each use. Similarly, Registered Nurse #5 did not sanitize the glucometer after using it for finger stick blood sugar tests on Residents #412 and #87. The nurse also failed to perform hand hygiene after removing gloves and before leaving the residents' rooms. Although Registered Nurse #5 was aware of the requirement to clean the glucometer after each use, they did not adhere to this practice during the observed instances. Additionally, Licensed Practical Nurse #1 did not sanitize the blood pressure machine and cuff after using them on Residents #7 and #74. Despite having received education on the necessity of cleaning the equipment after each use, Licensed Practical Nurse #1 admitted to missing this step. The Director of Nursing and Infection Prevention Nurse confirmed that licensed nurses had received in-service education on cleaning equipment between resident usage.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services and assistance to maintain grooming and personal hygiene. This deficiency was identified during a Recertification and Complaint Survey, where it was found that two residents, Resident #48 and Resident #169, were not provided regular showers according to their care plans. The facility's policy required that residents be offered showers as specified in their care plans, but this was not adhered to for these residents. Resident #48, diagnosed with Cerebral Palsy and Depression, required substantial assistance for showering and had a care plan specifying showers twice a week. However, records showed that Resident #48 received only bed baths on certain dates and not the scheduled showers. Interviews revealed that Resident #48 preferred showers at a later time, but this preference was not accommodated, and there was a lack of communication among staff regarding the resident's preferences and care needs. Resident #169, with diagnoses including Non-Alzheimer's Dementia and Bipolar Disorder, was also dependent on staff for bathing. The care plan specified showers twice a week, but records indicated that showers were not consistently provided according to the schedule. Staff interviews highlighted a lack of awareness and communication regarding the resident's shower schedule, contributing to the failure to provide the necessary care. The Director of Nursing acknowledged the issue but could not explain why the residents did not receive showers as per their care plans.
Failure to Maintain Pressure Relief Mattress for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident at risk for developing pressure ulcers received care consistent with professional standards to prevent pressure ulcers. This deficiency was identified for a resident with a history of healed pressure ulcers who had a care plan for using a pressure ulcer relieving device when in bed. The resident was observed with a deflated air mattress on three occasions, which was not addressed by the facility staff despite the resident's complaints of pain and discomfort. The facility's policy required regular inspection and maintenance of mattresses, including specialized pressure relief mattresses. However, there was no documentation of the use of pressure relieving devices for the resident, and the maintenance log did not record any entries regarding the deflated mattress. Interviews with staff revealed a lack of awareness and communication regarding the mattress issue, with the primary Certified Nursing Assistant unaware of the deflation, and the Maintenance Director stating that the maintenance department does not oversee mattresses. The Wound Care Nurse was only notified of the issue after the surveyor's observation, and a leak was found in the mattress.
Failure to Provide Adequate Behavioral Health Care and Monitoring
Penalty
Summary
The facility failed to ensure that Resident #118 received necessary behavioral health care and services, as evidenced by multiple incidents of behavioral symptoms such as stealing from other residents and involvement in resident-to-resident altercations. The facility did not evaluate the effectiveness of interventions to address the resident's behavior, lacked an individualized approach in the care plan, and failed to monitor and supervise the resident adequately. The care plan for victimization/aggressive behavior was not updated following an altercation on 08/02/2024, and there was no documented evidence of close observation or 1:1 monitoring as required by the care plan. Resident #118 was admitted with diagnoses including violent behavior, unspecified mood disorder, and Parkinson's disease, which contributed to moderate cognitive impairment and required supervision with most activities of daily living. Despite these needs, the facility's care plans were not effectively implemented or updated to address the resident's ongoing behavioral issues. The care plans included interventions such as identifying triggers, room changes, and psychiatric evaluations, but these were not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and coordination in monitoring Resident #118's behavior. Certified Nursing Assistants and Licensed Practical Nurses acknowledged the resident's behavior issues but did not consistently monitor or redirect the resident when they left their unit. The Director of Social Services and the Director of Nursing were aware of the resident's behavior but did not ensure that appropriate interventions were in place or that care plans were updated. This lack of coordination and documentation contributed to the facility's failure to provide necessary behavioral health care and services to Resident #118.
