Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Nathan Littauer Hospital Nursing Home during CMS and state inspections, most recent first.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident with cognitive impairment did not have a documented fall prevention plan involving mattresses. Another resident with edema lacked a care plan for physician-ordered ACE bandage use. A third resident with vision issues had no care plan for vision needs or specialist follow-up.
The facility failed to maintain food service safety and cleanliness standards in the main kitchen and resident unit nutrition areas. Observations included debris on kitchen equipment, missing temperature logs, and dirt accumulation on various surfaces. Interviews revealed staff negligence in cleaning duties, with plans to develop a duty list for daily responsibilities.
A facility exceeded the acceptable medication error rate, with errors involving two residents. One resident received insulin late, after eating, without a follow-up glucose check or notification to a nurse or physician. Another resident self-administered a nebulizer treatment left at the bedside, contrary to facility policy. The DON confirmed no residents were authorized to self-administer medications.
The facility was cited for not designating a specific individual as the Infection Preventionist, with the DON performing dual roles due to staffing issues. The Administrator was unaware of the requirement for a distinct Infection Preventionist role, leading to a citation under regulatory standards.
A survey found that a medication cart in the facility's West Unit Team 1 contained opened medications without proper labeling, including insulin vials and eye drops lacking open or expiration dates. Interviews revealed that staff did not consistently follow procedures for labeling medications, despite receiving training on this practice.
The facility failed to properly constitute its Quality Assessment and Assurance Committee, as the Director of Nursing was also serving as the Infection Preventionist, contrary to regulations. The Administrator was unaware of the requirement for these to be separate roles, leading to a deficiency that could impact all residents.
The facility failed to maintain residents' dignity as staff wore gloves while feeding them, contrary to the facility's policy on dignity and respect. Observations showed staff consistently using gloves for infection control, despite some recognizing it could be perceived as undignified. The DON acknowledged no written policy required glove use during feeding, highlighting inconsistency in practice and understanding among staff.
The facility was cited for failing to maintain a clean and safe environment, with surveyors observing soiled floors, disrepair in door frames and walls, and unfinished repairs in resident rooms. Staff interviews revealed ongoing issues with cleanliness and maintenance, despite previous efforts to address these concerns.
A facility failed to provide meaningful activities for a resident, leading to a deficiency in supporting their well-being. The resident, who was unable to complete a mental status interview, was observed over several days in bed, non-verbal, and not participating in activities. The Activities Director admitted that one-on-one visits were not documented, contrary to facility policy, and the DON confirmed this lack of documentation.
Two residents experienced neglect due to miscommunication and inadequate care. One resident was not monitored or cared for during a night shift, while another rolled out of bed and hit their head due to improper assistance. Both incidents highlight failures in communication and adherence to care protocols.
A facility failed to provide a written notice of its bed hold policy to a resident and/or their representative upon transfer to the hospital. The resident, who had severe cognitive impairment, was transferred due to a fall and possible fracture. The facility's policy requires such notification, but it was not documented. The Director of Nursing acknowledged the inconsistency in completing the notice of discharge, which includes the bed hold policy notification.
A resident with mild cognitive impairment and a history of shortness of breath fell in their room and was assisted by CNAs into a wheelchair without notifying a nurse or reporting the incident. The resident's shortness of breath was attributed to anxiety by an LPN, and the fall was only discovered after the resident was hospitalized post-discharge.
A resident with severe cognitive impairment had an injury of unknown origin that was not reported within the required timeframe. An LPN discovered a discolored area on the resident's foot but failed to report it to an RN, delaying the investigation. The injury, later identified as a fracture, was reported to the Department of Health two days late, resulting in a deficiency citation.
The facility breached confidentiality by including social security numbers on the Criminal History Record Check form, which was not requested. The New Employee Director admitted to inadvertently distributing these documents with private information, despite securing them in a locked cabinet. This mistake was recognized and acknowledged during a recertification survey.
A facility failed to involve a resident's family member in quarterly care plan meetings, despite the resident being cognitively intact and the family visiting daily. The facility's policy required family participation in care planning, but the family was only involved in the initial and discharge planning meetings, not the quarterly ones.
