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 Renaissance Rehabilitation And Nursing Care Center during CMS and state inspections, most recent first.
Verbal and Mental Abuse During Resident Care: A CNA was witnessed handling a resident roughly and screaming while providing care, with the resident and family member on the phone hearing cursing and abusive language. The resident, who had significant neurologic impairment and depended on staff for all ADLs, reported being scared, nervous, and unsafe afterward, and the record noted no documented complete nursing assessment, psych referral, or provider follow-up after the incident.
A facility failed to provide required supervision for two residents. One resident who needed 2-person assist for bed mobility was turned by a CNA with only 1 staff present, slid from the bed, and sustained a femur fracture. Another resident with severe cognitive impairment and a care plan for close supervision ambulated alone, fell in a hallway, and fractured a hip. Interviews showed staff and rehab personnel knew the resident should not have been walking alone, but the resident was not monitored at the time of the fall.
Failure to timely report abuse and injury incidents: A resident with severe mobility limitations fell from bed during CNA care and sustained a femur fracture, another resident with a high fall risk walked unassisted and fell with a hip fracture, and a dependent resident was verbally abused and handled roughly during care. The facility’s records showed the first two incidents were not reported to the NYS DOH, and the abuse allegation was substantiated after staff witnessed rough handling and screaming during care.
Failure to update care plans after major changes in condition affected three residents. One resident with total-assist needs fell from bed and sustained a femur fracture, but the fall and ADL care plans were not revised. A second resident voiced suicidal ideation during PT eval, yet no depression or SI care plan was added. A third resident reported not feeling safe after a substantiated abuse incident, but the victimization care plan was not updated.
A facility failed to ensure psychiatric assessment and services after a resident voiced suicidal ideation during PT eval and after another resident experienced a substantiated abuse incident and said they did not feel safe. Records showed no psych assessment after either event, despite existing behavioral health needs, psychotropic meds, and prior psych follow-up history.
The facility did not meet its own minimum CNA staffing requirements for day, evening, and night shifts over a two-month period, resulting in unsupervised residents, foul odors, and delays in care such as feeding, showers, and medication administration. Staff and residents reported long wait times, incomplete care, and difficulty performing necessary tasks due to inadequate staffing. Facility leadership acknowledged ongoing recruitment challenges and a lack of understanding regarding the use of the Facility Assessment to determine staffing needs.
The facility did not ensure RN coverage for at least 8 consecutive hours daily on multiple weekends, resulting in periods with no RN present. During these times, two residents experienced falls and another sustained a burn, none of whom were assessed by qualified staff until days later. LPNs contacted the DON by phone for guidance, but there was no documentation of in-person RN assessment or presence.
Three residents did not receive timely assessment by an RN after significant incidents, including open wounds and unwitnessed falls with injury or complaints of pain. In each case, LPNs documented the events and notified physicians, but there was no evidence of RN assessment or documentation prior to residents being moved or treated, and staffing records confirmed the absence of RNs during these critical periods.
A resident with cognitive impairment and poor safety awareness experienced two separate burn injuries from hot beverages due to inadequate supervision and lack of timely interventions. After the first incident, only resident education was provided, and no root cause analysis or comprehensive investigation was conducted. The second burn occurred months later, with delayed implementation of safety measures such as a lidded mug and cupholder, and these interventions were not promptly added to the care plan or communicated to staff. Both incidents were not reported to the state health department as required, and staff interviews revealed gaps in awareness and follow-through on accident prevention protocols.
A resident with cerebrovascular disease, dysarthria, and asthma, who was dependent on staff for bathing, did not consistently receive scheduled showers as outlined in their care plan and personal preference. Documentation and interviews confirmed missed showers, with accountability records showing fewer showers provided than required, and staff acknowledging lapses in both care delivery and documentation.
A resident with occasional urinary and bowel incontinence was not provided with a toileting program or individualized continence care, despite having intact cognition and expressing a preference to use the toilet rather than wear adult briefs. Staff did not update the care plan or trial a toileting program, and the resident's incontinence episodes increased. Interviews revealed that the resident was capable of being toileted with assistance, but staff cited insufficient staffing and did not implement appropriate interventions.
A resident with insomnia and other medical conditions did not receive six doses of a prescribed sleep medication due to delays in obtaining prior insurance authorization and failures in staff communication and medication management. The LPN did not notify the provider or pharmacy when the medication was unavailable, and the DON and pharmacy had unclear responsibilities regarding insurance approval, resulting in the resident's needs not being met.
The facility's governing body failed to implement effective policies to manage a prolonged outage of the large elevator, impacting meal delivery and evacuation processes. Despite awareness of the issue, no Quality Assurance Performance Improvement plan was documented to address the problem. The facility owner/operator was uncertain if the issue was discussed in meetings and believed alternative measures were in place, although no documentation supported this.
The facility failed to maintain a safe and functional environment due to a large elevator being out of order since spring 2024. This led to disruptions in meal delivery, with food temperatures falling into the danger zone, as un-insulated linen carts were used instead of the large, insulated meal truck. The facility's administration and maintenance staff were aware of the issue but faced delays in obtaining parts for repair, affecting resident activities and overall service provision.
The facility did not maintain a clean and homelike environment, with observations of sticky floors, overflowing garbage, and soiled briefs in resident rooms. Staff reported being overwhelmed due to understaffing, impacting their ability to complete tasks. The administrator noted the need for additional training and oversight for housekeeping staff.
The facility failed to maintain an effective infection prevention and control program, lacking a current Water Management Plan, failing to implement COVID-19 precautions, and breaching infection control during medication administration. Staff were unaware of Enhanced Barrier Precautions, leading to inadequate protective measures for residents with urinary catheters.
The facility did not implement an antibiotic stewardship program, failing to track and monitor antibiotic use as required. The RN Unit Manager was unaware of the term 'antibiotic stewardship' and did not track antibiotic use for residents. The DON/Infection Preventionist admitted responsibility but acknowledged that tracking was not being done, and the Administrator confirmed the Nursing Department's responsibility for monitoring antibiotic use.
The facility did not ensure the designated Infection Preventionist, the DON, completed specialized training in infection prevention and control before starting their role. The DON only completed a 4-hour mandatory training certificate, with no additional specialized training documented. This was confirmed during a survey and an interview with the DON.
The facility failed to prevent accident hazards and provide adequate supervision, resulting in multiple incidents involving residents. One resident on anticoagulants experienced falls without documented neuro-checks or hospital evaluation. Another resident had a non-functional enabler rail for over a month, affecting mobility. A third resident fell and fractured a hip, with no updated care plan interventions. Additionally, a fourth resident had multiple falls with major injuries, but their care plan was not updated. These incidents highlight systemic issues in fall prevention and care plan management.
The facility experienced chronic staffing shortages, leading to delays in resident care and unmet needs. Residents reported long wait times for assistance, and observations revealed soiled conditions and strong odors in rooms. Staff interviews confirmed the overwhelming workload due to understaffing, with management acknowledging recruitment challenges and the frequent use of overtime incentives.
The facility failed to ensure a Registered Nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required by regulations. This deficiency was identified during a recertification survey, revealing that no RN was present on specific dates. The facility's Staffing Coordinator, Director of Nursing, and Administrator acknowledged staffing challenges and confirmed that emergencies were managed by contacting the on-call Nurse Practitioner or Director of Nursing.
The facility did not conduct annual performance reviews for CNAs, as required. The DON, responsible for these reviews, had not completed them since the aides' employment began. Interviews confirmed the lack of recent appraisals, and the facility is recruiting an Assistant DON to address this issue.
The facility failed to maintain proper food safety standards, with observations of improper food temperatures and expired items. Staff interviews revealed a lack of adherence to protocols, and improper transport methods may have contributed to the issue.
The facility failed to develop and implement a QAPI plan to address issues from a large elevator outage, affecting food safety, resident dining arrangements, and live music activities. The elevator had been malfunctioning since spring 2024 and was shut down by mid-July, leading to operational challenges. Staff interviews revealed a lack of documentation and planning in QAPI meetings, with no documented plans for safe resident transport, food safety, or alternative activities.
