Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Humboldt House Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow professional standards and its own policies for food storage and sanitation. In the kitchen, an active ceiling and A/C leak near the walk‑in refrigerator and freezer created standing water on the floor, while tray catties with food covers and a shelving unit with uncovered condiments and peanut butter were stored directly under the leaking area and tarp. Inspectors observed heavy grease and food debris on the commercial oven range and on the wall behind the stove and two‑bay sink, along with broken and missing wall tiles and peeled plaster. Ceiling pipes above food prep and serving stations were covered with thick dust, and a hand wash sink had a leaking drainpipe, a non‑working paper towel dispenser, and a stack of wet paper towels in the basin. The walk‑in freezer had a damaged door gasket, black debris on the window, significant condensation and ice buildup on the door, and a large ice accumulation inside. Interviews with dietary, maintenance, and administrative staff confirmed these problems had been ongoing for months and that staff were aware of the leaks, structural damage, and cleaning deficiencies.
A resident with CVA, schizophrenia, intellectual disability, and severe cognitive impairment, who required total assistance for hygiene and toileting and was incontinent of bowel and bladder, was found lying in bed on heavily urine-soaked linens, wearing only an incontinent brief, with multiple soiled linens, a soiled brief, feces, and dried food debris on the floor nearby. Despite this condition, a CNA delivered and left a lunch tray, which the resident fully consumed while still soiled. The care plan and Kardex lacked specific instructions for managing incontinence, staff acknowledged that incontinence care should occur every 2 hours and before meals, and leadership and a family member confirmed that the resident should not have been left in that undignified state, with the family member reporting ongoing issues of the resident being found soiled during visits.
A resident with a history of CVA, schizophrenia, and intellectual disability, who was severely cognitively impaired and totally dependent for personal hygiene and toileting, was found lying on a urine-soaked sheet with multiple soiled linens, feces, and dried food debris on the floor, and was served and consumed lunch without being cleaned or the room being sanitized. The resident’s care plan and Kardex lacked a bowel and bladder incontinence plan or clear incontinent care instructions, and there was no documentation of care refusal. A CNA reported providing care only once early in the morning despite an expectation for incontinent care every 2–3 hours, and video showed this CNA delivering the lunch tray while the resident remained soiled. The RN unit manager and corporate DON confirmed the resident required total assist for incontinence care and that care should have been provided regularly and before meals, while a family member reported the resident was consistently found soiled during visits.
A resident with quadriplegia, chronic kidney disease, and a history of UTIs had an indwelling Foley catheter and a care plan directing staff to keep the drainage bag below bladder level, provide catheter care each shift, and monitor and document output. Surveyors repeatedly observed the urine drainage bag, containing a large volume of amber urine with white mucus, lying directly on the floor while an LPN entered the room to administer medications and feed the resident without correcting the bag’s position. Later, despite posted enhanced barrier precautions and available supplies, a CNA wearing only gloves placed a urinal directly on the floor, emptied approximately 1,800 mL from the drainage bag while intermittently placing both the bag and urinal on the floor, left the spigot open on the floor during the process, and failed to clean the spigot tip with alcohol, contrary to facility policy and expected infection control practices.
Failure to Protect Residents from Abuse and Neglect: A cognitively impaired resident with a history of aggression repeatedly struck other residents, including hitting a resident in the face, throwing an object at another resident, and causing injury, fear, and pain. The facility’s monitoring and documentation after these incidents were incomplete, and staff did not consistently recognize the events as abuse. In a separate incident, an LPN/CNA used profanity toward a resident, refused requested care, and left the resident in a soiled brief with pants down and inadequate dignity protection; staff observed the condition and described it as abuse, but the facility did not.
Failure to timely report abuse allegations and investigation results: The facility did not report several suspected abuse events to the State Agency within required timeframes, and it also failed to send completed investigation findings within 5 working days. Incidents involved a resident with dementia and anxiety in a physical abuse allegation, a resident with cognitive impairment who reported verbal aggression and loss of dignity, and two residents involved in a suspected sexual abuse event. Staff and leadership acknowledged the events, but reporting was delayed or incomplete.
Insufficient overnight nursing staffing led to delayed resident care and missed medication administration. Residents reported long waits for pain meds, incontinent care, showers, and call bell response, while records showed one resident with dementia and hypothyroid missed a scheduled levothyroxine dose. Overnight schedules showed only one nurse on one shift and two nurses on another, below the facility’s expected minimum of one nurse per floor; the DON, staffing coordinator, RN supervisor, NP, and administrator all acknowledged the staffing was below that level.
The facility failed to ensure access to psych services when provider recommendations were made. A resident did not receive psychotherapy after the psychiatrist recommended it, and staff acknowledged no referral had been placed. Another resident with aggression, wandering, and elopement behaviors had a delay in psych follow-up during a period when the facility was between psychiatric providers. Leadership stated the facility did not have an appropriate process in place to secure psych coverage or arrange outside services when needed.
Medical Director Minimized Resident-on-Resident Altercation: The Medical Director did not fulfill responsibilities for overseeing resident care policies and coordinating medical care when discussing an altercation between two residents with dementia. After one resident punched another in the face, causing an abrasion, pain, crying, and fear, the Medical Director stated it was not abuse and described such behavior as something that happens when residents with dementia fight. The Administrator and DSW stated they expected the Medical Director to be knowledgeable about dementia-related behaviors and took the comments seriously.
Pest control was not effectively maintained across multiple resident-use floors, with rodent droppings found in resident rooms and a dietary storage area, dead mice discovered in a resident room, and a reported hole near a radiator where mice had chewed through baseboard. Fly activity was also observed in nourishment areas, the dishwash room, and several resident rooms, while ILT glue boards were full and exterminator reports showed the traps were not being inspected as expected.
Surveyors found damaged ceilings and walls, dust-coated fans, sticky and soiled floors, and persistent urine and body odor on multiple unit floors. Residents, family members, and staff reported that housekeeping was not keeping the areas clean, and staff observed leaking and water damage near resident beds, a nonfunctional fan in a tub/shower room, and room surfaces that were visibly deteriorated and unclean.
A resident who was cognitively intact and required extensive to maximal assist for bathing did not receive a weekly shower for three weeks despite wanting one. The care plan and shower schedule indicated weekly showers, but there was no documentation of a refusal or weekly skin checks in the progress notes. The resident stated the missed shower bothered them, and staff noted the shower schedule may have been affected by a room move.
Missing Nurse Aide Registry Screening for New Hires: The facility lacked documentation showing that a RN supervisor, a unit clerk, and a dietary supervisor were screened through the NYS Nurse Aide Registry before starting work. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy required background checks and registry screening, but personnel files contained no verification for these employees, and the Admin and HR Director could not locate the records.
A facility failed to include resident or representative participation in care planning and failed to keep a resident’s care plan current after a change in status. One resident with dementia and other diagnoses had no documented invitation sent to the representative for care plan meetings, and another resident’s care plan still listed 1:1 observation even after that intervention had been discontinued following an elopement-related transfer and placement of a wander guard.
A resident with hemiplegia, hemiparesis, stroke, aphasia, and severe cognitive impairment was observed seated in a wheelchair with the leg rests extended straight out and both feet hanging several inches above the floor for extended periods. Staff interviews confirmed the resident’s legs and feet were not properly supported, the leg rests were too long and not angled correctly, and the resident could not maintain both legs on the rests.
Failure to Follow Through on Ophthalmology Recommendations: A resident with schizoaffective disorder, DM2, and anxiety had outside ophthalmology consults recommending cataract surgery and later Laser Peripheral Iridotomy for both eyes, but the facility did not schedule the needed appointments. The resident reported worsening vision and said nothing had been done after giving paperwork to staff. Staff stated the consults were supposed to be reviewed and appointments arranged through the facility process, but the surgery referral had fallen through the cracks.
A resident with severe cognitive impairment, Wernicke’s encephalopathy, alcohol dependence, and type II DM eloped from the facility after exiting through a service door and fenced gate, then was found in a wheelchair at a nearby corner store. The resident’s care plan called for a wander detection bracelet and checks every shift, but staff observed the resident without the bracelet, the placement checks were not consistently implemented, and overnight functionality checks were not being completed. Interviews and record review also showed the service door alarm was not sounding and the door was not secure when the resident left.