A resident with a history of [REDACTED] did not receive necessary vision care, including an eye exam and new glasses, since admission to the facility. Despite the resident's cognitive ability to communicate their vision difficulties, the facility failed to arrange a follow-up ophthalmology appointment as recommended in a previous consult. The resident's care plan lacked provisions for vision care, and staff interviews revealed a lack of awareness and coordination in addressing the resident's needs.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. Resident #3, who had severe cognitive impairment and a history of falls, did not have a care plan that included the use of multiple mattresses in their room as a fall prevention measure. Despite the presence of these mattresses being a daily safety precaution, it was not documented in the care plan, and staff were unaware of its inclusion. Resident #9, who had intact cognition and chronic bilateral lower extremity edema, did not have a care plan that included the physician-ordered intervention of wrapping their legs with ACE bandages. Although the resident and staff confirmed the daily application and removal of the bandages, this intervention was not documented in the care plan, leading to a lack of formalized care planning for this medical condition. Resident #19, who was cognitively intact and had vision problems, did not have a care plan addressing their vision needs or the use of glasses. The resident reported difficulty with vision and the need for an ophthalmology appointment, which had not been scheduled since their admission. The facility's failure to coordinate follow-up specialist visits and update the care plan to include vision care needs contributed to the deficiency.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Action for those identified: Resident #3- Identified and implemented a care plan for Falls was identified and implemented. Interventions have been initiated to reflect current approaches in plan to ensure safety. Resident #9- Reviewed and updated care plan for [MEDICAL CONDITION]. Interventions have been added to care plan to reflect approaches currently in place to ensure patient centered care and current needs. Resident #19- Identified and implemented a care plan for Vision. Interventions have been added to reflect current needs. Identification of other residents and corrective action: Every resident has potential to be affected by this deficient practice. All care plans for each resident will be audited for accuracy, correct those needed and to ensure all needs are addressed. Measures and Systemic Changes: The Interdisciplinary Care Plan Committee Policy was reviewed and updated appropriately. Education will be provided to staff regarding the changes in policy and for the process of completion of the care plan for each resident to ensure the care plan is person centered for each individual. Monitoring: All care plans will be audited weekly following the care plan meeting schedule. All care plans will be reviewed at least once within a 90 day period. This will be audited weekly for 3 months consecutively. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Ann(NAME) Mogensen, Director of Nursing by 3/31/25
Deficiencies in Food Service Safety and Cleanliness
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in both the main kitchen and resident unit nutrition areas. During the initial inspection, surveyors observed a build-up of debris on the manual can opener and mixer, dust and dirt on fire extinguishers, and a large pool of free-standing water on the floor of the walk-in refrigerator. Additionally, the storage area for clean pots, pans, and food containers had items that were not fully dried, and the rolling toaster had a significant amount of debris underneath. The final rinse pressure on the dishwasher was below the recommended level due to a malfunctioning gauge. In the East nutrition area, temperature logs for the refrigerator and freezer were missing for several dates, and there was a noticeable accumulation of dirt, grime, and food particles on various surfaces, including the refrigerator/freezer unit, microwave, and drawers. Interviews with the Director of Food Services and the Environmental Services Director revealed that staff were not diligent in cleaning and maintaining the equipment and kitchen areas. The Environmental Services Director acknowledged the lack of cleanliness and mentioned the development of a duty list to ensure daily responsibilities are completed.