The facility failed to provide annual training on resident abuse prevention as required by its policy. The Director of Nursing could not produce documentation for three out of five sampled CNAs, and staff interviews revealed uncertainty about when the training occurred.
The facility did not provide timely notification to a resident's designated representative regarding the termination of Medicare Part A services. The representative was informed via telephone only one day before the last covered day, instead of the required two-day notice. This deficiency was identified during a recertification survey.
The facility did not provide written notification to two residents and their representatives regarding hospital transfers, as required. One resident was transferred twice due to medical issues, and another was transferred after presenting with bruising and pain. Facility staff were unclear about who was responsible for providing these notifications.
A facility failed to notify a resident and their representative in writing about the bed hold policy during hospital transfers, as required by their policy and state regulations. The resident, with conditions including a urinary tract infection and type 2 diabetes, was transferred to the hospital twice without receiving the necessary written information. Interviews revealed a lack of responsibility and procedure for providing these notifications.
Two residents experienced falls without subsequent updates to their care plans. One resident, with a history of falls and conditions like dementia, fell twice in February without new interventions added. Another resident, identified as a high fall risk, fell in August, resulting in a hip fracture, yet their care plan remained unchanged. Staff interviews revealed a lack of consistent care plan updates and communication gaps among the facility's nursing staff.
Three residents with severe cognitive impairments did not receive timely personal hygiene care due to staffing shortages. Observations revealed residents in soiled briefs and rooms with strong odors, indicating a lack of necessary services. Staff interviews confirmed that staffing challenges affected the timeliness of care.
A resident with cognitive impairment and other health issues was observed with open red areas on their skin, which were not assessed or reported to medical staff. Despite having a care plan for skin care, facility staff failed to communicate the resident's skin changes, leading to a deficiency in care.
A resident at risk for pressure ulcers did not receive proper care as their heels were not offloaded while in bed, despite physician orders. Staff were unaware of the order due to poor communication and documentation in the electronic medical record system. The DON acknowledged delays in entering care plans, contributing to the deficiency.
Expired IV Vancomycin bags were found in a medication room, with expiration dates ranging from July to August. An LPN was unsure if the facility intended to return them to the pharmacy, while an RN Unit Manager confirmed they should have been discarded. The DON noted that multi-dose insulin vials are no longer used, and the LPN should not have administered insulin from an open vial labeled for another resident.
A facility failed to document a medication irregularity review for a resident receiving Enoxaparin. The pharmacist recommended a review for a stop date, but the provider did not document the plan in the medical record. The Nurse Practitioner later acknowledged the oversight, citing workload challenges.
A facility failed to ensure a resident's drug regimen was free from unnecessary medications, specifically the anticoagulant Enoxaparin. Despite a pharmacy recommendation to discontinue the medication, it continued to be administered without proper documentation or a care plan. The oversight was attributed to communication lapses and an overlap in Nurse Practitioners, with the new NP not intending to discontinue the medication due to the resident's condition.
The facility did not store drugs and biologicals according to professional standards, as expired 22-gauge insyte autogaurd needles were found on a medication cart. An LPN stated that these needles should have been discarded, and the facility's policy lacked guidelines for storing such medical supplies.
A facility failed to ensure a resident's right to formulate advance directives due to inadequate assessment of the resident's cognitive capacity. The resident, with fluctuating cognition, had a MOLST form updated without a signed confirmation or involvement of a health care proxy. Conflicting cognitive assessments and lack of physician documentation on capacity contributed to the deficiency.
A resident with declining cognition was not promptly communicated about changes in their advance directives, including a Do Not Hospitalize order. The facility failed to inform the resident's representative of these changes and the resident's deteriorating condition, leading to confusion and distress after the resident's death.
A resident with a history of aggression physically assaulted another resident, and the facility failed to implement 30-minute safety checks as required. Despite the facility's policy on abuse prevention, there was no physician's order for monitoring, and no evidence of such monitoring being conducted. The DON admitted to not entering the order, and both an LPN and RN confirmed the lack of documentation, leading to a deficiency in protecting residents from abuse.
A resident alleged abuse during a vascular appointment, but the facility failed to investigate or report the incident to the state health department. The resident, with a history of delusional disorders, had a bruise attributed to a fall. Staff interviews revealed a lack of communication and documentation, and the facility administrator was unaware of the allegation until contacted by the Attorney General.
A facility failed to create a comprehensive care plan for a resident dependent on hemodialysis, despite having a physician order and documentation for dialysis procedures. Interviews revealed that nursing staff were responsible for care plan updates, but due to workload, the care plan was not completed, violating facility policy.
The facility failed to provide appropriate dialysis care for two residents. One resident lacked a dialysis communication book, and necessary assessments before and after dialysis were not consistently performed. Another resident had no comprehensive care plan for hemodialysis, and communication sheets were missing for several treatment dates. These deficiencies indicate a failure to adhere to professional standards of practice for dialysis care.
Three residents in an LTC facility received medications earlier than prescribed due to an LPN administering 5:00 PM medications between 2:23 PM and 2:31 PM. The LPN stated they were instructed by the DON to do so due to a lack of relief. The RN Unit Manager and Nurse Practitioner were unaware of the early administration, and the DON confirmed it was a medication error.
The facility failed to provide CNAs with the required 12 hours of annual training, including dementia care and abuse prevention. Documentation showed incomplete training hours, and interviews confirmed a lack of recent in-services. The Director of Nursing cited staffing issues as a reason for the shortfall.
Verbal and Mental Abuse During Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from verbal and mental abuse. The resident had diagnoses including anoxic brain damage, hemiplegia following cerebrovascular disease affecting the right dominant side, and contractures of both hands. The resident’s quarterly MDS documented unclear speech, being sometimes understood, cognitive intactness, and dependence on staff for all activities of daily living, including eating, oral hygiene, toileting, showering, and dressing. The resident also had a care plan identifying a potential for victimization related to medical, cognitive, mood, and/or behavioral status. During care provided by a CNA, staff witnessed the CNA handling the resident in a rough manner and speaking in loud tones characterized as screaming. The resident reported that the CNA used ice cold water during hygienic care, was loud, was in the resident’s face, and used abusive language, including a racial slur. Staff statements documented that the CNA was rolling the resident back and forth roughly, yelling, and cursing while attempting to provide care. The resident’s representative was on the phone during the entire exchange and heard the staff cursing and the resident upset during the incident. The incident report and staff interviews documented that the resident became emotionally upset, angry, scared, nervous, and distraught after the event. The resident later stated they did not feel safe in the facility and would jump when staff entered the room. The record also reflected that there was no documented evidence of a complete nursing assessment, psychiatric referral, or medical provider follow-up after the incident. The allegation of abuse was substantiated, and the report stated there was no documented evidence that local law enforcement was called by the facility.
Failure to Provide Required Supervision During Bed Mobility and Ambulation
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of identified interventions for two residents who were reviewed for accidents. The deficiency involved one resident who required two-person assistance for bed mobility and another resident who was severely cognitively impaired and required close supervision for ambulation. The report states that both incidents resulted in actual harm, including fractures to the right hip/femur, and that the deficiency was not Immediate Jeopardy. For one resident, the care plan documented total dependence of two staff for bed mobility and other assistance needs, along with fall-risk interventions and a separate care plan directing assistance with transfers and bed mobility as recommended. During care on the unit, a CNA turned the resident on their side to adjust a pad under the resident and, while doing so, the resident’s right leg jerked forward and the resident slid off the bed onto the floor. The CNA acknowledged not following the care plan requiring two-person assistance. The resident was later documented with severe pain, a hematoma on the forehead, and x-ray findings of a distal femur fracture, and was transferred to the hospital for further evaluation. For the other resident, the record and interviews described severe cognitive impairment, poor safety awareness, impaired balance, and a high fall-risk score. The resident was documented as needing close supervision for ambulation, yet was found on the floor in the north hallway after apparently walking independently and losing balance. The incident was unwitnessed, and the resident reported going to the dining room and slipping and falling. Interviews with staff and rehabilitation personnel indicated the resident should not have been walking alone and should have been monitored or redirected, but the LPN who discovered the resident stated they did not know the resident’s care plan and did not know whether someone had been with the resident in the day room. The resident sustained a fractured right hip.
