Above 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 Sapphire Nursing At Meadow Hill during CMS and state inspections, most recent first.
The facility did not provide the required policy for inspecting Patient Care Related Electrical Equipment (PCREE) during a Life Safety survey. The Director of Plant Operations acknowledged the absence of the policy, which is a violation of NFPA 99 standards.
The facility did not maintain and test the emergency generator as required by NFPA standards. A review during a survey revealed that only a 2-hour load bank test was conducted instead of the mandatory 4-hour test, and documentation for the 4-hour test was missing. The Director of Plant Operations acknowledged the issue and planned to contact the vendor.
The facility failed to maintain its HVAC system according to NFPA standards, as discovered during a Life Safety recertification survey. Several fire/smoke dampers failed inspection, and a follow-up report on repairs was missing. The Director of Plant Operations acknowledged the issue, but documentation provided was incomplete and contained errors.
The facility was cited for failing to maintain its sprinkler system according to NFPA 101 standards. Observations included outdated water pressure gauges on the fire pump controller, corroded sprinklers in shower rooms, and missing documentation for fire pump repairs. The Director of Plant Operations acknowledged these issues and indicated that the vendor would be contacted.
A resident with severely impaired cognition did not receive necessary personal hygiene care, as observed with long, greasy hair and ungroomed nails. Despite a care plan requiring supervision and a physician's order for daily showers, staff interviews revealed time constraints and inadequate supervision as barriers to providing proper care.
The facility failed to document COVID-19 vaccination, education, or declination for two newly hired CNAs. Despite the facility's policy requiring written affirmation for those declining vaccination, there was no evidence of such documentation. Interviews revealed that verbal consent or education was given, but not documented, and the DON was unaware of this oversight.
A resident with limited mobility and severely impaired cognition was observed without a prescribed left palm guard on multiple occasions, despite facility policy requiring its daily application. A CNA admitted to not applying the device, and the RN Manager was unaware of the oversight. The palm guard was intended to prevent further contractures and protect the resident's hand.
The facility failed to maintain proper infection control practices for two residents. One resident with a pressure ulcer was not provided care with appropriate barrier precautions by staff, while another resident's urinary catheter drainage bag was found on the floor, violating infection control protocols. Staff acknowledged these oversights.
The facility failed to document that three CNAs received mandatory dementia care management training. One CNA, hired in 2023, had a last training record from 2024 without dementia care education. Another CNA, hired in 2019, also lacked documentation of dementia care training in their 2024 records. A third CNA, hired in 2023, had no documentation of completing the required training. The Assistant DON confirmed the missing documentation.
Two residents with severe cognitive impairment were not provided a dignified dining experience as CNAs stood over them while assisting with meals, contrary to facility policy. The CNAs acknowledged the requirement to sit at eye level but cited personal comfort and lack of available chairs as reasons for standing.
A resident with severe cognitive impairment and aphasia had a physician's order for oxygen at 2 L/min via nasal cannula as needed. Observations revealed the oxygen concentrator running at incorrect levels of 3 L/min and 1.5 L/min on separate occasions. An LPN confirmed that oxygen levels were set by licensed staff per physician orders but was unaware of the incorrect settings, suggesting a possible accidental adjustment by a CNA.
A facility failed to maintain a homelike environment due to a persistent urine odor in a resident's room and hallways. The resident, with impaired cognition and incontinence, had soiled clothing that was not properly bagged, contributing to the odor. Despite daily housekeeping, the odor persisted, and staff acknowledged that procedures for handling soiled clothing were not consistently followed.
The facility did not include a method for sharing information about occupancy, needs, and assistance capabilities in its emergency preparedness communication plan. This was identified during a life safety recertification survey, where the emergency preparedness binder lacked the necessary policy and procedure. The Administrator confirmed the absence of this information.
The facility failed to include a policy and procedure for sharing the emergency preparedness plan with residents and their families, as required by Section 483.73. During a survey, it was noted that the plan lacked a method for communication in emergencies, which was confirmed by the Administrator.
The facility did not ensure that hand washing fixtures in the kitchen's food prep areas could be operated without hands, as required by local codes. During a survey, it was found that all three food prep sinks lacked 4-inch wrist blades. The Director of Plant Operations acknowledged the issue.
Two residents in an LTC facility experienced abuse due to inadequate protection measures. One resident with cognitive impairment was inappropriately touched by another resident with a history of such behavior. Another resident reported being roughly handled by a CNA, resulting in a bruise. The facility's policies were not effectively implemented, leading to these deficiencies.