A facility failed to ensure two residents received needed behavioral health services. One resident with bipolar disorder, MDD, and GAD had psychiatry notes recommending psychotherapy/supportive counseling and group therapy, but no evidence of counseling being provided and the social worker admitted no referral was made. Another resident with FTD, dementia, and aggression had a psychiatry follow-up recommendation, but there was a long delay before the next psych visit while nursing notes documented aggression, wandering, and elopement attempts.
The facility did not maintain an effective pest control program, as evidenced by multiple observations of dead mice, rodent droppings, and food debris in resident rooms and common areas. Staff and residents reported ongoing rodent sightings, and interviews revealed inconsistent awareness and response among staff. The exterior garbage compactor area was found littered with food waste and soiled items, attracting pests and flies, with no clear policy on pest control or garbage disposal in place.
A resident with chronic venous ulcers did not consistently receive wound care treatments as ordered by the physician, with multiple missed treatments and lack of documentation in the medical record. Observations showed wounds were uncovered or not dressed as ordered, and staff interviews confirmed that treatments were not always completed or properly documented, contrary to facility policy.
Two cognitively impaired residents were found engaged in sexual activity without staff knowledge, highlighting a failure in monitoring and protection. Despite policies against abuse, both residents lacked the capacity to consent, and the incident was only discovered when a CNA entered the room. The facility's investigation concluded the encounter was consensual, despite evidence of cognitive impairment.
A resident readmitted with multiple pressure and vascular ulcers did not receive a timely skin assessment, delaying treatment initiation. Facility policy required immediate assessment and treatment, but this was not followed, resulting in a two-day delay in obtaining physician orders and starting treatment.
A resident readmitted with multiple pressure and vascular ulcers did not receive a timely skin assessment, delaying treatment initiation. The facility's policy required a comprehensive skin examination upon admission, but this was not completed, leading to a lapse in care. The resident had conditions including peripheral vascular disease and protein calorie malnutrition, with several documented ulcers. A proper assessment and treatment orders were delayed by two days, contrary to the facility's protocol.
The facility failed to protect residents from abuse, including a resident threatened with scissors and two residents engaged in non-consensual sexual activity. Despite staff witnessing these incidents, appropriate actions were not taken to separate the residents or prevent further harm, leading to immediate jeopardy and substandard care.
The facility failed to report abuse and neglect incidents involving three residents in a timely manner. A resident-to-resident altercation involving a threat with scissors was not reported for three days, causing mental anguish. Additionally, two residents engaged in non-consensual sexual activity were not reported immediately, allowing the behavior to continue. Staff interviews confirmed the delay in reporting, contrary to facility policy.
The facility failed to provide a safe, clean, and homelike environment, with issues including inconsistent hot water temperatures, inadequate bathroom access, and poor maintenance. Residents reported difficulties with hygiene due to cold water, and some had to travel long distances to access bathrooms. Observations revealed soiled walls, mold, foul odors, and non-functioning call bells, indicating a failure to uphold residents' rights.
The facility failed to serve food and drinks at safe and appetizing temperatures, affecting residents on multiple floors. Meals were often cold and unpalatable, with residents reporting dissatisfaction and some relying on external food sources. Test trays confirmed that food temperatures were below required standards, posing a risk of foodborne illness.
The facility failed to maintain food safety standards in three nourishment unit refrigerators, with issues such as undated and unlabeled food items, liquid spills, and unsafe temperatures. Observations revealed that the Fourth floor Unit refrigerator lacked a thermometer and was not maintaining a safe temperature, while the Second floor Unit refrigerator also lacked a thermometer. Staff interviews indicated a failure to adhere to policies for food storage and temperature monitoring, leading to unsafe conditions.
A resident was not informed or allowed to participate in their care plan meeting, despite being cognitively intact and eager to attend. The facility's policy required advance notice for such meetings, but the responsible social worker failed to notify the resident, leading to their exclusion. Staff interviews confirmed the oversight, acknowledging the resident's disappointment.
A facility failed to treat residents with respect and dignity, as evidenced by an LPN's unprofessional behavior towards a resident and the lack of privacy in a shared bathroom. A resident was upset after an LPN used inappropriate language and slammed medication on a tray table. Additionally, a shared bathroom on the dementia unit lacked stall doors or privacy curtains, raising privacy concerns. Staff acknowledged these issues, highlighting deficiencies in resident care.
A facility failed to promptly and thoroughly investigate a resident-to-resident altercation involving a threat with scissors. The incident was not reported immediately, leading to a delayed investigation. The investigation lacked interviews with involved residents and potential witnesses, and the responsible party of the affected resident was not notified. The Director of Nursing considered the incident isolated, and the Administrator acknowledged the delay in reporting.
The facility failed to provide adequate hygiene and nail care for residents unable to perform activities of daily living. A resident did not receive timely incontinence care, leading to saturated linens and improper hygiene practices by CNAs. Another resident, dependent on staff for personal hygiene, had long, debris-filled fingernails, posing an infection risk. A third resident expressed a need for nail care, but staff only cleaned under the nails without trimming them, despite the potential harm of long nails.
A facility failed to provide adequate care and treatment for residents, including delays in antibiotic administration for a UTI, improper PICC line maintenance, and failure to administer prescribed supplements for electrolyte imbalances. These deficiencies were due to inaccurately transcribed orders, lack of supplies, and poor communication and documentation.
The facility failed to offer and document pneumococcal and influenza immunizations for several residents, as well as provide education on the benefits and side effects. Despite policies requiring documentation within five days of admission, records for residents with conditions like diabetes and COPD lacked evidence of immunization offers or education. Interviews confirmed the admitting nurse's responsibility for documentation, but the necessary records were not found.
Ongoing Kitchen Sanitation, Structural Damage, and Improper Food Storage Under Active Leaks
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own sanitation and food storage policies. Intermittent observations of the kitchen revealed an active ceiling leak near the walk‑in refrigerator and freezer, with a large opening in the plaster ceiling and a tarp suspended to divert water into a floor drain. An adjacent air conditioning ventilation unit was actively leaking, resulting in standing water pooled on the floor in front of the walk‑in units. Under this leaking area, staff had stationed tray catties holding numerous food covers and plate warmers, and a metal shelving unit extended under the tarp holding multiple uncovered condiments and food items such as salt, pepper, sugar, creamer packets, and containers of peanut butter. Additional observations showed widespread sanitation and maintenance problems in the kitchen. There was a significant accumulation of gray, dusty debris on ceiling pipes throughout the kitchen, including above food preparation and serving stations. The hand wash sink near the kitchen entry had an active drainpipe leak when in use, with a stack of partially wet paper towels in the basin and a non‑working paper towel dispenser above it. The wall behind the stove, oven, and two‑bay sink was heavily soiled with thick black grease and food debris and had broken and missing wall tiles, with peeled plaster in areas behind the stove, oven, and above the two‑bay sink. The commercial oven range’s exterior surfaces were heavily coated with grease and food debris, and staff acknowledged the stove should be cleaned after each meal but that it was not being cleaned properly. The walk‑in freezer also exhibited multiple structural and cleanliness issues. The freezer door gasket was not securely attached and protruded between the door and unit, and there was black debris on the freezer window, condensation and ice buildup on the interior and exterior lower sides of the door, and a large accumulation of ice on the floor and ceiling inside the unit. Interviews with the Food Service Director, Administrator, and Maintenance Supervisor confirmed that the kitchen ceiling leak and roof issues had been ongoing for months, that the freezer had required repeated service for condensation and ice buildup, and that broken and missing wall tiles had been a known issue since the prior year. Staff also acknowledged that condiments and tray catties should not be stored under the leaking ceiling, that the gasket needed replacement, that the pipes over prep areas should be cleaned, and that the wet paper towels at the hand sink should not be used, confirming ongoing noncompliance with the facility’s sanitation and food storage policies.