Failure to Timely Report Abuse and Injury Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse and injuries were reported immediately, and no later than two hours after the allegation was made, to the administrator and other required officials, including the State Survey agency, for three residents reviewed for abuse and falls. The report states that the facility did not report incidents involving a resident who fell from bed and sustained a right hip fracture, a resident who walked unassisted despite requiring close supervision and fell with a right hip fracture, and a resident who was verbally abused by a CNA during care. The facility policy defined mental abuse and neglect and stated that immediate reporting should occur as soon as possible and not exceed 24 hours, with certain injuries and substantiated abuse or neglect requiring reporting to the State Agency within 24 hours or per state guidelines. One resident had diagnoses including fusion of the spine, a history of healed traumatic fracture, and chronic pain syndrome, and was cognitively intact but dependent on staff for most activities of daily living. The resident’s care plan identified a high fall risk and required staff to keep the call bell and needed items in reach and to remind the resident to call for assistance. The internal incident report documented that a CNA was providing bed mobility care when the resident’s right leg jerked with spastic movement, causing the resident to slide off the bed and fall to the floor. The CNA acknowledged not following the plan of care requiring two-person assistance. X-ray findings showed a distal femur fracture, and the resident was transferred to a hospital for further evaluation and admitted for a right femur fracture. The chart review indicated that this incident was never reported to the New York State Department of Health. Another resident had diagnoses including history of falling, generalized osteoarthritis, and chronic pain. The resident’s MDS indicated supervision or touching assistance was required for sit-to-stand and walking 10 feet, and the care plan identified the resident as at increased risk for falls with multiple prior falls. The facility’s investigative synopsis documented that the resident was found on the floor in a hallway after apparently losing balance while ambulating, and the resident reported slipping and falling while going to the dining room. The investigation concluded the event was an accidental fall related to impaired balance and high fall risk, but the Director of Rehabilitation stated the resident should not have been walking alone and should have been redirected or accompanied. The chart review indicated that this incident was never reported to the New York State Department of Health. A third resident had anoxic brain damage, hemiplegia following cerebrovascular disease, and contractures of both hands, and was dependent on staff for all activities of daily living. The resident’s care plan identified a potential for victimization due to medical and cognitive status. The internal incident report documented that the resident was receiving care from a CNA when staff witnessed rough handling and loud screaming, and the resident reported that the CNA used ice-cold water during hygiene care. The RN supervisor removed the CNA from the environment, and statements from staff supported the allegation that the resident was handled roughly and subjected to loud, disruptive, and agitated vocalizations. The investigation substantiated abuse. The record also showed that the nurse supervisor called a number believed to be the Justice Center but left no return number, and the facility did not call local law enforcement; law enforcement became involved only after the resident’s representative called them.
Failure to Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to revise and update care plans after significant changes in residents’ psychosocial and physical condition were documented for three residents reviewed for care planning. The facility policy defined a significant change in condition as a decline or improvement requiring an updated assessment and care plan revision, and stated that care plans must be updated when risk increases or new problems arise, including after falls, behaviors, infections, hospitalization, skin issues, or adverse events. Resident #9, who had diagnoses including fusion of spine site unspecified, personal history of healed traumatic fracture, and chronic pain syndrome, was cognitively intact and dependent on staff for most or all ADLs. After an incident in which a CNA was providing care, turned the resident on the left side, and the resident’s right leg jerked forward causing the resident to slide off the bed and fall to the floor, x-ray showed a distal femur fracture and the resident was transferred to the hospital for further evaluation. The resident’s fall risk care plan had been entered earlier and listed interventions such as keeping the call bell in reach and the room well lit and clutter free, but it was not updated after the fall and fracture. The resident’s ADL care plan also continued to reflect one-staff assistance even though the incident documentation stated the resident required total assist by two persons in bed mobility and toilet care. Resident #4 was re-admitted with diagnoses including unspecified fracture of the right femur, peripheral vascular disease, and anxiety disorder, and the admission MDS documented a brief interview of mental status score of 15 with no cognitive impairment. During a PT evaluation, the therapist documented that the resident was voicing suicidal ideation and notified the social worker and Director of Rehabilitation, but there was no further documentation regarding depression or suicidal ideation and no care plan was added or revised for psychosocial well-being, depression, or suicidal ideation. Resident #1 had diagnoses including anoxic brain damage, hemiplegia following other cerebrovascular disease affecting the right dominant side, and contractures of both hands, and was dependent on staff for all ADLs. After an abuse incident in which staff were observed handling the resident roughly and yelling while providing care, the resident reported not feeling safe and the allegation was substantiated, but the potential for victimization care plan was not updated to reflect the resident’s statement or the incident.
Failure to Assess Residents After Suicidal Statement and Abuse Incident
Penalty
Summary
The facility failed to ensure that residents who made serious behavioral health statements or experienced a traumatic incident were assessed and provided necessary psychiatric services. The facility assessment stated that it was dedicated to effectively managing medical conditions and medication-related issues that may contribute to psychiatric symptoms and behavioral challenges, and the facility policy on Psychiatry and Psychology Services stated that residents would be provided, arranged for, or referred to psychiatric and psychological services sufficient to meet identified needs. However, the record showed no psychiatric assessment for one resident after a suicidal statement was documented by Physical Therapist #1 during evaluation, and no psychiatric assessment for another resident after an abuse incident in which the resident reported being handled roughly and stated they did not feel safe. One resident was readmitted with diagnoses including unspecified fracture of the right femur, peripheral vascular disease, and anxiety disorder, and had a BIMS score of 15 indicating no cognitive impairment. On 11/20/2025, Physical Therapist #1 documented that the resident was voicing suicidal ideation during evaluation and notified the Social Worker and Director of Rehabilitation. The chart contained no further documentation regarding the suicidal ideation, and review of the record revealed that no staff member completed a psychiatric assessment before or after the statement. The resident’s chart included psychotropic medication orders such as alprazolam and escitalopram, and care plans addressed behavior changes, psychosocial well-being, and anxiety, but there was no care plan for depression or suicidal ideation. The other resident had diagnoses including anoxic brain damage, hemiplegia following cerebrovascular disease affecting the right dominant side, and contractures of both hands, and was dependent on staff for all activities of daily living. After an incident on 01/25/2026, the internal investigation documented that a CNA was witnessed handling the resident roughly and yelling during care, and the resident reported being treated roughly and having ice cold water used during hygiene care. The investigation substantiated abuse, and the resident later stated they had been nervous, jumped when staff entered the room, and did not feel safe in the facility. Review of the chart revealed no psychiatric assessment after the incident, despite prior psychiatric follow-up history in the record and the resident’s report of fear and lack of safety.
Failure to Maintain Minimum CNA Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff, specifically Certified Nurse Aides (CNAs), to meet the needs of residents on all shifts over a two-month period. Staffing schedules for July and August 2025 showed that the facility did not meet its own minimum staffing requirements for CNAs on any day or evening shift and was below the minimum on most night shifts. The facility's staffing policy and assessment required a minimum of 11 CNAs for day and evening shifts and 6 for night shifts, but these levels were not achieved. Observations revealed unsupervised residents, foul odors, and strong smells of urine in resident areas, indicating lapses in care and supervision due to inadequate staffing. Interviews with residents and staff confirmed the impact of insufficient staffing. Residents reported long wait times for call bells, cold meals, irregular showers, and delays in receiving medications. CNAs described being unable to complete assigned tasks, such as getting residents out of bed, providing showers, and supervising common areas. They also reported difficulty in feeding residents and performing necessary transfers, especially when staffing dropped to three or fewer CNAs per shift. Registered Nurses (RNs) indicated that they were unable to complete medication passes and assessments on time due to the need to assist CNAs with basic care tasks. Facility leadership, including the Staffing Coordinator, DON, and Administrator, acknowledged ongoing staffing challenges and difficulties in recruitment and retention. The Staffing Coordinator noted that agency staff were unreliable and that the facility often relied on staff working double shifts. The Administrator admitted to being unaware of the role of the Facility Assessment in determining staffing needs. The Corporate Administrator stated that the Facility Assessment was intended to guide staffing decisions, but it was not reviewed with the new administrator. These actions and inactions led to the facility's failure to ensure adequate staffing to maintain the well-being of each resident.