Missing Inspection Policy for Electrical Equipment
Penalty
Summary
The facility failed to ensure that Patient Care Related Electrical Equipment (PCREE) was inspected and tested in accordance with NFPA 99 standards. During a Life Safety recertification survey, it was observed that the facility's policy and procedure for inspecting both PCREE and non-PCREE were missing and not provided to the surveyors. This deficiency was noted during the survey conducted over two days. In an interview, the Director of Plant Operations acknowledged the absence of the policy and stated that it would be located. The lack of documentation and adherence to the required inspection protocols led to the citation under the relevant NFPA and state regulations.
Generator Maintenance and Testing Deficiency
Penalty
Summary
The facility failed to ensure that the emergency generator was maintained and tested in accordance with NFPA 101 and NFPA 110 standards. During a life safety recertification survey, it was observed that the facility's generator logs documented a 2-hour load bank test instead of the required 4-hour load bank test. Additionally, documentation for the 4-hour load bank test was missing and not provided at the time of the survey. In an interview, the Director of Plant Operations acknowledged the issue and mentioned that the vendor would be contacted to address the discrepancy.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Residents Identified ò All residents, visitors and staff have the potential to be affected by the deficient practice. ò Facility contacted the Generator company to conduct the 4-hour load test. ò Visit is scheduled to be completed on (MONTH) 7th, 2025. Residents at Risk ò All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes ò Re-education to the Director of Plant Operation on the importance of running the 4-hour load test once every 36 months. ò Ensure facility is maintaining a schedule for when test comes due with an audit. ò If not in compliance, vendor will be contacted immediately. Monitoring of Corrective Action ò The Director of Plant Operations or Designee will complete audit to ensure each testing is within compliance with the NFPA 101 Electrical system monthly x3 months or until 100% compliance. ò If non-compliance is found, this will be reported to the Administrator and Director of Plant Operation. Vendors will be contacted to fix any issues presented. ò All findings and results will be submitted to the monthly QAPI meeting. ò QAPI committee will determine if further information is required. Responsible: Director of Plant Operations or Designee
Failure to Maintain HVAC System in Compliance with NFPA Standards
Penalty
Summary
The facility failed to maintain its heating, ventilation, and air conditioning (HVAC) system in accordance with the National Fire Protection Association (NFPA) standards, specifically NFPA 101, 90 A, and NFPA 80. During a Life Safety recertification survey, it was discovered that the facility's fire/smoke dampers were inspected, tested, and cleaned by a vendor between April 4 and 6, 2025. However, several dampers failed, including damper 2 FD-008 on December 4, 2024, and damper 2 FD 124 in a specific room on December 6, 2024. A follow-up report indicating the repairs for these failures was missing and not provided at the time of the survey. In an interview with the Director of Plant Operations, it was stated that the vendor would be contacted to address the issue. On the following day, a statement was provided indicating that damper 2 FD-008 was corrected on June 16, 2023, but it did not specify how the deficiency was corrected. The Director of Plant Operations later mentioned that the date was a typo. The lack of proper documentation and follow-up on the damper repairs led to the deficiency being cited during the survey.
Plan Of Correction
Plan of Correction: Approved May 5, 2025 Corrective Actions for Residents Identified: - All residents, visitors, and staff have the potential to be affected by the deficient practice. - Fire damper vendor was contacted 5/1/2025 and will be on site to inspect fire dampers. Resident at Risk: - All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - Education to Director of Plant Operations to ensure that if there are issues with inspection that needs to be repaired, it is to be completed in a timely manner to remain in compliance. - Audit will be created to ensure that all reports received are dated correctly and no damper failure reported. - If damper failure is noted, the Vendor will be contacted to repair the dampers. Monitoring of Corrective Actions: - The Director of Plant Operations or Designee will ensure all reports are dated appropriately when receiving report from fire damper vendor and that any damper failure is addressed. Weekly x4, monthly x3 or until 100% compliance. - If non-compliance is found, this will be reported to the Administrator and Director of Plant Operations. Vendors will be contacted to fix any issues present. - All findings will be submitted to monthly QAPI. - QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee
Deficiencies in Sprinkler System Maintenance
Penalty
Summary
The facility failed to maintain its sprinkler system in accordance with NFPA 101 standards, as observed during a Life Safety recertification survey. On two resident floors and in the basement, several deficiencies were noted. The water pressure gauge on the fire pump controller was found to be outdated, with no evidence of replacement or recalibration. Additionally, documentation confirming the replacement or recalibration of the water pressure gauge was missing. During an interview, the Director of Plant Operations acknowledged the issue and mentioned that the vendor would be contacted. Further inspection revealed that sprinklers in the shower rooms on both the first and second floors exhibited signs of corrosion. Additionally, a review of the facility's sprinkler logs indicated that the fire pump had failed during its annual service, and a follow-up report detailing the repairs was not available at the time of the survey. The Director of Plant Operations again stated that the vendor would be contacted to address these issues.