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: Manual can opener was found to have build-up of debris in the cutting area of the device. Mixer had dirt and debris on and under the device. Dust and dirt were on top of two fire extinguishers in the main kitchen. All three of these items were addressed immediately and cleaned during/after the initial walk through. Staff were reminded during a daily kitchen huddle on (MONTH) 6th that the areas need to be cleaned daily. East Nutrition Area: Temperature logs for the refrigerator/freezer in the East Nutrition area were missing dates from (MONTH) 6, 8, 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. West Nutrition Area: Temperature logs for the refrigerator and freezer were found to be missing dates for (MONTH) 9, 10, and 12, 2025. Dirt and grime was found on top of refrigerator/freezer unit. Dirt, grime, and food particles were found on the freezer bottom and shelves. Dirt, grime, and food particles were found on the refrigerator bottom and shelves. There was dirt and grime on the seals of the refrigerator and freezer. There was dirt, grime, and food particles within the microwave. There was dirt, grime, and food particles built up on the drawers under the microwave. The above listed items were addressed with the staff members responsible for the area at a daily staff huddle on (MONTH) 6th, 2025. Staff were reminded that they are responsible for the cleaning of the refrigerator/freezer, as well as the microwave and drawers underneath. Staff were also reminded that the refrigerator/freezer temps need to be taken and recorded daily. The refrigerator/freezer unit, microwave, and drawers under the microwave were properly cleaned on Friday (MONTH) 28th. Walk-in freezer was found to have a large puddle of free-standing water on the floor. Eastern Refrigeration was called to come address the puddle. A small water leak was found around the walk-in cooler and fixed. The storage area for clean pots, pans, and food containers had multiple containers stacked together that were not fully dried. Containers, pots, and trays were put away wet and contained moisture. Shortly after inspection, all pots and pans were pulled and inspected to ensure there was no wet nesting. The staff members responsible for cleaning and putting away dishes were reminded that all pots, pans, and containers need to be fully dried and contain no moisture before they are put away. The rolling toaster contained a large amount of debris under and behind the apparatus. The rolling toaster was moved and the counter was thoroughly cleaned. The issue was addressed with staff at a daily kitchen staff huddle on (MONTH) 6th, 2025. Responsible staff were reminded that this area needs to be cleaned after each use. Dirt and grime were found on the shelving unit above the grill cooking area. The shelving unit was wiped down and properly cleaned shortly after inspection. Discussion with the cooks took place on (MONTH) 6th, 2025 at daily staff huddle reminding the responsible staff members that the kitchen shelving unit needs to be cleaned each day. Final rinse pressure on the dishwasher was 13psi. The signage on the device had a recommendation of 20psi (+ or - 5psi). At the time of inspection, management was aware that the psi was not correct and a call had been made to Action Service, our repair company. (NAME), the Tech from Action Service, had come out and determined the machine was functioning as it should but there was a problem with the PSI Gauge and sensor. The part was immediately ordered and replaced/fixed on Tuesday (MONTH) 4th. Identification of other residents and corrective action: All above listed items will be audited at a frequency of twice per week. The Nutrition Management team already conducts a monthly food safety/sanitation audit. The audit frequency will change from monthly to twice per week for a period of 3 months or 90 days. Measures and Systemic Changes: Education and In-Servicing will take place with Nutritional Services staff to ensure compliance. Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Monitoring: Twice a week audits will be tracked and reviewed at monthly QAPI meetings measuring compliance of deficient items. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation, or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Joe Clemens, Manager of Nutrition Services, by 3/31/25.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 8% during a recertification survey, exceeding the acceptable threshold of 5%. This was observed in two residents out of 16 during a medication pass. The facility's policy requires that medications be administered in accordance with specific guidelines, including timely administration and proper documentation in the electronic Medication Administration Record (eMAR). One resident, who had moderate cognitive impairment, was supposed to receive insulin before meals as per physician orders. However, the insulin was administered 90 minutes after a blood glucose reading of 347 mg/dL and after the resident had already consumed lunch. The LPN responsible for administering the insulin acknowledged the delay and did not take another blood glucose reading or report the late administration to a registered nurse or physician. Another resident, also with moderate cognitive impairment, was observed self-administering a nebulizer treatment that had been left at their bedside by an LPN. The LPN had signed off on the administration of the nebulizer treatment without ensuring the medication was consumed or that the resident rinsed their mouth afterward. The facility's Director of Nursing confirmed that no residents were authorized to self-administer medications, and medications should not be left at the bedside.