Failure to Provide Required RN Coverage and Resident Assessment
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, for four out of nine weekends reviewed, there was no RN present in the building for periods ranging from 36 to 48 hours. During these times, the facility relied on Licensed Practical Nurses (LPNs) who would contact the Director of Nursing (DON) by phone for guidance, but there was no documentation that the DON or any other RN was physically present or had assessed residents during these periods. The facility's staffing policy and assessment indicated the expectation of having sufficient RN coverage, including the DON as a full-time RN and additional RN managers and supervisors, but these staffing goals were not met. During the periods when no RN was present, several incidents occurred involving residents. Two residents fell out of bed, with one sustaining a bloody nose and another complaining of hip pain, but neither was assessed by an RN. Another resident sustained a burn on the thigh and was not assessed by qualified staff until two days later by a wound care physician. Interviews with the staffing coordinator and DON confirmed that there were times when no RN was scheduled, and the DON would only provide guidance remotely without documentation of being on duty or assessing residents in person. The administrator acknowledged awareness of the RN staffing gaps, particularly on weekends and night shifts.
Failure to Ensure Timely RN Assessment and Documentation After Resident Incidents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of quality, as evidenced by the lack of timely assessment by a registered nurse (RN) following significant incidents involving three residents. In the first case, a resident with paranoid schizophrenia and neurocognitive disorder was found with three open wounds on the left hip, reportedly caused by a coffee burn. There was no documented evidence that an RN assessed the wounds in a timely manner after discovery, and staffing records confirmed that no RN was present in the facility for over 36 hours during the period when the wounds were identified and reported. Communication about the incident occurred via group text, but no RN assessment was documented until after the wound care physician evaluated the resident days later. In the second case, a resident with metabolic encephalopathy, dysphagia, and lupus experienced an unwitnessed fall and complained of hip pain. The incident was documented by an LPN, and the physician was notified with x-rays ordered. However, there was no documentation of an RN assessment following the fall, and staffing records indicated that no RN was on duty at the time. Interviews with staff revealed uncertainty about whether an RN assessment occurred, and the Director of Nursing could not recall the event or confirm that an RN had evaluated the resident prior to their transfer from the floor to the bed. The third case involved a resident with dementia, depression, and anxiety who was found on the floor with a bloody nose after an unwitnessed fall. The resident was assisted back to bed by LPNs without documented RN assessment prior to the move. There was also no evidence of 72-hour post-fall monitoring or treatment for the bloody nose. Staffing records again showed no RN on duty at the time, and interviews with staff and the Director of Nursing confirmed that the expected process of RN assessment and documentation was not followed. The Director of Nursing acknowledged being the backup when no RN was present but did not come to the facility or document any assessment.
Failure to Prevent and Investigate Recurrent Resident Burns from Hot Beverages
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and poor safety awareness, resulting in two separate burn incidents from hot beverages. The first incident occurred when the resident spilled hot chocolate on their thigh, which was not reported to staff until the following day. Documentation shows that the only intervention after this incident was resident education, and there was no thorough investigation or root cause analysis conducted to determine how the accident occurred or to prevent recurrence. The care plan was updated to address wound care but did not include specific interventions for hot beverage safety or increased supervision. A second burn incident occurred several months later when the same resident sustained second-degree burns after placing a hot cup of coffee next to their thigh while self-propelling in a wheelchair. Again, the facility did not conduct a root cause analysis or a comprehensive investigation to determine if the accident was avoidable. The only new interventions at the time were the provision of a lidded coffee mug and cupholder, but these were not promptly added to the resident's care plan or communicated to all relevant staff. The care plan update focused on wound care and supervision during meals but did not address burn prevention or hot beverage management until much later. Both burn incidents were not reported to the New York State Department of Health as required. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of awareness regarding the need for a root cause analysis and timely reporting. There was also a delay in updating care plans and staff instructions to reflect necessary interventions for hot beverage safety, despite recommendations from the dietary team and discussions in morning reports.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for bathing did not consistently receive showers as specified in their care plan and personal preference. The facility's policy required individualized care to maintain residents' quality of life, including honoring preferences for bathing routines. Documentation showed that the resident was to receive showers twice weekly, specifically on Tuesday and Friday evenings. However, review of Certified Nurse Aide accountability records revealed that the resident received only 5 out of 9 scheduled showers in one month and only 3 showers in the following month. During interviews and observations, the resident confirmed that showers were not always provided as scheduled, and staff corroborated that there were occasions when the resident did not receive their shower on the assigned shift. The Staff Development LPN stated the resident did not refuse showers, and the DON acknowledged a pattern of incomplete documentation by CNAs on certain shifts. The resident's medical history included cerebrovascular disease, dysarthria, and asthma, and they were cognitively intact at the time of the deficiency.
Failure to Provide Individualized Continence Care and Toileting Program
Penalty
Summary
A deficiency was identified when a resident with occasional urinary and bowel incontinence was not provided with appropriate services to maintain or improve continence. The resident was admitted with intact cognition and required staff assistance for toileting, hygiene, and transfers. The care plan indicated the resident should be maintained on a toileting program to promote dignity and prevent skin breakdown, with interventions such as monitoring for skin issues and using easily removable clothing. However, there were no updates to the care plan after the initial entry, and documentation showed that a toileting program trial had not been attempted, despite the resident's increasing incontinence episodes. Observations and interviews revealed that the resident expressed a clear preference not to wear adult briefs and requested assistance to use the toilet. The resident reported that staff did not respond to their calls for help, resulting in episodes of incontinence. The family member confirmed that the resident was able to use the toilet when out with family and that wearing briefs was not good for the resident's skin. Staff interviews indicated that the resident was capable of being toileted with assistance, but a toileting program was not implemented, and staff cited insufficient staffing as a barrier to providing this care. Further interviews with clinical and rehabilitation staff confirmed that the resident had not been placed on a toileting program, and there was no recommendation against toileting from the rehabilitation team. The nurse practitioner stated that the resident should be trialed with voiding if they were aware of their need to use the bathroom, and the DON stated the resident was not on a voiding program due to requiring two-person assistance for transfers. The lack of individualized continence care and failure to honor the resident's preferences led to the deficiency.
Failure to Provide Timely Pharmaceutical Services Due to Lapses in Communication and Medication Management
Penalty
Summary
Pharmaceutical services failed to meet the needs of a resident who was prescribed eszopiclone for insomnia. The resident, who had diagnoses including bipolar disorder, Lupus anticoagulation syndrome, and insomnia, did not receive six consecutive doses of the medication. Documentation showed the medication was not administered over several days, with some days marked as unavailable and others lacking any documentation. The facility's medication administration policy required staff to check overflow supplies, emergency boxes, and to notify the medical provider and pharmacy if a medication was unavailable, but these steps were not consistently followed. The nurse did not contact the medical provider or pharmacy to obtain the medication or an alternative, and there was no documentation in the nurse progress notes regarding the missed doses or unavailability of the medication. The delay in administration was due to the need for prior insurance authorization, which was not obtained until after multiple missed doses. The resident reported the issue through a grievance, and interviews revealed that staff, including the LPN and DON, were aware of the medication's unavailability but did not take all required actions to resolve the issue or communicate with the medical provider in a timely manner. The pharmacy also indicated that prior authorization was necessary, but there was confusion about who was responsible for obtaining it and notifying the facility. The physician and nurse practitioner were not promptly informed of the missed doses, which delayed the possibility of ordering an alternative medication.