Deficiency in Personal Hygiene Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene. Resident #90, who had severely impaired cognition and required supervision with activities such as toileting, dressing, and personal hygiene, was observed multiple times with long, greasy hair, an unshaven face, and long, ungroomed fingernails. The resident's care plan indicated a need for supervision in personal hygiene, and a physician's order specified daily showers. However, observations on several occasions revealed that these hygiene needs were not met. Interviews with staff members, including a Certified Nurse Aide (CNA), a Licensed Practical Nurse (LPN), and a Registered Nurse Unit Manager, highlighted a lack of adequate time and supervision to ensure the completion of personal hygiene tasks. The CNA acknowledged responsibility for daily personal hygiene care, including nail grooming, but cited time constraints as a barrier. The LPN and Unit Manager confirmed that CNAs were expected to provide nail care and that nurses were responsible for supervising these tasks. Despite these expectations, the resident continued to exhibit signs of neglect in personal hygiene, indicating a failure in the facility's care processes.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified ADL care Provided for Dependent Residents. Resident #90 did not suffer ill effect from deficient practice. Residents who are dependent will be provided with ADL care every shift as evidenced by appearance will be well groomed. Nails will be trimmed and clean. Hair will be washed and without odor. Facial hair will be shaved to residents liking. Upon notification of this deficiency, Resident #90 was immediately provided nail care, shaved, and had his hair washed and groomed. Resident #90 was assessed and appeared to suffer no ill effects as a result of this deficient practice. Nurse Aide #17 was immediately reeducated regarding providing all ADL and grooming care to residents daily as ordered. Nurse Aide #17 was also provided guidance on time management to assist with completion of all tasks. LPN #18 and Nurse Manager #11 were both provided education regarding supervising Nurse Aides care to ensure all ordered cares were provided. Resident at Risk: Dependent residents can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficiency. All other residents appeared to be appropriately groomed. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Change: All nursing staff (CNA’s and Nurses) will be provided in-service education in regard to expected care of residents by Nurse Staff Educator/Designee. Specifically, residents who require total assistance with care. ADL level of care is listed on Resident Care profile card in EMR. The Administrator reviewed the facility’s policy on Activities of Daily Living and found it to be incompliance with all State and Federal Regulations. Education regarding the provision of daily ADL care, and grooming was provided to all nursing staff. Education regarding supervising CNAs to ensure daily grooming is provided to all residents was provided to all nurses. Monitoring of Corrective Actions: The DON has created an audit to ensure that daily grooming and ADL care is provided to all residents on a daily basis. Audits will be conducted on resident hygiene and grooming on all units daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS. The DNS/Designee will be responsible for completion of this plan of correction.
Lack of COVID-19 Vaccination Documentation for New Staff
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the COVID-19 vaccine, and provided with education regarding the benefits, risks, and potential side effects of the vaccine. Specifically, there was no documented evidence of immunization records for two certified nurse aides who were newly hired. The facility's policy, revised in November 2024, mandates that all staff and residents who decline vaccination must sign a written affirmation indicating they were offered the opportunity for COVID-19 vaccination but declined. However, the immunization records for the two certified nurse aides lacked documentation of COVID-19 immunization, education, or declination. During interviews, the Infection Control Preventionist/Assistant Director of Nursing acknowledged that the facility offered immunizations for COVID-19, influenza, and pneumococcal vaccinations to staff and residents. They admitted that the two newly hired certified nurse aides had only received verbal consent or education, with no documentation to support that education was provided or that declinations were recorded. The Director of Nursing was unaware of the lack of documentation for these two staff members, highlighting a gap in the facility's adherence to its own policy and regulatory guidelines.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified CNA #1 and CNA #2 was offered COVID-19 vaccine. Residents at Risk: - No resident at risk by deficient practice. - No resident at risk by deficient practice. An audit of new hires was conducted to ensure all new hires have either received the COVID-19 vaccine or have a declination signed on file. Systemic Changes: - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - Audit tool created to ensure declination is received if staff does not have COVID vaccine. Monitoring of Corrective Actions: - The Director of Nursing or Designee will review all new hires to ensure the facility has a declination on file should the staff choose not to be vaccinated. Bi-weekly x 8 weeks, then monthly x 3 months. Any issues noted will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Failure to Apply Prescribed Palm Guard for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion and mobility received the necessary care and equipment to maintain or improve function. Specifically, a resident with severely impaired cognition and an upper extremity impairment was observed on three separate occasions without the prescribed left palm guard, which was ordered by the physician to prevent further contractures. The facility's policy required the nursing department to apply and remove such devices daily, and the nurse manager was responsible for ensuring this information was recorded in the Certified Nurse Aide Accountability Record. During interviews, a Certified Nurse Aide admitted to not applying the resident's palm guard despite knowing it was their responsibility. The Registered Nurse Manager was unaware that the resident was not wearing the palm guard, and the Director of Rehabilitation confirmed the importance of the device in preventing contracture worsening and protecting the resident's hand. The deficiency was identified during a recertification survey, highlighting a lapse in adherence to the facility's policy and physician's orders.