Failure to Provide Dignified Incontinence Care and Clean Environment During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect and dignity, including maintaining cleanliness and appropriate incontinence care. The resident had diagnoses of CVA, schizophrenia, and intellectual disability, was severely cognitively impaired, and required total assistance for personal hygiene and toileting, with documented bowel and bladder incontinence. The resident’s care plan and Kardex specified total assistance for hygiene and toileting but did not include specific interventions or instructions for managing bowel and bladder incontinence. On the survey date, the resident was observed in bed wearing only an incontinent brief, a small blanket, and a flat sheet that was visibly soaked and soiled with urine from shoulders to the foot of the bed. Between the bed and the wall, there were multiple soiled flat sheets, a soiled brief, a large amount of feces, and dried food debris on the floor. Later the same day, the resident remained in bed on the heavily soiled sheet while their lunch tray, which had been fully consumed, sat on the overbed table, and the soiled linens, brief, feces, and food debris remained on the floor. CNA staff reported that the resident had been washed and provided incontinence care earlier in the morning and acknowledged that incontinence care should be provided every two hours, that they had not returned to the room since the morning, and that the resident should have been cleaned before receiving lunch. Video surveillance showed that the same CNA delivered the lunch tray shortly before the resident was observed eating while still soiled. Although the bed linens were later changed, the dried food debris and large amount of feces remained on the floor behind the bed. The unit manager, corporate DON, and a family member all stated that the resident should have been provided care and that the situation was undignified, with the family member reporting that the resident was always soiled with urine and feces during visits and that prior complaints to staff had not resulted in changes.
Failure to Provide Timely Incontinent Care and Hygiene for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically grooming and personal hygiene, to a resident who was incontinent of bowel and bladder. The resident had diagnoses including cerebral vascular accident, schizophrenia, and intellectual disability, and the MDS documented severe cognitive impairment, total assistance needs for personal hygiene, and total assistance of two staff for toileting. Despite these needs, the resident’s care plan and Kardex did not include a bowel and bladder incontinence care plan or specific instructions for incontinent care, and there was no documentation that the resident refused care. On the survey date, observations showed the resident in bed wearing only an incontinent brief, with a small blanket and a flat sheet that was visibly soaked with urine from the shoulders to the foot of the bed. Multiple soiled flat sheets and a soiled brief were found on the floor between the bed and the wall, along with a large amount of feces and dried food debris. The resident remained on the heavily soiled sheet for at least 40 minutes, during which time the lunch tray was delivered and fully consumed while the room and the resident’s bedding remained soiled. Later observation showed that although the bed linens had been changed, the dried food debris and large amount of feces remained on the floor behind the bed. Interviews confirmed that incontinent care was expected every two to three hours and that the resident should have been cleaned before receiving lunch. The CNA assigned to the resident stated they had provided incontinent care around 7:30 a.m., had not returned since, and acknowledged the resident should have been cleaned before lunch. Video surveillance showed that this CNA delivered the lunch tray shortly before 1:00 p.m., contradicting their initial statement that they had not provided the lunch tray. The RN Unit Manager stated the resident was incontinent and required total assistance, was unsure if the resident was care planned for incontinence, and confirmed that incontinent care should occur every two to three hours and before meals. A family member reported the resident was always soiled with feces and urine during visits, and the Corporate DON stated incontinent care should be completed every two to three hours and that the resident and room should have been cleaned before lunch, noting that the facility does not document ADL completion.
Improper Foley Catheter Management and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services for a resident with an indwelling Foley catheter, in accordance with its own urinary catheter care and enhanced barrier precautions policies. The resident had diagnoses including quadriplegia, chronic kidney disease, and depression, was cognitively intact, and had a documented history of urinary tract infections. The care plan and Kardex directed staff to monitor for signs and symptoms of urinary tract infection, position the drainage bag and tubing below the level of the bladder, provide Foley catheter care every shift, and monitor and document Foley output every shift. On multiple observations during one morning, the resident’s urinary drainage bag, containing approximately 1,000 milliliters of amber urine with a large amount of white mucus in the tubing, was seen lying directly on the floor under the bed. An LPN entered the room to administer medications and later to feed the resident breakfast, but did not correct the position of the drainage bag, which remained on the floor at 8:55 AM, 9:10 AM, 10:16 AM, and 11:26 AM. Staff interviewed acknowledged that the drainage bag should not have been on the floor and that it should have been emptied because it was full, particularly given the resident’s propensity for urinary tract infections. Later that morning, despite a sign on the resident’s door indicating the need for enhanced barrier precautions and the availability of supplies, a CNA entered the room wearing only gloves and no gown to empty the urinary drainage bag. The CNA picked the drainage bag up from the floor, placed a clean urinal directly on the floor without a barrier, opened the drainage spigot, and filled the urinal to the top. The CNA then placed the drainage bag with the spigot open back on the floor, emptied the urinal into the toilet, returned the urinal to the floor, and finished emptying the bag into the urinal. The CNA replaced the spigot into the bag holder without cleaning the spigot tip with alcohol and confirmed that 1,800 milliliters had been emptied. Facility nursing leadership and the infection preventionist stated that drainage bags should never be on the floor and that staff were expected to follow enhanced barrier precautions, including gown and glove use, when providing care to residents with Foley catheters.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse, mistreatment, and neglect when it did not implement sufficient interventions to prevent repeated resident-to-resident physical abuse by a cognitively impaired resident with a history of aggression. The resident involved had diagnoses including frontotemporal neurocognitive disorder, dementia without behavioral disturbances, and adult failure to thrive, and was documented as severely cognitively impaired. The care plan identified behaviors such as self-directed harm or harm toward others, with interventions including supervision, redirection, and minimizing stimuli, but the record states there were no changes made to the plan of care after several altercations and no documented evidence that interventions were evaluated for effectiveness after each incident. On one occasion, the aggressive resident approached another resident, asked for a Pepsi, and struck that resident on the cheek after the resident blocked access to the drink. On another occasion, the aggressive resident entered a resident’s room and made physical contact with the resident’s face, causing redness. On a later occasion, the aggressive resident threw a box of gloves at a resident, hit the resident in the face with the box, and then punched the resident on the left cheek with a closed fist. On another occasion, the aggressive resident walked up to a resident and struck the resident in the face, causing an abrasion to the cheek, redness extending toward the temple, fear, and severe head pain rated 8 out of 10. The report states behavior monitoring documentation was incomplete or absent after several of these incidents, and in some cases the other resident involved was not placed on the 24-hour nursing report as documented in the investigation summary. The facility also failed to recognize abuse and neglect in an incident involving a CNA and another resident. That resident had diagnoses including hypertension, DVT, and anemia, and required substantial assistance with toileting, transferring, and dressing. The resident reported that the CNA used profanity, refused requested care, and later left the resident in a wheelchair with a soiled brief, pants down, and without proper clothing coverage. Staff observed the resident in that condition, and multiple staff members described the incident as abuse and a violation of dignity, while the facility determined it was not abuse because the resident did not report physical or psychological harm. The report also states the DON later said the incident was only reported because the facility wanted to fire the CNA.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to timely report allegations of abuse, neglect, mistreatment, and an injury of unknown source to the State Agency and failed to send the results of abuse investigations within five working days for five residents reviewed. The report states that the facility did not ensure alleged violations involving abuse or neglect were reported immediately, and in some cases were not reported within the required 2-hour or 24-hour time frames. The deficiency was identified during complaint investigations completed as part of an extended recertification survey. For one resident with dementia, anxiety, and arthritis, the facility investigation documented an allegation of physical abuse involving another resident. The administrator was first made aware within minutes of the event, and the incident was reported to the State Agency the same evening. However, there was no documented evidence that the full investigation results were sent within five working days. Interviews showed that nursing leadership and the administrator each believed another person was responsible for submitting the completed investigation, and the administrator acknowledged the full investigation should have been submitted. For another resident with hypertension, DVT, anemia, and moderate cognitive impairment, the facility investigated a verbal aggression and dignity-related incident involving a CNA. The resident reported being spoken to with profanity, denied assistance, and left in a soiled brief with pants down while preparing for therapy. The incident was reported to the State Agency the next day, but the investigation results were not sent within five working days. The DON and administrator stated they did not consider it abuse because they believed the resident did not suffer physical or psychological harm, although staff and the resident described the event as upsetting and a violation of dignity. For two additional residents, one with Parkinson’s disease, dementia, and schizophrenia and another with dementia, stroke, and anxiety, the facility investigated a suspected sexual abuse event after one resident was found in a wheelchair next to the other resident’s bed. Staff stated the situation appeared suspicious and required immediate reporting, but the incident was not reported to the State Agency until the following day. Interviews confirmed that nursing staff and leadership understood the event had potential for sexual abuse, yet the report was not made within the required 2-hour timeframe. The administrator later stated the incident was not reported correctly and that the DON and administrator were responsible for timely reporting.