Infection Preventionist Role Not Designated
Penalty
Summary
The facility was cited for not designating an individual as the Infection Preventionist responsible for the facility's Infection Prevention Control Practices. Instead, the Director of Nursing (DON) had been performing a dual role as both the Infection Preventionist and Nurse Educator since May 10, 2023. This dual role was due to staffing issues, as stated by the DON during an entrance interview. The facility's policy and procedure on Infection Prevention and Control, revised in 2024, indicated that inquiries concerning infection control should be referred to the Infection Preventionist or DON. However, the facility failed to have a specified individual solely responsible for infection prevention, which is a requirement under the regulations. During the survey, it was revealed that the Administrator was unaware that the Infection Control Preventionist should not have a dual role with the DON. The review of key personnel documentation from 2023 confirmed that the DON was listed as the designated Infection Preventionist. The deficiency was identified under the 10 New York Code of Rules and Regulations 483.80 (b) (1)-(4) (c), which mandates that the Infection Preventionist should have a specific role without dual responsibilities. This oversight in staffing and role designation led to the citation during the recertification survey.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The Infection Control Committee policy was reviewed and revised to correctly identify the Infection Preventionist. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: An annual audit will be conducted to ensure that the IP continues to meet the requirements as set forth in F882. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Director of Nursing by 3/31/25
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice, as observed during a recertification survey. Specifically, the West Unit Team 1 medication cart contained opened medications, including vials of insulin and other medications, without open or expiration dates. Additionally, several bottles of eye drops lacked labels identifying the resident and did not have open or expiration dates. This deficiency was identified through observation, record review, and interviews with facility staff. Interviews with staff revealed a lack of adherence to the facility's policy regarding medication labeling. A Licensed Practical Nurse (LPN) stated that medications were labeled by the pharmacy, but acknowledged that labels on eye drops had fallen off, and they did not write expiration dates on the bottles. The Assistant Director of Nursing confirmed that it was the nurse's responsibility to label medications with open and expiration dates upon opening. The Director of Nursing reiterated that nurses were trained to label medications and check expiration dates before administration. Despite this training, the deficiency was noted, indicating a lapse in following established procedures.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: Immediate inspection of the West Unit Team 1 medication cart was performed and any medications found without label or date were appropriately disposed of and new ones were supplied by pharmacy and appropriately stored, labeled and dated per policy. Identification of other residents and corrective action: All residents are at risk for this deficient practice. All medication cart drawers were checked and any medications found without label or dated will be appropriately discarded and new ones will be supplied by pharmacy that are appropriately stored, labeled and dated per policy. Measures and Systemic Changes: Medication Administration Policy reviewed no changes. All nurses will be educated on policy regarding proper labeling and storage of medication. Monitoring: Auditing will be done twice a week for one month, then weekly for one month, then biweekly for one month. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: 3/31/25 Lynne Kaiser ADON
Improper Constitution of Quality Assurance Committee
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance Committee was properly constituted, as required by regulations. Specifically, the Director of Nursing was also serving as the Infection Preventionist, which is not permissible. The facility's Quality Assurance and Performance Improvement Plan outlined that the committee should include the Administrator, Medical Director, Director of Nursing, and Infection Preventionist, among others. However, due to staffing issues, the Director of Nursing was fulfilling multiple roles, including that of the Infection Preventionist and Nurse Educator. This dual role was not recognized by the Administrator, who was unaware that the Infection Preventionist should be a separate position. The facility's policy and procedure for Infection Prevention and Control, last revised in 2024, stated that the Infection Prevention and Control Committee should oversee the implementation of infection control policies and practices. During interviews, it was revealed that the facility held monthly meetings, but the responsibility for signing in was left to the staff. The Administrator admitted to being unaware of the requirement for the Infection Preventionist to be a distinct role, which contributed to the deficiency. This oversight had the potential to affect all residents of the facility, as the committee's role is crucial in coordinating and evaluating performance improvement projects.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Corrective Action for those identified: No residents were affected by the deficient practice. The Infection Preventionist role was reassigned to the ADON, who achieved certification on 2/22/25. Identification of other residents and corrective action: No residents were affected by the deficient practice. Measures and Systemic Changes: The QAPI policy was reviewed with no changes. The ADON job description was revised to include the Infection Preventionist responsibilities on 3/6/25. Monitoring: Audits of QAPI attendance will be completed to ensure the IP is present. This will be completed x 90 days. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Administrator by 3/31/25.