Failure to Address Elevator Outage in Facility
Penalty
Summary
The governing body of the facility failed to establish and implement effective policies for managing and operating the facility, specifically regarding the consistent operation of the large elevator. Since the spring of 2024, the large elevator was not functioning consistently, impacting meal delivery, evacuation processes, and the movement of larger items. Despite being aware of the issue, the facility did not ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to address the elevator's downtime. The facility's policy on 'Elevator Breakdown-Single Car Operation' was not effectively executed, as there was no documentation of interventions or plans to mitigate the impact of the elevator outage on residents and staff. During interviews, the facility owner/operator acknowledged awareness of the broken elevator but was uncertain if it was discussed in QAPI meetings, as they did not attend these meetings. They believed that staff maintained food temperatures and provided alternative activities during the elevator's downtime. The owner/operator also mentioned that the elevator had issues for several months, with repair delays due to unavailable parts and staffing problems at the elevator technician company. Despite these challenges, the facility owner/operator did not believe the broken elevator negatively impacted residents' safety or health.
Elevator Malfunction Leads to Unsafe Environment and Meal Delivery Issues
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the large elevator being out of order since the spring of 2024. This deficiency was observed during the recertification and abbreviated surveys conducted from September 5 to September 13, 2024. The facility's policy on 'Elevator Breakdown-Single Car Operation' was not effectively implemented, leading to significant disruptions in meal delivery, evacuation processes, and the movement of larger items. The large elevator's downtime impacted the quality of life and convenience for residents, as well as the provision of services. The breakdown of the large elevator resulted in meal trays being transported on un-insulated linen carts, which could not maintain safe food temperatures. This issue was confirmed by interviews with Activity Aides and the Food Service Director, who acknowledged that food temperatures were within the danger zone. The facility's inability to use the large, insulated meal truck due to the elevator's size constraints further exacerbated the problem. The Food Service Director and Supervisor admitted to not checking food temperatures on the units since the elevator shutdown, prioritizing speed over safety in meal delivery. The facility's administration and maintenance staff were aware of the elevator's issues but faced challenges in obtaining the necessary parts for repair. The Director of Maintenance documented multiple attempts to follow up with the elevator repair company, which was experiencing staffing problems and delays in part availability. The elevator's malfunction also affected resident activities, with several concert activities canceled due to the elevator's shutdown. Despite being aware of the situation, the facility owner/operator and Administrator did not have a clear timeline for the elevator's repair, contributing to the ongoing deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as observed during the recertification survey. On Unit 2, resident rooms were found with sticky floors, overflowing garbage receptacles, garbage strewn on the floor, and soiled adult briefs lying on the floor. On Unit 1, the floor near the nursing station and in front of the elevator was littered with garbage and appeared stained. Additionally, the Unit 1 dining room floor had dried spills of coffee, and breakfast trays were left on tables well past meal completion time. Interviews revealed that the facility was chronically understaffed, contributing to the inability to maintain cleanliness. A Certified Nurse Aide reported being overwhelmed with the responsibility of providing morning care, feeding, and assisting with housekeeping for 30 residents, which hindered the completion of all tasks. The facility's administrator acknowledged the need for additional training and oversight for housekeeping staff, despite having sufficient staff available during two shifts.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Firstly, the facility did not have a current Water Management Plan to address potential Legionella risks. Although a Facility Risk Assessment was provided, it lacked a comprehensive Water Management Plan detailing the water management team, flow diagrams, and control measures. This plan was not made available until several days into the survey. Additionally, the facility did not properly implement infection control precautions for residents with COVID-19. In one instance, a resident who tested positive for COVID-19 did not have appropriate signage on their door to indicate necessary precautions. The Director of Nursing acknowledged that signs should have been posted immediately upon receiving a positive test result, but this was not done. Furthermore, there was a breach in infection control practices during medication administration. An LPN was observed using a glucometer on multiple residents without sanitizing it between uses. The LPN admitted that the glucometer should be sanitized between residents, and the Unit Manager confirmed that nurses are responsible for this task. Additionally, the facility failed to implement Enhanced Barrier Precautions, as staff were not aware of these requirements. A resident with a urinary catheter did not have signage indicating Enhanced Barrier Precautions, and staff were not using appropriate personal protective equipment during care.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required, which led to a deficiency in monitoring antibiotic use. The undated Antibiotic Stewardship Policy stated that the facility should promote appropriate antibiotic use and track infections to reduce adverse events. However, during the recertification survey, it was found that the facility did not have documentation of tracking antibiotic use, including the appropriate use and duration of antibiotic treatment. Interviews revealed that the Registered Nurse Unit Manager was unaware of the term 'antibiotic stewardship' and did not track or report antibiotic use for residents in July and August 2024. The Director of Nursing/Infection Preventionist acknowledged their responsibility to track antibiotic use but admitted that it was not being done, and there was no list of infections or antibiotic use being maintained. The Administrator confirmed that the Nursing Department was responsible for monitoring antibiotic use, but this was not being completed.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist, who was the Director of Nursing, completed specialized training in infection prevention and control prior to assuming their role. During a recertification survey conducted from September 5 to September 13, 2024, it was found that the Director of Nursing only completed a 4-hour New York State Infection Control Mandatory Training Certificate on October 15, 2023. There was no documented evidence of any additional specialized training in infection control. On September 6, 2024, a request was made to review the documentation of the Infection Preventionist's specialized training. The review revealed the lack of further specialized training beyond the mandatory certificate. In an interview on September 9, 2024, the Director of Nursing confirmed that they did not have any other specialized training in infection control.
Deficiencies in Accident Hazard Prevention and Resident Supervision
Penalty
Summary
The facility failed to ensure that residents remained as free from accident hazards as possible, as evidenced by multiple incidents involving four residents. Resident #161 experienced falls on two occasions while on anticoagulant medication, yet there was no documented evidence of neuro-checks following these falls, nor was the resident sent to the hospital for evaluation. The facility's policy required neuro-checks and monitoring, but these were not documented in the resident's medical record. Additionally, the staff did not remind the physician of the resident's anticoagulant medication, which could have influenced the decision to send the resident to the hospital. Resident #35 had a loose and non-functional shepherd's hook/enabler rail for over a month, which affected their ability to perform daily bed mobility tasks. Despite the resident informing staff and maintenance about the issue, the repair was not completed. The maintenance team was aware that a full repair required the resident to be out of bed, but this was not coordinated, leading to prolonged inaction. The lack of communication between maintenance and nursing staff contributed to the delay in addressing the safety hazard. Resident #18 fell and sustained a hip fracture, yet their fall care plan was not updated with new interventions to prevent future falls. The resident reported that they attempted to go to the bathroom independently due to delays in staff response to call bells. The cluttered state of the resident's room and the lack of accessible call bells further contributed to the unsafe environment. Similarly, Resident #87 experienced multiple falls with major injuries, but their care plan was not updated with new interventions, indicating a systemic issue in the facility's approach to fall prevention and care plan management.
Chronic Staffing Shortages Impact Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of understaffing documented in the facility's records. The Facility-Wide Assessment indicated the necessary staffing levels, but the actual staffing sheets revealed that the facility was understaffed on numerous days across several months. This understaffing led to significant delays in resident care, with reports of residents waiting extended periods for assistance, such as waiting to be transferred out of bed or having their call bells answered. Residents and their family members reported various issues related to the staffing shortages. One resident mentioned waiting four hours for a response to their call bell, while another noted the absence of staff late at night. Observations during the survey revealed residents in soiled conditions and rooms with strong odors, indicating a lack of timely care. Interviews with residents and staff highlighted the chronic nature of the staffing issues, with staff being overwhelmed by the number of residents they were responsible for, leading to delays in care and incomplete tasks. The facility's management acknowledged the staffing challenges, citing difficulties in recruiting and retaining nursing staff. The Director of Nursing and the Administrator both noted that staffing shortages were a persistent issue, affecting the timeliness and quality of resident care. Despite efforts to recruit new staff and offer incentives for overtime, the facility continued to struggle with maintaining adequate staffing levels, impacting the overall well-being of the residents.