Insufficient overnight nursing staffing and delayed resident care
Penalty
Summary
The facility did not ensure sufficient nursing staff with appropriate competencies were available on a 24-hour basis to meet resident needs on floors two, three, and four. The facility assessment stated staffing was census- and acuity-based, and an addendum indicated that for a census of 149 the minimum would be one LPN per unit per shift with an RN on call. Resident Council minutes from July and August 2025 documented complaints that CNA staff, especially on nights, were slow to answer call bells and that all nursing staff needed to respond more quickly. Multiple residents described long delays in care. One resident who could not move independently reported waiting over two hours for incontinent care and being left in a soaking wet brief. Another resident reported repeated overnight delays in receiving pain medication, including waiting hours after ringing the bell. A third resident stated they had gone three weeks without a shower because staff said there was not enough staffing. Another resident reported call lights being turned off without anyone returning, and another stated the third shift had the worst staffing and call lights took a long time to be answered. Medication administration records showed that a resident with dementia, hypothyroid, and hypertension did not receive a scheduled 4:00 AM levothyroxine dose on one occasion. Staff interviews indicated they prioritized duties across all three floors and were unable to get to that medication pass. Review of overnight schedules showed that on one night only the nursing supervisor was working in the building, and on another night only two nurses were present. The staffing coordinator, DON, RN supervisor, NP, and administrator all acknowledged that the overnight staffing was below the facility’s expected minimum of one nurse per floor, and several stated that one or two nurses on the overnight shift with a census of 147 to 149 residents was not appropriate or not recommended.
Failure to Ensure Access to Psychiatric and Psychotherapy Services
Penalty
Summary
The facility was cited for not being administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain residents’ highest practicable physical, mental, and psychosocial well-being. The survey found that psychiatric services were not consistently available, and the facility did not ensure that residents could access psychotherapy or follow-up psychiatric care when recommended by providers. The facility assessment identified mental/behavioral health providers as contracted resources, and the administrator’s job description stated that consultants and other support resources were to be appropriately utilized, but the facility did not have a clear process in place to secure those services during a lapse in psychiatric coverage. For one resident, the psychiatrist recommended psychotherapy services, but the social worker stated no referral request had been made and acknowledged that this should have been done. The psychiatrist stated they expected the social worker to follow up with the recommendation and arrange counseling or group therapy. The DON stated the resident was not participating in psychotherapy with the facility psychologist, that the facility could not provide a phone number for the psychologist and communicated only by email, and that no policy on psychology consultants could be located. For another resident, nursing notes documented aggressive behavior, elopement attempts, wandering, and entering other residents’ rooms. A nurse practitioner documented follow-up after a resident-to-resident altercation and recommended psych follow-up as indicated. The facility’s leadership stated there was about a month when the facility was between psychiatric providers, that the July-to-September gap was not appropriate after the recommendation was made, and that if no psychiatrist was available the physician should have been notified. The administrator stated there was a lapse when there was no psychiatric provider and that the facility should have looked at other resources and made an appointment for the resident and any others who needed psychiatric services during that time.
Medical Director Minimized Resident-on-Resident Altercation
Penalty
Summary
The facility did not ensure that the Medical Director carried out responsibilities for implementing resident care policies and coordinating medical care. The undated Medical Director job description and policy stated the Medical Director was responsible for overseeing resident care policies, promoting safety and accountability, guiding clinical staff, and ensuring resident care decisions respected residents’ rights, dignity, and individualized care. The deficiency was cited under F600 Free from Abuse and Neglect, scope and severity L, with reference to 10NYCRR 415.15(a)(1)(2). During a telephone interview, the Medical Director stated that an incident involving two residents on the dementia unit, in which one resident punched another resident in the face and caused an abrasion to the left cheek, pain, crying, and fear of the aggressor, was not abuse and was just two residents with dementia fighting. The Medical Director said residents with dementia cannot be controlled and that this population is going to hit each other sometimes. The Administrator and Director of Strategic Planning stated they expected the Medical Director to be knowledgeable about dementia and the behaviors associated with it, and both indicated the Medical Director’s comments required further discussion and were taken seriously.
Pest Control Program Not Maintained
Penalty
Summary
The facility did not maintain an effective pest control program for the first, second, third, and fourth resident-use floors. Survey observations and interviews documented evidence of rodents, including rodent droppings in multiple resident rooms and in a dietary storage area, as well as dead mice found inside a resident room. The facility’s pest control policy stated it maintained an ongoing program to keep the building free of insects and rodents and used an outside contracted pest control vendor. On the first floor, rodent droppings were observed behind the door of the Dietary Storage Room. The Dietary Director stated they had moved chemicals, crates, and cardboard in that area and that older droppings may have been disturbed, and also stated the area behind the door needed to be swept again. On the fourth floor, rodent droppings were observed in a resident room near damaged cove base and floor tile, and the Regional Maintenance Director stated the debris could be rodent droppings and shavings from the damaged corner and that the floor tile needed repair. On the third floor, rodent droppings were observed in a resident room at the foot of a bed, under a nightstand, in a drawer, in the closet, and under another bed. In that room, a metal rodent trap box contained bread, a paper towel, and four dead mice on glue paper. The resident stated they had seen mice running around the room and had placed bread in the box to catch them. The Regional Maintenance Director stated they were unaware of the dead rodents or the resident’s actions and said a different approach to rodent control would be needed in that room. Additional rodent evidence was found on the third and second floors, including droppings behind furniture and in drawers, and a resident reported seeing a mouse run from the closet to under the bed two days earlier. A licensed exterminator’s report noted mice had chewed through rubber baseboard near a radiator and recommended sealing the hole, but a later observation found a small hole in that same area and the Regional Maintenance Director stated they were not aware of it or the recommendation. Fly activity was also observed in multiple areas, including nourishment areas, the dishwash room, and several resident rooms. Insect light traps had glue boards with at least 200 dead insects, and multiple exterminator reports instructed that glue boards be replaced and conditions conducive to small fly reproduction be reported, yet the device inspection summaries on those reports indicated zero of three insect light traps were inspected. Residents and staff reported flies bothering residents in their rooms, including one resident with foot wounds who stated flies gravitated toward them, and another resident who said flies bothered them while eating in their room.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment on the second, third, and fourth resident-use floors. Surveyors observed damaged walls and ceilings, dust-laden fans in resident rooms, sticky and soiled floors, and unpleasant odors throughout multiple areas of the building. The cited policy required residents to be provided with a safe, clean, comfortable, and homelike environment, and required housekeeping surfaces and environmental surfaces to be cleaned regularly and when visibly soiled. On the third floor, a resident room had a plaster ceiling with a large discolored, cracked, and peeled area near the end of a resident’s bed. Staff stated the ceiling damage had been present for about a year and had leaked on and off, and another staff member reported that the ceiling had leaked the prior week and the floor had been wet, with buckets sometimes used to catch water near a resident’s bed. Another third-floor resident room had a large area of peeling and crumbling paint and plaster with brown discoloration above the residents’ bed, and both residents stated the ceiling needed to be fixed and painted. A third-floor tub and shower room had brown, rust-like streaks on the wall and a nonfunctional ventilation fan. On the second floor, surveyors observed ceiling and wall plaster damage in a tub and shower room, and a resident stated there was sometimes water on the bathroom floor and that the water spread into the corner, forcing the resident to work around it to use the bathroom. Another second-floor resident room had cracked and damaged walls and a peeled plaster ceiling above and beside the resident’s bed. On the fourth floor, a resident room had drywall cut into rectangular sections and taped to the wall, along with additional wall damage near the window. Surveyors also observed dust-coated fans in resident rooms on the second and third floors. The hallways and nurses’ station areas on the third and fourth floors had sticky floors with multiple brown and black spots and debris, and the fourth floor had a urine odor that permeated the area. Intermittent observations over several days noted pungent urine and unpleasant body odor on the third and fourth floors. Residents, family members, and staff reported that the floors were sticky and dirty, that housekeeping did not mop daily, and that the facility had urine and feces odors and did not feel homelike. The DON acknowledged occasional offensive odors, and the Assistant Administrator stated the Environmental Services Director position had recently been vacated.