Dignity Concerns with Glove Use During Feeding
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by staff wearing gloves while feeding residents in the West dining room and by the East nurses station. Observations were made on multiple occasions where staff members wore gloves during feeding, which was not aligned with the facility's policy on promoting dignity and respect. The policy, effective since May 2020, emphasized that residents should be cared for in a manner that enhances their quality of life and individuality. Despite this, staff members, including Certified Nurse Aides and Licensed Practical Nurses, were observed wearing gloves while feeding residents, citing infection control as the reason. Interviews with staff revealed a lack of consensus on the dignity implications of wearing gloves during feeding. Some staff members believed it was necessary for infection control, while others recognized it could be perceived as undignified by residents. The Director of Nursing acknowledged that there was no written policy mandating glove use during feeding and suggested that concerns about dignity could be addressed in individual care plans. However, the inconsistency in practice and understanding among staff members contributed to the deficiency in maintaining residents' dignity during feeding.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and home-like environment, as evidenced by multiple deficiencies observed during a recertification survey. The surveyors noted that the floors in the corridors of both the East and West Units were soiled with dirt, particularly next to walls, in corners, and along door thresholds. Additionally, door frames and doors in several resident rooms were in disrepair, with scrapes, chips, and gouges. The walls in these units were also found to be in poor condition, with scrapes, chips, and unpainted areas. In one specific resident room, the wall was unfinished due to a previous water pipe break, and the ceiling tiles in the television rooms had visible water stains. Furthermore, the shower rooms were soiled with dirt and a dark black substance on the walls, and the handrails throughout the units were scuffed and scraped, exposing the underlying wood. Interviews with facility staff revealed that the Environmental Services Director acknowledged the lack of cleanliness and was in the process of developing a duty list for daily responsibilities. The Engineering Supervisor stated that their team was responsible for the facility's overall appearance and received multiple work orders daily for maintenance issues. They also mentioned a previous attempt to address the facility's appearance with a full touch-up on walls and door frames about a year ago. However, ongoing issues persisted, and a 3-month renovation plan was in place to address these concerns, including fixing resident room doors and improving the general appearance of the facility.
Failure to Provide Meaningful Activities for a Resident
Penalty
Summary
The facility failed to ensure the provision of meaningful activities for a resident, leading to a deficiency in supporting the resident's physical, mental, and psychosocial well-being. The facility's policy required the Department of Recreational Therapy to provide leisure programs for all residents, including those unable to attend group activities, on a seven-day-per-week basis. However, Resident #10, who was admitted with a diagnosis that included an inability to complete a mental status interview, was observed over several days in bed, non-verbal, and not participating in any activities. The resident was noted to be in the same position with the lights and television off, indicating a lack of engagement in meaningful activities. Interviews with the Activities Director revealed that although the resident was assessed for activity preferences upon admission, there was no documentation of one-on-one activity visits for the resident. The Activities Director acknowledged that one-on-one visits were not documented, which was a deviation from the facility's policy. The Director of Nursing confirmed the lack of documentation for one-on-one activities, which contributed to the deficiency in providing adequate support for the resident's quality of life.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 Corrective Action for those identified: A progress note regarding the programming offered/implemented was completed on 2/13/25. The resident #10 passed away prior to receiving the statement of deficiencies. Identification of other residents and corrective action: All residents have the potential to be affected by the deficient practice. An audit of all recreation care plans for appropriate goals/interventions and appropriate documentation will be completed and any gaps identified will be addressed. Measures and Systemic Changes: Implemented policy “Recreation Program Development” 3/10/2025. Updated the Recreation Attendance sheet to include the time of a 1 on 1 visit. Education of the Recreation staff related to the new policy and documentation will be completed by 3/31/25. Monitoring: A weekly review of residents with a change in condition/status will be completed x30 days and as changes occur. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Erin Fazzio, Supervisor of Recreation, by 3/31.