Deficiency in RN Staffing Requirements
Penalty
Summary
The facility failed to comply with the regulatory requirement of having a Registered Nurse (RN) on duty for at least eight consecutive hours per day, seven days a week. During the recertification survey conducted from September 5 to September 13, 2024, it was found that the facility did not have an RN on duty on specific dates, namely April 12, April 13, April 27, and May 18, 2024. This deficiency was identified through a review of nurse staffing reports and confirmed by interviews with the facility's Staffing, Human Resources and Payroll Coordinator, Director of Nursing, and Administrator. The Staffing Coordinator acknowledged the challenge of maintaining adequate staffing levels and stated that the facility does not use staffing agencies, relying instead on offering bonuses and incentives to staff for covering extra shifts. The Director of Nursing confirmed that there were instances when no RN was present in the building, and emergencies during such times would be managed by contacting the on-call Nurse Practitioner or the Director of Nursing. The Administrator also admitted uncertainty about the presence of an RN for the required hours and mentioned ongoing recruitment efforts for nursing staff.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that certified nursing aide performance reviews were completed at least once every 12 months for five certified nurse aides. During the recertification survey, it was found that the Director of Nursing/Staff Educator, who is responsible for documenting these reviews, had not completed annual performance appraisals for the aides since their employment began in November 2022. Interviews with the Director of Nursing and a certified nurse aide revealed that performance appraisals had not been conducted in recent years, despite the aides having been employed for over a year. The facility acknowledged the issue and mentioned ongoing recruitment for an Assistant Director of Nursing to assist in completing these reviews.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a dinner observation, the temperatures of meat, mashed potatoes, milk, and super shake were found to be outside the acceptable range for food safety. Additionally, perishable foods in the kitchen were not labeled and dated, and nonperishable foods were expired. The facility's policy required that food temperatures be taken before serving, but this was not adhered to, as evidenced by the improper temperatures recorded during the survey. Interviews with staff revealed a lack of awareness and adherence to food safety protocols. The Food Service Director acknowledged that consuming expired food could lead to food poisoning, and the Administrator was unaware that food was being served in the danger zone. The improper use of linen carts for transporting meal trays due to elevator size constraints further complicated the situation, potentially contributing to the temperature discrepancies. Expired food items, such as gravy mix, were also found in the emergency supply area, indicating a broader issue with food management and safety practices within the facility.
Failure to Address Elevator Outage in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to address the issues arising from the large elevator being out of service. The elevator had been malfunctioning since the spring of 2024 and was completely shut down by mid-July 2024. This led to several operational challenges, including the inability to maintain food at safe temperatures when served on the units, residents having to eat on disposable plastic plates, and approximately ten residents who previously ate lunch in the main dining room being unable to do so. Additionally, live music performances were halted for about two months due to the inability to transport equipment using the small elevator. Interviews with various staff members, including the Director of Activities, Director of Maintenance, and the Administrator, revealed that the broken elevator was not documented as a topic in QAPI meetings, nor was there a QAPI plan created to address the outage. The facility did not document any meetings or plans to ensure safe resident transport, maintain food safety, or provide alternative activities. The Director of Maintenance mentioned that Medsleds were put in place for emergency transport, but there was no documentation of this or any staff education on the matter. The facility also restricted admissions for residents who would be difficult to transport in an emergency, but again, this was not documented. The facility owner/operator was aware of the elevator issues but did not attend QAPI meetings and was unsure if the topic was discussed. They believed that food temperatures were maintained and were unaware of the cessation of live music performances. The Food Service Director admitted to not checking food temperatures on the units after the elevator shutdown, prioritizing quick delivery over safety checks. This lack of documentation and planning highlights the facility's failure to address the operational challenges posed by the elevator outage effectively.
Deficiency in Annual Abuse Prevention Training
Penalty
Summary
The facility was found deficient in providing annual training to staff on resident abuse prevention during the recertification and abbreviated surveys conducted from 9/5/24 to 9/13/24. The facility's policy mandates that employees receive training on abuse prevention upon employment and annually thereafter. However, the Director of Nursing was unable to provide documentation of such training for the past 12 months for three out of five sampled certified nurse aides. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, revealed that while they had been in-serviced on the facility's abuse protocol, they could not recall when the training occurred. This lack of documentation and uncertainty among staff indicates a failure to comply with the facility's policy and regulatory requirements.
Failure to Provide Timely Notification of Service Termination
Penalty
Summary
The facility failed to ensure that residents and/or their designated representatives were fully informed of their right to an expedited review of a service termination. Specifically, for residents receiving Medicare Part A services, the facility did not provide timely notification of the termination of services using the Notice to Medicare Provider Non-coverage form CMS-10123. This deficiency was identified during a recertification survey conducted from September 5, 2024, to September 13, 2024. The issue was evident in the case of one resident, who last received rehabilitative services on March 26, 2024. The resident's designated representative was informed of the service termination via telephone only one day prior to the last covered day, instead of the required two-day notification period. The social worker explained that the notice was given late because it was the day they received the notice to obtain the signature.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reasons for hospital transfers, as required by regulations. Specifically, two residents were transferred to the hospital without receiving written notices. Resident #38, who had diagnoses including urinary tract infection and type 2 diabetes mellitus, was transferred to the hospital on two occasions, 5/17/24 and 5/29/24, due to medical issues such as altered mental status and minimal urine output. Despite these transfers, the facility did not provide written notification to the resident or their representative, as confirmed by the Director of Nursing, who stated that the facility does not provide such notifications. Similarly, Resident #18, with diagnoses including vascular dementia and chronic obstructive pulmonary disease, was transferred to the hospital on 8/3/2024 after presenting with bruising, nausea, and hip pain. Again, the facility failed to provide written notification to the resident or their representative about the transfer. Interviews with facility staff, including the Director of Social Work and the Director of Nursing, revealed a lack of clarity regarding responsibility for providing these notifications, with the Director of Social Work indicating that nursing staff were responsible, yet no written notifications were provided.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers, as required by their own policy and state regulations. Specifically, for one resident reviewed for hospitalization, there was no evidence that written notice of the bed hold policy was provided when the resident was transferred to the hospital on two separate occasions. The facility's policy mandates that residents and their representatives receive written information about the state's bed hold duration and payment amount before any transfer to a hospital or therapeutic leave. The resident involved had medical conditions including a urinary tract infection, retention of urine, and type 2 diabetes mellitus. The resident was discharged to the hospital twice, with discharge assessments documenting these transfers. Despite requests for documentation, the facility could not provide evidence of written notification of the bed hold policy for these transfers. Interviews with the Director of Social Work and the Director of Nursing revealed a lack of responsibility and procedure for providing such notifications, with the Director of Nursing stating that the facility does not provide written notification of the bed hold policy during hospital transfers.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive care plans with measurable objectives, time frames, and appropriate interventions for two residents who experienced falls. Resident #87, who had a history of falls and was at increased risk due to conditions such as dementia and depression, experienced falls on two occasions in February 2024. Despite these incidents, the fall care plan was not updated with new interventions to prevent further falls. Additionally, there was no documented evidence of an Accident/Incident Report for one of the falls, and the Director of Nursing was unable to locate the incident report for the fall on February 10, 2024. Resident #18, diagnosed with vascular dementia and other conditions, was identified as a high fall risk. This resident fell on August 2, 2024, resulting in a hip fracture. The fall care plan was not updated with new interventions following this incident, despite the resident's high fall risk status. The only new intervention noted at the time of the fall was to encourage the resident to call for assistance. However, the care plan itself did not reflect any changes or additions to address the increased risk of falls. Interviews with facility staff, including the Director of Nursing and a Registered Nurse Unit Manager, revealed a lack of consistent updates to care plans following falls. The Director of Nursing admitted to feeling overwhelmed and unable to consistently update care plans, while the Registered Nurse Unit Manager stated that new interventions should be added to care plans following falls. A Licensed Practical Nurse was unaware of recent falls and any new interventions for Resident #18, indicating a communication gap and lack of awareness among staff regarding the residents' care plans and fall prevention strategies.