Missed Shower and Missing Skin Check Documentation
Penalty
Summary
The facility did not ensure that a resident’s right to make choices about significant aspects of life in the facility was honored when Resident #5 did not receive a shower for three weeks despite wanting one. Resident #5 was admitted with paralysis of the right side of the body and depression. The resident’s MDS dated 6/19/2025 documented that the resident was cognitively intact, understood and was understood by others, and required maximal assistance from staff for bathing. The comprehensive care plan and CNA closet care plan documented that the resident required extensive to maximal assistance of two staff members for bathing and was to receive a shower once a week. The record review showed no documentation in the interdisciplinary progress notes from 08/19/2025 through 09/16/2025 that a nurse completed a skin check, and there was no documentation that the resident refused a shower. The shower schedule indicated the resident was to receive a weekly shower on Mondays. During interviews, Resident #5 stated they had not had a shower in three weeks and wanted one, and later stated they did not receive a shower the prior night and that it bothered them. CNA #4 stated that if a resident does not get a shower, they should get one on the next shift, and that a room move might have affected the shower schedule. LPN #7 stated weekly skin checks were not documented for Resident #5, and DON #1 stated staff would be expected to document the weekly skin check in progress notes.
Missing Nurse Aide Registry Screening for New Hires
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not have documentation showing that three of eight reviewed employees were screened through the New York State Nurse Aide Registry before their first day worked at the facility. The employees identified were a Registered Nurse Supervisor, a Unit Clerk, and a Dietary Supervisor. The facility’s written policy, revised in April 2021, stated that it would conduct employee background checks and would not knowingly employ or engage any individual with a finding in the state nurse aide registry related to abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. Review of the personnel files for the Dietary Supervisor, Unit Clerk, and Registered Nurse Supervisor showed no documentation of a Nurse Aide Registry check. The Dietary Supervisor worked full-time at the facility from 04/08/2025 through 04/25/2025, the Unit Clerk worked full-time from 04/08/2025 through 06/05/2025, and the Registered Nurse Supervisor was a per-diem employee who started on 04/08/2025 and last worked on 05/05/2025. During interviews, the Administrator stated the registry should be checked for all employees before they start working and believed the check had been done for the Dietary Supervisor but could not locate the paperwork or digital record. The Human Resources Director stated the current process was to look up each new hire on the registry and print the verification sheet before the start date, but could not locate documented checks for any of the three employees.
Care Plans Were Not Updated or Shared With Resident Representatives
Penalty
Summary
The facility did not ensure that comprehensive care plans included, to the extent practicable, the participation of the resident and the resident’s representative, and did not document an explanation when participation was not practicable. Survey review found that Resident #74, who had vascular dementia, anxiety, and depression and was severely cognitively impaired on the most recent MDS, had no documented evidence that the resident or the resident’s representative was invited to care plan meetings. The resident’s representative stated they had not been invited to a care plan meeting since admission and wanted to attend, while the Social Worker stated they did not invite the representative and that the invitation would have fallen through the cracks. The facility also did not ensure that Resident #29’s comprehensive care plan was reviewed and revised after the resident’s condition changed. Resident #29 had diagnoses including Wernicke’s encephalopathy, alcohol dependence, and type II diabetes, and the MDS documented severe cognitive impairment. After an elopement event, the resident was placed on one-to-one supervision and later transferred to the fourth floor, where one-to-one supervision was discontinued and a wander guard was placed. However, the comprehensive care plan continued to list one-to-one observation as an intervention even after it was no longer active. During interviews, the Resident Care Coordinator stated that care plan development and revision were their responsibility and acknowledged that Resident #29’s care plan was not accurate because it still reflected one-to-one observation after that intervention had been discontinued. The DON also stated that the care plan was not revised timely and that the one-to-one intervention was no longer active after the resident’s elopement-related changes. The cited deficiency was based on the facility’s failure to include resident or representative participation in care planning and failure to revise the care plan after the resident’s status changed.
Wheelchair positioning left resident’s feet unsupported
Penalty
Summary
The facility did not ensure that Resident #88 received care and treatment in accordance with professional standards of practice for positioning while seated in a wheelchair. Resident #88 had diagnoses including right-sided hemiplegia, right-sided hemiparesis, cerebral infarction, and aphasia, and the MDS documented severe cognitive impairment, partial/moderate assistance for transfers, and dependence for lower body dressing and footwear. The care plan identified limited physical mobility and, by 9/11/25, included locomotion on the unit with extensive assist of one staff member using a manual wheelchair with a calf board. During observation on 9/9/25, Resident #88 was seated in the wheelchair in the dining room with the leg rests extended straight out, while both feet hung approximately four to six inches above the floor for an extended period. The resident’s legs were straight down and the feet were pointed downward, with occasional movement of the right leg toward the leg rest but inability to raise it onto the support. During observation on 9/11/25, a CNA wheeled the resident to the dining room with both leg rests extended straight out; the left leg was on the leg rest initially, the right leg was hanging down, and after the CNA walked away the left leg fell off the leg rest. For the remainder of the observation, both feet remained pointed downward with the heels and toes several inches above the floor, and the resident at times placed one foot on top of the other. Staff interviews confirmed the positioning problem and that the wheelchair supports were not appropriate for the resident. The CNA stated the resident’s legs should have been on the leg rests and that the leg rests should have been in a downward position so the resident could reach them. The LPN stated both feet and legs should have been supported. The RCRC stated the leg rests should not have been straight out and should have been angled downward so the resident could rest their feet, and that the legs and feet should have been supported for circulation and to prevent foot drop or contractures. The DOR stated the leg rests were straight out, extended longer than they should have been, and even when angled downward they would still have been too long for the resident’s feet to reach. The DON, NP, and Administrator each stated staff were expected to ensure the resident was positioned correctly and that the resident’s legs and feet were supported.
Failure to Follow Through on Ophthalmology Recommendations
Penalty
Summary
The facility did not ensure that Resident #57 received proper treatment and assistance with vision services after outside ophthalmology recommendations for cataract surgery were made. Resident #57 had diagnoses including schizoaffective disorder, diabetes mellitus type 2, and anxiety disorder, and the MDS dated 06/13/2025 documented the resident was cognitively intact and had adequate vision. The comprehensive care plan did not include anything related to vision. An outside consult dated 10/29/2024 documented that Ophthalmologist #2 recommended cataract surgery in both eyes, and a later eye consult dated 04/24/2025 documented that the resident was waiting for cataract surgery but was unsure when it was scheduled. A consult dated 06/10/2025 documented cataracts and anatomic narrow angles in both eyes, with the cataracts causing blurred vision and the resident reporting difficulty reading close material unless using more light. That same consult stated the resident would benefit from cataract surgery and that Laser Peripheral Iridotomy should be done in the interim while waiting for cataract surgery. A further consult dated 07/25/2025 documented that the resident needed to continue care with Ophthalmologist #2, needed Laser Peripheral Iridotomy to both eyes, and needed cataract surgery ASAP. During interview, the resident stated they were going blind and that nothing had been done despite giving paperwork to staff after appointments. Facility staff stated they were unaware the cataract surgery had not been scheduled, that consults were supposed to be reviewed and appointments made through the facility process, and that the appointment from October 2024 was never scheduled because it fell through the cracks. The DON stated the resident should have been scheduled for cataract surgery in October 2024, but the appointment was not scheduled after the June 2025 recommendation either.