Neglect of Residents Due to Miscommunication and Inadequate Care
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by two incidents involving Resident #10 and Resident #19. Resident #10, who was admitted with a diagnosis of [REDACTED], did not receive care during the night shift from 11:00 PM to 7:00 AM on January 29-30, 2025. The resident was found soaked and unchanged, indicating a lack of personal care and monitoring. This incident was attributed to a miscommunication regarding the assignment of caregivers, as the resident required no male caregivers, and the assigned Certified Nurse Aide was male. Resident #19, who was cognitively intact and required substantial assistance for mobility and personal care, experienced an incident on January 21, 2024, when they rolled out of bed and hit their head on furniture. This occurred while receiving care from a Certified Nurse Aide, who failed to use a second person for assistance as required. The resident was using a soft mattress pad overlay, which moved and caused them to slide to the floor. The resident sustained a bump on the forehead and was sent to the emergency department for evaluation. Both incidents highlight a failure in communication and adherence to care protocols, resulting in neglect of the residents' needs. The facility's policy on resident abuse and neglect was not followed, leading to these deficiencies in care. The incidents were investigated, and it was determined that staff did not provide the necessary care and supervision to prevent harm to the residents.
Failure to Provide Bed Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to a resident and/or the resident's representative upon transfer to the hospital. This deficiency was identified during a recertification survey, where it was found that the facility did not ensure the required notification was given to a resident who was transferred to the hospital due to a fall and possible fracture. The facility's policy, effective since October 2022, mandates that residents and their representatives be informed in writing about the bed hold policy in a language and manner they understand prior to any facility-initiated transfer or discharge. Resident #12, who had severe cognitive impairment and was responsible for making decisions regarding daily life tasks, was transferred to the emergency department. However, there was no documented evidence that the bed hold policy notice was provided at the time of transfer. Interviews with the Director of Nursing revealed that the responsibility for ensuring the bed hold policy notification was completed fell on nursing, social work, and the business office. The Director acknowledged that the notice of discharge, which includes the bed hold policy notification, had not been consistently completed.
Unreported Fall and Lack of Assessment for Resident
Penalty
Summary
Resident #62, who had mild cognitive impairment and a history of shortness of breath, experienced a fall in their room prior to being discharged from the facility. The incident was not reported to a nurse, and no assessment or interventions were conducted following the fall. The resident was found on the floor by three Certified Nurse Aides (CNAs), who assisted the resident into a wheelchair without notifying a nurse or reporting the incident. The CNAs involved, including CNA #8 who led the response, did not follow protocol by failing to report the fall to a nurse. CNA #8 informed a Licensed Practical Nurse (LPN) that the resident was short of breath but did not mention the fall. The LPN, unaware of the fall, attributed the shortness of breath to the resident's anxiety and administered a nebulizer treatment. The resident was discharged the following morning without any documentation or intervention related to the fall. The incident came to light when the resident's family informed the facility's Social Worker that the resident had fallen and was subsequently hospitalized due to persistent shortness of breath. The facility's Director of Nursing initiated an investigation after being notified by the Social Worker. The investigation revealed that the CNAs involved did not follow the proper procedure of reporting the fall and ensuring a nurse assessed the resident before moving them.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident within the required timeframe, leading to a deficiency. On January 23, 2025, a Licensed Practical Nurse (LPN) discovered a purple/blue area on the right foot of a resident during a routine skin check. However, the LPN did not report this finding to a Registered Nurse (RN) for further assessment, which delayed the investigation and reporting process. The injury was not reported to the State Survey Agency until January 25, 2025, which was beyond the mandated two-hour reporting window for such incidents. The resident involved had severe cognitive impairment and was unable to recall any incident that could have caused the injury. The resident was later assessed by a provider who ordered an x-ray to rule out a fracture. The x-ray revealed a displaced fracture of the 4th and 5th metatarsal necks, likely due to minimal impact, as the resident had significant osteopenia. Despite the injury being discovered on January 23, 2025, it was not until January 25, 2025, that the Director of Nursing (DON) reported the incident to the Department of Health, following the discovery of the injury by a Certified Nurse Aide during morning care. The facility's policy required immediate reporting of suspected abuse, neglect, or injuries of unknown origin, but this protocol was not followed. The DON acknowledged that the LPN should have notified an RN immediately after the initial discovery on January 23, 2025, to ensure timely assessment and reporting. The delay in reporting the injury to the Department of Health constituted a failure to comply with regulatory requirements, resulting in a deficiency citation.