Improper Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure that all medications and biologicals were stored safely, specifically concerning the storage of insulin pens. During a recertification survey, it was observed that insulin pens belonging to four different residents were stored together in a compartment in the top drawer of a medication cart on the 5th floor. This storage method did not comply with the facility's policy, which requires medications to be stored in accordance with manufacturer's specifications and professional standards to ensure proper sanitation. A registered nurse administering medications acknowledged the oversight, stating that the insulin pens should have been stored separately in individual plastic bags but were not due to being busy. However, the Director of Nursing contradicted this by stating there was no requirement to store insulin pens in individual plastic bags. This discrepancy highlights a lack of consistent understanding and implementation of the facility's medication storage policy.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination by not supporting their bathing preferences. Resident #48, who has cerebral palsy and depression, was assessed as cognitively intact and required substantial assistance for bathing. The resident expressed a preference for showering, which was documented as somewhat important in their assessment. However, the facility did not document the resident's bathing preferences in their care plan, and the resident's scheduled showers were not consistently provided. Instead, the resident received bed baths on several occasions without evidence of refusal or preference for this alternative. Interviews with staff revealed a lack of awareness and communication regarding the resident's preferences. Certified Nursing Assistants reported that the resident sometimes refused showers due to the early schedule, preferring evening showers instead. However, this preference was not communicated to or acknowledged by the nursing staff, and the resident's care plan was not updated to reflect this change. The Director of Nursing confirmed that the shower schedule could be adjusted based on resident preferences, but this was not done for Resident #48, leading to the deficiency.
Inaccurate Documentation in MDS Assessments
Penalty
Summary
The facility failed to ensure accurate documentation in the Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their recorded statuses. Resident #462's discharge status was inaccurately documented as being discharged to a short-term general hospital, while the nursing progress notes indicated the resident was discharged to the community. The MDS Coordinator acknowledged this oversight during an interview. Resident #311's diagnosis of Schizophrenia was omitted from the quarterly MDS assessment, despite being documented in the Hospital and Community Patient Review Instrument and a psychiatric evaluation. The MDS Coordinator expressed caution in coding Schizophrenia due to a memorandum from the Centers for Medicare and Medicaid Services, although the new psychiatrist did not diagnose Schizophrenia. Resident #118's behavioral symptoms were not documented in the MDS assessment, despite an incident where the resident was involved in a physical altercation after grabbing money from another resident. The Director of Nursing confirmed that the MDS Coordinator was responsible for the accuracy of the assessment. These inaccuracies in the MDS assessments reflect a failure to adhere to the facility's policy, which mandates a standardized and comprehensive assessment process to ensure proper care delivery and resident-centered care planning.
Failure to Submit Direct Care Staffing Data Timely
Penalty
Summary
The facility failed to submit the required direct care staffing information for Quarter 3 of 2024 in a timely manner, as mandated by the Centers for Medicare and Medicaid Services (CMS). According to the CMS Electronic Staffing Data Submission Payroll-Based Journal, facilities are required to submit direct care staffing information, including agency and contract staff, based on payroll and other auditable data. This data must be submitted quarterly and received by the end of the 45th calendar day after the last day of each fiscal quarter to be considered timely. However, the facility did not submit the necessary data for the period from April 1 to June 30, 2024, by the specified deadline. During interviews conducted as part of the Recertification Survey, the Director of Human Resources stated that they are responsible for ensuring all time management records of staff are completed and sent to the Administrator for submission. The Administrator, who is responsible for submitting the Payroll Based Journal, acknowledged awareness of the deadline but could not explain the failure to submit the data, attributing it to an oversight. This oversight resulted in non-compliance with the CMS requirements for timely submission of staffing data.