Elopement Prevention and Supervision Failure
Penalty
Summary
The facility failed to keep a resident’s environment free from accident hazards and failed to provide adequate supervision related to elopement prevention. Resident #29 had diagnoses including Wernicke’s encephalopathy, alcohol dependence, and type II diabetes, and the MDS documented severe cognitive impairment. The comprehensive care plan identified the resident as at risk for elopement and included interventions to apply a wander detection bracelet, check it every shift, post the resident’s picture at reception, place the resident on one-to-one observation, and consider a secured unit. On 05/26/2025, Resident #29 exited the facility through a service/delivery entrance and a fenced gate and was later found in a wheelchair at a local corner store about two blocks away. The nursing progress note documented that the resident stated they exited through a side door, went down the main elevator, through double doors that were held open, and down the kitchen hallway to the service entrance door, which was slightly open and not alarming. The facility investigation summary documented the resident’s elopement from the building and that the resident was returned without injury or distress. The record review and interviews showed the wander guard interventions were not consistently in place. During observation on 09/10/2025, the resident did not have a wander guard bracelet on the wrists or ankles, and none was observed on the wheelchair or walker. Staff interviews indicated the resident usually did not wear the bracelet, and the order to check placement every shift had only recently been entered. The night supervisor log for wander guard functionality checks showed no monitoring for the resident until 09/10/2025, and the MDS Coordinator stated they had never checked the resident’s wander guard function and did not believe the resident had one. Interviews also described that the service door alarm was found not sounding and the door was not secure when the resident exited.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility did not ensure that two residents received the necessary behavioral health care and services to attain or maintain their highest practicable mental and psychosocial well-being. One resident had diagnoses including bipolar disorder, major depressive disorder, and generalized anxiety disorder, was cognitively intact, and had a care plan that included psychiatric follow-up as indicated. Psychiatry notes documented ongoing anxiety, depression, irritability, crying spells, medication refusal, and a recommendation for psychotherapy and/or supportive counseling and group therapy, but the resident’s record contained no evidence that psychotherapy or counseling services were ever completed. During observation and interview, the resident was awake, well groomed, and expressed anxiety about blood pressure and wanting additional people to talk to. The resident stated they were not receiving counseling and wanted it because psychiatry had recommended it. Staff interviews showed the referral process depended on social work review of psychiatry notes, but the social worker acknowledged no referral request had been made for psychotherapy even though it had been recommended. The DON also confirmed the resident was not participating in psychotherapy with the facility psychologist and that the recommendation had not been followed through. A second resident had diagnoses including frontotemporal neurocognitive disorder, dementia without behavioral disturbances, and adult failure to thrive, with a care plan addressing impaired cognition, aggression, wandering, and antidepressant use. A psychiatry note documented follow-up in four weeks after an initial consult, but there were no further psychiatry visits until much later. Nursing notes during the intervening period documented aggression toward staff and other residents, elopement attempts, wandering, and entering other residents’ rooms. Staff interviews indicated there was a lapse in psychiatry provider coverage and that the resident waited an extended period after a follow-up recommendation before being seen again, with no timely outside psych referral arranged.
Failure to Maintain Effective Pest Control and Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents and evidence of rodent activity on three of four resident-use floors. Multiple observations revealed dead mice in traps, rodent droppings in resident rooms, and physical damage to room structures such as crumbled walls and exposed insulation. Food debris, such as cookie wrappers and crumbs, was found in resident drawers and on floors, often mixed with rodent droppings. Staff and residents reported recent and ongoing sightings of live mice in resident rooms, with some residents stating that rodents had been an issue for several months. Interviews with staff, including CNAs, the Housekeeping Supervisor, LPNs, and the DON, indicated inconsistent awareness and response to the rodent problem. Some staff were unaware of the extent of the droppings and dead rodents, while others acknowledged the need for immediate cleaning and pest control. The Housekeeping Supervisor was newly promoted and unfamiliar with the deep cleaning schedule, and the DON had not personally observed rodents but recognized the health concerns associated with their presence. Maintenance staff reported that rodent traps were checked and changed, and a licensed exterminator serviced the building every two weeks, but evidence of rodent activity persisted. The exterior of the facility, particularly the garbage compactor area, was found to be littered with food waste, soiled items, and garbage, attracting flies and creating conditions conducive to pest infestation. Interviews with the Food Service Director, Regional Maintenance Director, and Administrator revealed shared responsibility for maintaining the garbage area, but also a lack of clear policies on pest control and garbage disposal. Internal records and exterminator reports documented ongoing issues with food spillage, accessible garbage, and rodent activity, with some improvement noted after changing exterminators, but continued deficiencies in maintaining a pest-free environment.
Failure to Administer and Document Physician-Ordered Wound Care
Penalty
Summary
A deficiency was identified when a resident with chronic venous hypertension, lymphedema, and chronic kidney disease did not receive wound care treatments to bilateral lower extremity ulcers as ordered by the physician. The resident's care plan required treatments to be administered as ordered and for refusals to be documented and addressed, but there was no evidence in the care plan or medical record that the resident refused care. Physician orders specified cleansing the wounds with normal saline and applying Medi honey gel every evening shift, but multiple dates were identified where the treatment was not documented as completed. Observations revealed the resident's wounds were uncovered or not dressed as ordered, with visible open ulcers and dried drainage present. The resident reported that wound care was not consistently performed and that dressings were not applied on certain days. Review of treatment administration records and nursing notes confirmed that wound care was not documented as completed on several dates, and there was no documentation of resident refusal or alternative interventions. Skin and wound assessments indicated deterioration of the wounds during the period when treatments were missed. Interviews with nursing staff and facility leadership confirmed that treatments were not completed or documented as required. Staff acknowledged that the physician's orders were not always followed, and that documentation was incomplete when treatments were missed or not performed. Facility policy required all treatments to be administered as ordered and refusals to be documented, but these procedures were not consistently followed for this resident.
Failure to Protect Cognitively Impaired Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents who were found engaged in sexual activity without staff knowledge. Both residents were cognitively impaired and lacked the ability to consent. The facility's policy on abuse prevention and capacity to consent clearly states that residents have the right to be free from abuse, including sexual abuse, and that consent is not valid if a resident lacks the capacity to consent. Despite this, the incident occurred, indicating a failure in monitoring and protecting the residents. Resident #1, diagnosed with dementia, depression, and altered mental status, was documented as severely cognitively impaired. Their care plan noted a risk for mood and behavior problems, and they had a history of wandering and making inappropriate sexual comments. On the day of the incident, Resident #1 was found in Resident #2's room, engaged in a sexual encounter. Staff intervention was delayed as the incident was only discovered when a Certified Nurse Aide entered the room. The resident's cognitive impairment and history of disrobing and confusion about other residents being their spouse were known to the staff, yet adequate supervision was not provided. Resident #2, with diagnoses including Wernicke's encephalopathy and vascular dementia, was also severely cognitively impaired. Their care plan noted behavior problems, including disrobing and being not always redirectable. The incident was reported to law enforcement, but the facility did not receive any feedback. Interviews with staff and family members revealed that both residents lacked the capacity to consent, yet the facility's investigation concluded the encounter was consensual. This discrepancy highlights a significant oversight in assessing and ensuring the residents' safety and protection from abuse.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #1 was discharged on [DATE] and has since passed away. a. Resident #2 had a room/floor change after the incident occurred. Resident #2's care plan has been reviewed and found to be appropriate. A psychosocial evaluation has been completed by social work and resident does not even recall the incident. b. No further incidents have occurred. II. All wandering residents who lack capacity have the potential to be affected by this deficiency. a. A 100% audit of current residents who lack capacity, that may be displaying behaviors (handholding, arms around each other, seating preferences, etc.) will be conducted. Any concerns will be brought to the IDT and the behaviors and potential relationship will be reviewed and interventions will be care planned as appropriate. III. Facility policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021 and Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022 have been reviewed and found to be appropriate. a. A monthly “relationship meeting” will be held to include Administrator, DON, Social Work, and the Dementia Unit Manager/Designee to discuss/identify any residents that may be displaying behaviors that could suggest a developing relationship between residents. The Unit Manager/Designee will be the chairperson/spokesperson for all nursing employees assigned to the unit. Care plans and further interventions updated as indicated. b. All nursing staff will be educated on the establishment of the 4th floor “relationship meeting.” c. All nursing staff will be educated on identification and reporting any residents who are displaying behaviors such as (hand holding, arms around each other, seating preference, etc.). d. Any staff reports related to the identification of the potential for resident relationship development will be reported immediately to their immediate supervisor. Nursing Supervisory staff will be educated to begin the process of convening the IDT to audit the circumstance of this relationship to include resident capacity, family and MD notification, and care plan review. IV. Any changes in behavior or adverse interactions will be reported immediately to DON/Administrator or designee and brought to morning report daily for review and QAPI monthly. a. Administrator will audit the monthly relationship meetings to ensure completion and follow through monthly x 3 months, then quarterly thereafter. b. At monthly QAPI, the Administrator will review the results of the monthly relationship meeting and any other reported occurrences of potential relationships developing. V. The administrator is responsible for this plan.