Deficiency in Timely Personal Hygiene Care Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents received necessary services to maintain good personal hygiene, as observed during a recertification survey. Three residents, who required staff assistance for personal hygiene and toileting, did not receive morning care in a timely manner. Resident #45, with severe cognitive impairment and requiring assistance for personal hygiene and toileting, was observed in a soiled adult brief and pajama top, with morning care not yet provided due to short staffing. Resident #66, also with severe cognitive impairment, required assistance with toileting and was found with a soiled adult brief on the floor, and the room had a strong smell of urine. Morning care had not been completed for this resident either. Similarly, Resident #78, with severe cognitive deficits, was observed with feces on their hands and surrounding areas, indicating a lack of timely personal hygiene care. Interviews with staff, including the Director of Nursing and the Administrator, revealed that staffing shortages were a known issue, affecting the timeliness of resident care. The facility's policies emphasized the importance of providing necessary care to maintain residents' hygiene and dignity, but these were not adhered to due to insufficient staffing levels.
Failure to Assess and Report Skin Changes
Penalty
Summary
The facility failed to ensure that Resident #45 received treatment and care in accordance with professional standards of practice, specifically regarding the assessment and care planning for changes in the resident's skin condition. Resident #45, who has diagnoses including cognitive communication deficiency, chronic kidney disease, and generalized anxiety disorder, was observed with several open red areas on their skin, which were not assessed or reported to the Physician or Nurse Practitioner. The resident's care plan included interventions for skin care, but there was no documented evidence of assessment or notification of medical staff regarding the observed skin changes. Interviews with facility staff revealed that the resident's skin changes and itching were observed by multiple staff members, including a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), but were not reported to the appropriate medical personnel. The LPN admitted to observing the resident's scratching over a month ago and applying ointment without reporting it. The facility's Nurse Practitioner stated they were not informed of the resident's skin changes, and thus no assessment was conducted. The lack of communication and failure to follow the care plan's interventions led to the deficiency in providing appropriate treatment and care for Resident #45.
Failure to Prevent Pressure Ulcers Due to Inadequate Communication and Documentation
Penalty
Summary
The facility failed to ensure proper care to prevent pressure ulcers for a resident identified as being at risk. The resident, who had severe cognitive deficits and was at risk for pressure ulcers, had a physician's order to offload heels while in bed. However, during multiple observations, the resident's heels were found resting directly on the mattress without any offloading device or pillow, contrary to the care plan interventions and physician's recommendations. Interviews with staff revealed a lack of awareness and communication regarding the resident's care needs. Certified Nurse Aides and a Licensed Practical Nurse were unaware of the heel offloading order, and it was not discussed during morning rounds or change of shift rounds. Additionally, the electronic medical record system used by the staff did not display tasks related to heel offloading for the resident, and the Director of Nursing acknowledged delays in entering care plans into the system. This lack of communication and documentation contributed to the deficiency in care provided to the resident.
Expired Medications Not Removed Timely
Penalty
Summary
The facility failed to ensure the timely identification and removal of expired medications during a recertification survey. Specifically, several bags of IV Vancomycin with expiration dates ranging from July 17, 2024, to August 10, 2024, were found in the first-floor unit medication room. These expired medications were observed both in the refrigerator and on a shelf outside the refrigerator. The facility's policy, last revised in August 2023, mandates that discontinued drugs should be removed from the medication cart and disposed of according to the procedures outlined in the manual, and drugs should not be kept after their expiration date. During interviews, a Licensed Practical Nurse (LPN) expressed uncertainty about whether the facility intended to return the expired IV Vancomycin to the pharmacy. The LPN indicated that Registered Nurses (RNs) are responsible for checking expired IV medications. The Registered Nurse Unit Manager confirmed that the pharmacy was contacted to pick up the expired medications, but they were not collected, and acknowledged that the expired medications should have been discarded. Additionally, the Director of Nursing stated that the facility no longer uses multi-dose insulin vials and emphasized that the LPN should not have administered insulin from an open vial labeled for a different resident.
Failure to Document Medication Irregularity Review
Penalty
Summary
The facility failed to ensure that the attending provider documented in the resident's medical record that an identified medication irregularity had been reviewed and what actions, if any, had been taken to address it. This deficiency was identified during a recertification survey for a resident who was receiving Enoxaparin 40 mg injection. The consultant pharmacist recommended a review of the medication for a stop date and appropriate use based on diagnosis and patient mobility. Although the provider agreed with the recommendation and noted that the medication was discontinued, this was not documented in the resident's medical record. The Nurse Practitioner, who reviewed the drug regimen on a later date, stated that they did not discontinue the medication because it had already been discontinued and was necessary for the bed-bound resident. However, there was no documentation in the medical progress notes to reflect the provider's plan regarding the medication. The Nurse Practitioner acknowledged the oversight and the difficulty in documenting due to the large volume of work, but recognized the need to write a note in the patient's chart after reviewing and making changes.
Inadequate Monitoring of Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the anticoagulant Enoxaparin. The deficiency was identified during a recertification survey, where it was found that there was inadequate monitoring of the medication. The facility's policy requires a licensed pharmacist to review each resident's drug regimen at least once a month, with more frequent reviews depending on the resident's condition. However, for one resident, the medication regimen review recommendation from the pharmacy dated several months prior was not acted upon in a timely manner. The recommendation to discontinue the medication was signed by a Family Nurse Practitioner months later, but the medication continued to be administered without proper documentation or a care plan addressing potential side effects. Interviews with the Director of Nursing and the Nurse Practitioner revealed lapses in communication and documentation. The Director of Nursing acknowledged that the order should have been addressed and attributed the oversight to an overlap in Nurse Practitioners. The Nurse Practitioner, who started working at the facility after the initial recommendation, stated that they reviewed the recommendation but did not intend to discontinue the medication, as the resident was bed-bound and required it. Despite this, there was no documentation in the resident's medical record to reflect this decision, and the facility's process for updating medication orders was not followed, leading to the deficiency.
Expired Needles Found on Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored according to the manufacturer's specifications and professional standards of practice. During a recertification survey, it was observed that the 2nd floor unit south side medication cart contained expired 22-gauge insyte autogaurd needles, which are used for administering intravenous medications. The facility's policy on 'Storage of Drugs' did not include guidelines for the storage of medical supplies such as intravenous needles. On the specified date, three expired insyte autogaurd needles were found on the medication cart. A Licensed Practical Nurse (LPN) stated that these needles should not have been on the cart and should have been discarded. The LPN explained that the nurse responsible for starting an intravenous line should check the needle's expiration date, and the nurse with the medication cart keys should ensure all items in the cart are within their expiration range.
Failure to Ensure Resident's Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate advance directives, as evidenced by the handling of the Medical Orders for Life Sustaining Treatment (MOLST) for a resident with fluctuating cognitive abilities. The resident, who had a history of diabetes mellitus, a left above-knee amputation, osteomyelitis, and rheumatoid arthritis, initially completed a MOLST form indicating Do Not Resuscitate and Do Not Intubate orders, among other directives. However, the form was not signed, and there was no documentation confirming the physician's assessment of the resident's capacity to make such decisions at the time. Over time, the resident's cognitive status appeared to decline, as indicated by a Brief Interview for Mental Status score of 6, suggesting severely impaired cognition. Despite this, changes were made to the MOLST form, including the addition of comfort measures and a directive not to hospitalize, based on verbal consent witnessed by the social worker and psychiatric nurse practitioner. The resident's representative was not involved in these decisions, and there was no health care proxy in place to assist with care-related decisions. The situation was further complicated by conflicting assessments of the resident's cognitive abilities. While a psychologist noted the resident's inability to participate in psychological services due to cognitive deficits, the psychiatric nurse practitioner believed the resident was clear in expressing their wishes for comfort care. This discrepancy, along with the lack of a formal capacity assessment, contributed to the deficiency in ensuring the resident's right to formulate advance directives was upheld.