Staffing Shortages Compromise Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents, compromising their safety and well-being. The facility's staffing levels were consistently below the minimum levels assessed as necessary to provide adequate care. The staffing policy outlined the required number of licensed nurses and nurse aides, but the actual staffing schedules for April, May, and June 2024 showed repeated shortages, particularly on weekends. Interviews with staff and residents confirmed these deficiencies, with reports of inadequate staffing leading to delayed care and unmet needs. On specific dates, the facility experienced significant shortages of both Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs). For instance, on June 9, 2024, there were only 15 CNAs on the day shift against a required 20, and similar shortages were noted on other days. Staff interviews revealed that Registered Nurse Supervisors often had to perform the duties of LPNs due to these shortages. Additionally, the facility's Assistant Administrator, who also served as the Assistant Director of Nursing, acknowledged the staffing issues but was unclear on how adjustments were made according to the staffing policy. Residents reported negative impacts due to the staffing shortages, such as delayed medication administration and inadequate incontinence care. One resident mentioned waiting longer for medication on weekends and staying in bed due to insufficient staff to assist with transfers. Another resident expressed concerns about the lack of nurse aides, leading to delays in receiving care. The facility's Director of Nursing did not provide further clarification on the staffing procedure, indicating a lack of effective communication and management in addressing the staffing deficiencies.
Improper Garbage Disposal and Lack of Responsibility
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a Recertification Survey. The surveyors noted that the dumpster outside the facility was not covered, and various types of garbage were scattered on the ground around it. Items such as broken food service carts, an air conditioning unit, and wooden pallets were found lying next to the dumpster. Additionally, an overflowing garbage bin contained furniture, laundry containers, and computers, while an uncovered recycling bin had clear plastic bags with exposed cans and cardboard boxes. Flies were observed around the dumpster, indicating a lack of proper containment. Interviews with facility staff revealed a lack of clarity regarding responsibility for maintaining the garbage disposal area. The Director of Housekeeping stated that garbage pickup was scheduled for specific days and believed there was no need to cover bins containing non-perishable items. They also mentioned that the kitchen staff shared responsibility for maintaining the garbage bins. The Administrator was unaware of the garbage disposal issues and stated that the dumpster should not contain perishables, and lids should always be closed. It was unclear who was responsible for maintaining the garbage disposal area, contributing to the deficiency.
Inadequate Hot Water Supply in Facility
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the lack of consistent hot water supply across all six units observed during the recertification survey. The issue persisted from April through June, with maintenance logs indicating multiple entries of hot water supply problems. Observations revealed water temperatures significantly below the required 110 degrees Fahrenheit, with some shower rooms having no water flow or pressure. Residents reported being without hot water for months, and some were washed with cold water, highlighting the facility's failure to address the ongoing issue effectively. Interviews with staff and residents further confirmed the deficiency. The Maintenance Director acknowledged ongoing boiler repairs, while the Director of Nursing mentioned providing wipes to residents as a temporary measure. Despite these efforts, the Administrator claimed no resident complaints were received, contradicting resident statements during the Resident Council Meeting. The facility's inability to provide a policy on loss of hot water and the recurrence of the issue indicate a lack of adequate response to the deficiency.
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What surveyors actually found near you
We read the 1,488 citations issued within 25 miles in the last 12 months — including the 19 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bronx
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bronx Center For Rehabilitation & Health Care | 0.5 mi | ★★★★★ | 16 | 0 |
| Rebekah Rehab And Extended Care Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Williamsbridge Center For Rehabilitation And Nrsg | 1.9 mi | ★★★★★ | 0 | 0 |
| St Vincent Depaul Residence | 2 mi | ★★★★★ | 0 | 0 |
| Throgs Neck Extended Care Facility | 2.2 mi | ★★★★★ | 3 | 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.