Delayed Skin Assessment and Treatment for Resident with Ulcers
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Upon readmission, the resident, who had multiple pressure and vascular ulcers, did not receive a timely skin assessment that included measurements, descriptions, and staging of the ulcers. This delay resulted in a postponement in obtaining physician orders and initiating treatment. The facility's policy required a full assessment of pressure sores upon admission, but this was not completed for the resident, leading to a lack of documented treatment orders for the ulcers until two days after readmission. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that skin integrity assessments should be conducted by a Registered Nurse within 24 hours of admission or readmission. These assessments should include detailed documentation of the type, location, and measurements of wounds, with treatments initiated immediately upon identification of skin integrity alterations. However, in this case, the necessary assessments and treatments were delayed, as confirmed by the facility's records and staff interviews.
Delayed Skin Assessment and Treatment for Resident with Ulcers
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Upon readmission, the resident, who had multiple pressure and vascular ulcers, did not receive a timely skin assessment that included measurements, descriptions, and staging of the ulcers. This oversight resulted in a delay in obtaining physician orders and initiating treatment. The facility's policy required a comprehensive skin examination upon admission, but this was not completed for the resident, leading to a lapse in care. The resident, who was cognitively intact, was readmitted with diagnoses including peripheral vascular disease, congestive heart failure, and protein calorie malnutrition. The resident had one Stage 3 pressure ulcer and several unstageable pressure and vascular ulcers. Despite the hospital discharge summary documenting these conditions, the initial clinical admission assessment was incomplete and unsigned, lacking necessary details about the ulcers. It was not until two days later that a Registered Nurse Assistant Director of Nursing conducted a proper skin assessment and obtained physician orders for treatment, which were initiated the following day. Interviews with facility staff confirmed that skin assessments should be conducted within 24 hours of admission, but this protocol was not followed in this case.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically in cases involving resident-to-resident altercations and non-consensual sexual activity. Resident #129 was verbally and physically threatened by Resident #74, who was cognitively intact, with a pair of scissors. Despite the altercation being witnessed by a Certified Nurse Aide and reported to a Registered Nurse, the facility did not take immediate action to separate the residents or remove the potential weapon, allowing Resident #74 ongoing access to Resident #129. This inaction resulted in mental anguish for Resident #129, who expressed fear for their life. In another incident, Residents #104 and #122, both severely cognitively impaired and unable to consent, were observed engaging in non-consensual sexual activity. Staff witnessed the inappropriate contact but failed to separate the residents or implement protective measures. The facility's care plans for these residents did not include strategies to prevent sexual abuse, and there was no evidence of psychological evaluations or interventions following the incident. The lack of immediate action and supervision allowed the abuse to continue, highlighting a significant oversight in resident protection. The facility's policies on abuse prevention and capacity to consent were not followed, as evidenced by the staff's failure to recognize and address the abuse situations appropriately. Interviews with staff and administrators revealed a lack of understanding and adherence to procedures designed to protect residents from harm. The incidents involving Residents #129, #104, and #122 demonstrate a systemic failure to ensure resident safety and uphold their rights to be free from abuse, resulting in immediate jeopardy and substandard quality of care.
Failure to Report Abuse and Neglect in a Timely Manner
Penalty
Summary
The facility failed to report alleged violations of abuse immediately, as required by policy, for three residents during an Extended Recertification and Complaint survey. Registered Nurse #1 did not report an alleged resident-to-resident abuse incident involving Resident #74 and Resident #129 to the Administrator. This incident, which involved a verbal argument escalating to a threat with scissors, was witnessed by Certified Nurse Aide #1 but was not reported until three days later. This delay resulted in continued access between the residents and mental anguish for Resident #129. Additionally, the facility failed to report non-consensual sexual activity between Residents #104 and #122, both of whom lacked the capacity to consent. Certified Nurse Aide #2 observed inappropriate sexual touching between the two residents but did not report it immediately, considering it a common occurrence. This inaction allowed the behavior to continue, resulting in potential psychosocial harm to the residents involved. The facility's policy required immediate reporting of abuse allegations to the Administrator and appropriate officials, but staff failed to adhere to this policy. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that the incidents were not reported in a timely manner, which hindered the initiation of investigations and appropriate interventions.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during a complaint investigation. The investigation revealed significant issues with the facility's hot water system, with temperatures in resident rooms fluctuating well below the required range, making it unsuitable for resident hygiene. Despite daily temperature checks by maintenance staff, the water temperatures were inconsistent, and residents reported difficulties in accessing warm water for personal care. The maintenance director acknowledged the need for adjustments but failed to maintain consistent water temperatures across the facility. Additionally, the facility did not provide adequate access to bathroom facilities for residents, particularly on the Fourth Floor, where several bathrooms were out of service due to drainage issues. Residents without in-room bathrooms had to travel long distances to access the only available bathroom, leading to inconvenience and potential incontinence. The maintenance director admitted that the drainage problem was a large-scale issue that had not been addressed, affecting multiple floors and requiring external contractors for repairs. The facility also exhibited poor housekeeping and maintenance practices, with observations of soiled walls, mold in shower rooms, foul odors, and windows and ceilings in disrepair. Call bells in shared bathrooms were not functioning properly, posing a safety risk for residents. The maintenance director and housekeeping staff acknowledged these issues, but there was no documentation of plans to address them. These deficiencies highlight a failure to uphold the residents' right to a safe and homelike environment, as mandated by facility policies and regulations.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food and drink at safe and appetizing temperatures for residents on the Second, Third, and Fourth floor Units during the Extended Recertification and Complaint survey. The policy required potentially hazardous foods to be kept at 41 degrees Fahrenheit or below when cold, or 135 degrees Fahrenheit or above when hot. However, observations and interviews revealed that meals were served at suboptimal temperatures, making them unpalatable. Residents reported issues such as cold meals, hard biscuits, and unidentifiable food, leading some to avoid eating or rely on external food sources. During the survey, test trays were used to assess the temperature and palatability of meals. On the Second floor Unit, the baked ziti was 119 degrees Fahrenheit, zucchini was 110 degrees Fahrenheit, and coffee was 124.5 degrees Fahrenheit, all below the required temperature. Similar issues were observed on the Third and Fourth floor Units, with food items like baked ziti, zucchini, milk, mandarin oranges, and coffee served at temperatures below the facility's standards. The Dietary Director acknowledged that some food temperatures were below the acceptable range, which could pose a risk of foodborne illness. Interviews with residents and family members highlighted dissatisfaction with the food quality and temperature. Residents described the food as cold, bland, and sometimes inedible, with some relying on care packages or family-provided meals. The facility's failure to maintain proper food temperatures during storage, preparation, transport, and service contributed to the deficiency, as evidenced by the observations and resident feedback.