Confidentiality Breach in Employee Records
Penalty
Summary
The facility failed to maintain the confidentiality of Criminal History Record Check (CHRC) records by including social security numbers on the employee information document, which was not requested. This deficiency was identified during a recertification survey through record review and interviews. The New York State Department of Health Criminal History Record Check Form 103 contained employees' social security numbers and other confidential personal information. During an interview, the New Employee Director acknowledged receiving this form during the onboarding process and confirmed that the information was secured in a locked cabinet, with only the director having access. However, the director admitted to inadvertently providing the documents containing private information to the administrator for distribution, recognizing this as a mistake that would not be repeated.
Failure to Involve Family in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their representative were given the opportunity to participate in the development and implementation of the resident's person-centered care plan. Specifically, the family member of a resident, who was cognitively intact and able to make decisions, was not invited to participate in quarterly care plan meetings. The facility's policy required that residents and their designated representatives be encouraged to participate in care plan development, including initial, significant changes, and annual care plans. However, the family member was only involved in the initial care plan meeting and a follow-up meeting related to discharge planning, but not in the quarterly meetings. Interviews revealed that the Director of Social Work acknowledged that family members were not notified of quarterly care plan meetings unless there was a significant change or a specific request from the family. The family member of the resident, who visited daily, expressed that they were not made aware of or invited to these meetings. The facility's practice of not notifying family members of quarterly care plan meetings was inconsistent with their policy, leading to the deficiency cited in the survey.
Failure to Provide Vision Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities, as required by regulation 483.25(a). The resident, who was admitted with a diagnosis of [REDACTED], was cognitively intact and able to communicate effectively. Despite expressing difficulty with vision and the ineffectiveness of their old glasses, the resident had not been provided with an eye exam, new glasses, or a follow-up ophthalmology appointment since their admission. The last ophthalmology consult was dated July 2020, prior to the resident's admission, and recommended a follow-up in three months, which was not arranged by the facility. The resident's Comprehensive Care Plan, dated December 2024, did not include any plan for vision care or glasses. Interviews with the Director of Nursing and a Registered Nurse revealed that the resident had not been seen by an ophthalmologist since admission, and it was the unit manager's responsibility to coordinate such follow-up visits. The Registered Nurse was unaware that the resident wore glasses and acknowledged the omission in the care plan, indicating a lack of awareness and coordination in addressing the resident's vision needs.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Corrective Action for those identified: Resident #19 has an ophthalmology appointment scheduled for 3/14/25 at 1500. The care plan for Resident #19 was updated to include vision concerns and use of eye glasses on 2/14/25. Identification of other residents and corrective action: All residents are at risk for the deficient practice. An audit of all residents for indication for follow up vision assessments and/or use of eyeglasses will be completed to ensure care planning (inclusive of scheduling of necessary follow up appointment) is completed appropriately. Measures and Systemic Changes: A new policy “Care of Visually Impaired Residents” was initiated on 3/11/2025. Education of pertinent staff related to the new policy will be completed by 3/31/25. Monitoring: An audit of all new admissions will be conducted to ensure vision treatment and assistive devices are appropriately addressed. This will occur weekly x 4 weeks and then monthly x 3 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Annmarie Mogensen, Director of Nursing, by 3/31/25.
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What surveyors actually found near you
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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 Gloversville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fulton Center For Rehabilitation And Healthcare | 2 mi | ★★★★★ | 1 | 0 |
| Wells Nursing Home Inc | 5.1 mi | ★★★★★ | 1 | 0 |
| Wilkinson Residential Health Care Facility | 9.2 mi | ★★★★★ | 0 | 0 |
| River Ridge Living Center | 11 mi | ★★★★★ | 2 | 0 |
| Capstone Center For Rehabilitation And Nursing | 15.5 mi | ★★★★★ | 0 | 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.