Failure to Notify Resident's Representative of Changes in Condition and Advance Directives
Penalty
Summary
The facility failed to promptly inform the designated representative of a resident about changes in the resident's condition and advance directives. The resident, who was admitted with diagnoses including metabolic encephalopathy, white matter disease, and delusional disorder, initially had intact cognition but later showed severely impaired cognition. Despite this, there was no documented evidence that the resident's representative was promptly informed of the change in the resident's advance directives to Do Not Hospitalize. The representative was not notified until after the resident's death, leading to confusion and distress as the representative was unaware of the resident's deteriorating condition and the decision not to hospitalize. The report highlights a communication breakdown within the facility, where the resident's representative was not adequately informed about critical changes in the resident's care plan. The Director of Social Work acknowledged that the Medical Orders for Life Sustaining Treatment were updated to comfort care and palliative care, but the representative was not informed in a timely manner. The representative expressed that they were not aware of the changes and had expected to be contacted for any necessary approvals. The facility's failure to ensure proper notification contributed to the representative's lack of awareness regarding the resident's condition and care decisions.
Failure to Implement Safety Checks for Aggressive Resident
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving Resident #14, who was known to have a history of physical and verbal aggression. On July 30, 2024, Resident #14 physically assaulted another resident by punching them in the stomach. Despite the facility's policy on abuse prevention, which includes monitoring and intervention strategies, the necessary 30-minute safety checks were not implemented to prevent further incidents. The facility's documentation and interviews revealed that there was no physician's order for the 30-minute monitoring, and no evidence was found that such monitoring was conducted. The deficiency was further highlighted by the lack of communication and follow-through among the facility's staff. The Director of Nursing admitted to not entering the order for the 30-minute monitoring, and both the Licensed Practical Nurse and Registered Nurse Unit Manager confirmed that the intervention was not documented in the physician's orders or the Medication Administration Record. This oversight in documentation and execution of safety measures contributed to the failure to protect the resident from further abuse, as required by the facility's policies and state regulations.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were thoroughly investigated and reported to the New York State Department of Health. This deficiency involved a resident who, during a vascular appointment, alleged abuse by a staff member after being questioned about a bruise on their forehead. The facility was informed of the allegation on the same day by the vascular provider, but the social worker and nurse practitioner attributed the bruise to a fall and did not investigate or document the allegation until over a week later. The resident, who had a history of delusional disorders, was admitted with multiple diagnoses including diabetes and rheumatoid arthritis. The resident was independent in cognition but dependent on assistance for transfers. The vascular clinic noted the resident had a large bruise on their forehead and was covered in feces. Despite the resident's insistence that they were attacked, the facility staff attributed the bruise to a fall that occurred days earlier, and no immediate investigation was conducted. Interviews with facility staff revealed a lack of communication and documentation regarding the alleged abuse. The Director of Nursing and other staff members believed the resident's confusion was due to a possible urinary tract infection and did not consider the allegation credible. The facility's administrator was unaware of the allegation until contacted by the Attorney General's office, and the facility did not report the incident to the state health department, believing it was unnecessary since the vascular nurse practitioner had already reported it.
Failure to Develop Comprehensive Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was dependent on hemodialysis. The deficiency was identified during a recertification and abbreviated survey, where it was found that the resident, who had a diagnosis of chronic kidney disease, diabetes, and obesity, did not have a care plan addressing their dialysis needs. Despite having a physician order for hemodialysis three times a week and documentation in a dialysis communication binder for vital signs to be taken before and after dialysis, there was no documented evidence of a care plan in the resident's medical health record. Interviews with the Director of Nursing and a Registered Nurse Unit Manager revealed that the responsibility for updating care plans lay with the nursing staff. However, the Director of Nursing acknowledged the absence of a care plan for the resident's dialysis dependency. The Registered Nurse Unit Manager admitted that due to frequent medication administration duties, they were sometimes unable to update care plans. This lack of a comprehensive care plan for the resident's dialysis needs was a violation of the facility's policy and regulatory requirements.
Inadequate Dialysis Care for Residents
Penalty
Summary
The facility failed to provide appropriate dialysis care for two residents requiring such services, as identified during the recertification and abbreviated surveys. Resident #13, diagnosed with end-stage renal disease and dependent on renal dialysis, did not have a dialysis communication book available, which is essential for tracking vital signs and assessments before and after dialysis treatments. Despite the resident receiving hemodialysis at a community dialysis center three times a week, the necessary assessments were not consistently performed, as confirmed by the Registered Nurse Unit Manager and the Director of Nursing. The lack of consistent monitoring was attributed to potential staffing issues. Resident #162, who had diagnoses including kidney disease and type 2 diabetes, also did not receive adequate dialysis care. There was no comprehensive care plan documenting the required care related to hemodialysis treatments. Although the resident had a physician's order for hemodialysis three times a week, there were no communication sheets available for several dates when the resident was supposed to receive dialysis. The Clinical Manager of the Community Dialysis Center confirmed the resident's admission and discharge dates but could not recall if communication sheets were completed. This lack of documentation and oversight indicates a failure to adhere to professional standards of practice for dialysis care.
Medication Administration Errors Due to Early Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as observed during the recertification and abbreviated surveys. Three residents did not receive their medications in accordance with the prescriber's orders and accepted health standards. Specifically, medications such as antibiotics, antidiabetic pills, antihypertensives, inhalers for chronic obstructive pulmonary disease, and antipsychotics were not administered at the prescribed times. This occurred on a specific date when medications due at 5:00 PM were administered between 2:23 PM and 2:31 PM by a Licensed Practical Nurse (LPN). Resident #38, who had diagnoses including urinary tract infection and type 2 diabetes mellitus, was supposed to receive Methenamine Hippurate and Metformin at 5:00 PM, but these were administered early. Similarly, Resident #104, with conditions such as hypertensive heart failure and chronic obstructive pulmonary disease, was given medications like Carvedilol, Advair Diskus, Entresto, and Vitamin C earlier than prescribed. Resident #89, diagnosed with schizophrenia and dementia with agitation, received Olanzapine prematurely. The LPN responsible for these early administrations stated they did so because they needed to leave early and were instructed by the Director of Nursing to administer the medications before their shift ended. Interviews with the Registered Nurse Unit Manager and the Nurse Practitioner revealed that there was no authorization for early medication administration, and the situation was not communicated to the physician. The Director of Nursing confirmed that medications should not be given more than one hour before or after the ordered time and acknowledged that the early administration constituted medication errors. The facility's policy requires that any medication administration issues be reported and corrected, but this protocol was not followed in this instance.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required 12 hours of annual training, including education on dementia care management and resident abuse prevention. During a recertification survey, it was found that five CNAs did not complete the mandatory training hours. The Director of Nursing, responsible for documenting these in-services, could not provide sufficient evidence of the required training for the CNAs reviewed. Documentation provided showed only partial completion of the training hours, with some CNAs having as little as 30 minutes to 1 hour of training documented. Interviews conducted during the survey revealed that CNAs had not received recent in-services, although they had attended some in the past year. The Director of Nursing acknowledged the shortfall in training hours and attributed it to the current staffing situation, as the facility was in the process of hiring an Assistant Director of Nursing to help facilitate these in-services. The lack of adequate training was a violation of the New York State Department of Health requirements, which mandate at least 12 hours of annual training for CNAs.
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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 Staatsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Eleanor Nursing Care Center | 4.4 mi | ★★★★★ | 13 | 0 |
| The Baptist Home At Brookmeade | 6.7 mi | ★★★★★ | 0 | 0 |
| Golden Hill Nursing And Rehabilitation Center | 7.3 mi | ★★★★★ | 3 | 0 |
| Ferncliff Nursing Home Co Inc | 7.5 mi | ★★★★★ | 1 | 0 |
| Woodland Pond At New Paltz | 8.7 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.