Food Safety Deficiencies in Facility Refrigerators
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety across three nourishment unit refrigerators. Observations revealed that the refrigerators contained undated, unlabeled, and expired food and drink items. Additionally, there were liquid spills and dried substances on surfaces, and the Fourth floor Unit refrigerator was not maintaining a safe food storage temperature and lacked a thermometer. The Second floor Unit refrigerator also lacked a thermometer, which is against the facility's policy that requires temperature monitoring twice a day. During the survey, it was observed that the Third floor Unit nourishment kitchen had unidentified and undated items in the freezer and fridge, including latex gloves filled with frozen liquid. The Fourth floor Unit refrigerator was found to have a thermometer displaying unsafe temperatures, and it contained unlabeled and undated items, including a bologna sandwich and nourishment bags with items that should have been distributed to residents earlier. The refrigerator was also wet with brown liquid stains, and the temperature was consistently above the safe range, reaching up to 62 Fahrenheit. Interviews with staff, including registered nurses, dietary supervisors, and technicians, revealed a lack of adherence to the facility's policies regarding food storage and temperature monitoring. The dietary staff were responsible for checking temperatures, but the records were inconsistent, and the equipment was faulty. The Interim Maintenance Director acknowledged the need for new seals for the fridge and freezer, and the Administrator confirmed that the refrigerator should be replaced due to the unsafe conditions observed.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident was informed and allowed to participate in the development and implementation of their person-centered care plan. Specifically, a resident with diagnoses including benign intracranial hypertension, chronic pain syndrome, and migraine headache, who was cognitively intact, was not informed in advance about a scheduled care plan meeting. The facility's policy required that residents be given sufficient notice to participate in care planning meetings, but this was not adhered to in this case. The resident expressed disappointment at not being able to attend the meeting, which was important to them as they wanted to share their progress with their family. Interviews with facility staff, including a social worker and a nurse practitioner, confirmed that the resident was not informed of the meeting, and it was acknowledged that the resident should have been present. The social worker responsible for notifying the resident failed to provide evidence of communication or records of notification, leading to the resident's exclusion from the care planning process.
Deficiency in Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the behavior of a staff member towards a resident and the lack of privacy in a shared bathroom. Resident #134, who was cognitively intact and had a care plan requiring calm and reassuring care, was subjected to unprofessional behavior by Licensed Practical Nurse #6. The nurse allegedly used inappropriate language, slammed medication on the tray table, and left the room in a disrespectful manner, causing the resident to become upset and cry. This incident was corroborated by other staff members who witnessed the behavior. Additionally, the facility did not provide adequate privacy for residents using a shared bathroom on the dementia unit. The bathroom, used by both male and female residents, had three toilet stalls separated by partitions but lacked stall doors or privacy curtains. Observations confirmed that residents used this bathroom independently, raising concerns about privacy and dignity. Staff interviews revealed that the lack of privacy was a known issue, with several staff members acknowledging the problem and expressing concerns about its impact on residents. The facility's failure to address these issues violated the residents' rights to be treated with respect and dignity. The lack of privacy in the shared bathroom and the unprofessional conduct of a staff member towards a resident were significant deficiencies identified during the survey. These findings highlight the need for the facility to ensure that all residents are treated with dignity and that their privacy is respected in all aspects of their care.
Delayed and Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that all alleged allegations of abuse were thoroughly investigated for two residents. Specifically, there was a delay in the initiation of an investigation for a reported allegation of resident-to-resident abuse. The incident involved a verbal argument between two residents, which escalated when one resident threatened the other with a pair of scissors. The altercation was witnessed by a Certified Nurse Aide and reported to a Registered Nurse, who did not consider it a resident-to-resident altercation and thus did not report it to the Director of Nursing or Administrator. This resulted in a delay in the investigation, which was not initiated until three days after the incident. The investigation was incomplete as it did not include interviews with the involved residents or other potential witnesses. The Director of Nursing did not obtain a statement from the resident who was sent to the hospital and returned to a different room. Additionally, there was no documented evidence that the responsible party of the affected resident was notified of the altercation. The Director of Nursing considered the incident isolated and did not interview other residents. The Administrator acknowledged that the staff should have reported the incident immediately to allow for a thorough investigation.
Deficiencies in Resident Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate care for residents who were unable to perform activities of daily living, specifically in maintaining grooming and personal hygiene. Resident #27, who was admitted with diagnoses including diabetes mellitus, anxiety, and depression, did not receive timely incontinence care. The resident's brief and bed linens were saturated with urine, and the Certified Nurse Aide (CNA) performed incomplete incontinence care without proper hand hygiene or glove changes. The CNA also touched items in the resident's room with soiled gloves, leading to potential cross-contamination and infection control issues. Resident #102, who had a history of cerebral infarction and was legally blind, was dependent on staff for personal hygiene. The resident's fingernails were observed to be long, jagged, and filled with dark debris, which posed an infection control risk, especially since the resident ate with their hands. Despite the resident's preference for short nails, there was no documented evidence of nail care being provided, and the regular CNA stated that the resident did not refuse care. The resident's contracted hand had nails pressing into the palm, causing red indentations and discomfort. Resident #105, with diagnoses including diabetes mellitus and peripheral vascular disease, also had long, jagged fingernails with dark debris. The resident expressed a desire for nail care, but staff reportedly only cleaned under the nails without trimming them. The resident's nails were noted to be long and potentially harmful, yet there was no evidence of appropriate nail care being provided. The Director of Nursing acknowledged that long nails could be an infection control issue and expected staff to consult a provider for nail care in residents with certain medical conditions.
Deficiencies in Medication Administration and Care Planning
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. For Resident #16, there was a significant delay in the administration of antibiotics for a urinary tract infection due to inaccurately transcribed physician's orders. The resident, who had an indwelling Foley catheter, experienced a nine-day delay in receiving the correct dosage of Ciprofloxacin, which was not therapeutic for the infection. Additionally, there was no comprehensive care plan developed for the resident's Foley catheter care and urinary tract infection. Resident #305 experienced issues with the maintenance of a peripherally inserted central catheter (PICC) line. The dressing for the PICC line was not changed as ordered due to a lack of available supplies, and the dressing was observed to be peeling and loose. The facility's failure to maintain the PICC line dressing as per the physician's orders posed a risk of infection, and the Director of Nursing was not informed of the inability to complete the dressing changes as required. Resident #154 did not receive prescribed supplements for electrolyte imbalances due to a lack of communication and documentation. The resident, who had a history of hypokalemia, hypomagnesemia, and hypophosphatemia, received only a fraction of the scheduled doses of supplements. The pharmacy did not dispense the required supplements, and there was no evidence that the medical providers were notified of the unavailability of these medications. This lack of communication and documentation resulted in the resident not receiving the necessary treatment for their condition.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to ensure that each resident was offered pneumococcal and influenza immunizations, as well as documented education regarding the benefits and potential side effects of these vaccines. This deficiency was identified during an Extended Survey, which revealed that four out of five residents reviewed did not have documented evidence of being offered or declining the immunizations, nor receiving education about them. The facility's policies required that assessments of pneumococcal vaccination status be conducted within five business days of admission and that education and declination be documented in the resident's medical record. However, this was not adhered to for residents with various medical conditions, including diabetes, chronic obstructive pulmonary disease, and dementia. Interviews with facility staff, including the Infection Preventionist/Assistant Director of Nursing and the Director of Nursing, confirmed that the responsibility for obtaining and documenting immunization statuses fell on the admitting nurse, with oversight by the infection preventionist. Despite this, the Regional Director of Nursing was unable to locate the necessary immunization documents for the affected residents. This lack of documentation and adherence to policy resulted in a deficiency under 10 NYCRR 415.19 (a) (1).
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Buffalo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Catherine Laboure Health Care Center | 0.7 mi | ★★★★★ | 5 | 0 |
| Terrace View Long Term Care Facility | 1 mi | ★★★★★ | 2 | 0 |
| Delaware Oaks Center For Rehabilitation And Nursin | 1.1 mi | ★★★★★ | 2 | 0 |
| Buffalo Center For Rehabilitation And Nursing | 1.3 mi | ★★★★★ | 5 | 0 |
| Highpointe On Michigan Health Care Facility | 1.6 mi | ★★★★★ | 2 | 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.