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified ò Upon notification of this deficiency, resident #40 was reassessed and noted to have no new injuries nor ill effects as a result of this deficient practice. ò Resident 40 left palm guard was immediately placed. ò Palm guard placed in treatment orders to be signed off by nurse. ò Nurse manager #10 and CAN #8 were both provided education on ensuring that resident devices were placed daily as per order. Residents at Risk ò The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficiency, and no other resident was identified. ò While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes ò The facility reviewed Policy and Procedure titled Issues of Splints, Orthoses, and Prostheses and no revision is needed. ò All nursing staff will be educated on policy listed above and the importance of placing adaptive equipment per physician order. ò An audit tool was created by the DON to ensure compliance with adaptive equipment for individuals with limited position and mobility. Monitoring of Corrective Actions ò The Director of Nursing or Designee will randomly observe 3-5 residents who have limited position and mobility to ensure their equipment are being used and physician orders [REDACTED]. Any issues noted will be addressed immediately and reported to the administrator. ò On a monthly basis, the Director of Nursing will report the findings to the Administrator. ò On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. ò QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a resident with severe cognitive impairment and a Stage 3 pressure ulcer was on enhanced barrier precautions. However, during an observation, a Certified Nurse Aide and an LPN were seen providing incontinence care to this resident without wearing gowns, which was against the facility's policy for handling residents with wounds and indwelling medical devices. Both staff members acknowledged the oversight, with the CNA admitting they should have checked the precaution information before providing care. In the second incident, another resident with severe cognitive impairment and an indwelling urinary catheter was observed with the catheter drainage bag and a portion of the drainage tube lying on the floor. This was noted during two separate observations. An LPN confirmed that the drainage bag and tube should not be on the floor due to infection control concerns and stated that the privacy bag straps should be adjusted to prevent this. The CNA responsible for the resident's care admitted to missing the issue due to being busy.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Infection Prevention & Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Resident #129 and #118 did not suffer ill effect from this deficient practice. Staff will follow Infection prevention and control guidelines in regards to EBP as well as other transmission-based precautions. Resident’s medical devices, such as indwelling catheter/tubing will be placed in proper position and avoid touching the floor to prevent contamination. Resident #118 foley drainage tube, foley bag and privacy bag were immediately changed upon notification of this deficiency. This resident was assessed and found to have not [MEDICATION NAME] negative effects as a result of this deficiency. License Practical Nurse #15 and Certified Nurse Aide #14 were both re-educated on the facility’s infection control Policy and the need to ensure that residents foley drainage bags or tubes do not touch the floor. Resident #129 was assessed and found to have no signs of infection, no other signs of negative effects as a result of this deficiency. License Practical Nurse 21 and Certified Nurse Aide 20 were both re-educated on the facility’s Enhanced Barrier Precaution Policy and Procedure and the need to wear the recommended PPE. Monitoring for any signs of infection will be ongoing for this resident. Residents at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident that may have been affected by this deficient practice and no other resident was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes All staff will be provided in-service education in regards to EBP/Transmission based precautions by Infection Preventionist/Nurse Staff Educator/Designee. All nursing staff (Nurses and CNA’s) will receive in-service education in regards to proper placement of indwelling catheter tubing when residents are in and out of bed to prevent tubing touching the floor. The Administrator reviewed the facility’s infection control and Enhanced Barrier Precaution Policies and found them to be in compliance with all local, state and federal regulations. The Director of Nursing will initiate Infection Control and Enhanced Barrier Precaution re-education for all staff. Monitoring of Corrective Actions The DON has created an audit to monitor foley drainage bags and tubes not touching the floor. The DON has also created an audit to monitor compliance with PPE usage for all residents on EBP. Audits will be conducted on indwelling catheter placement in/out of bed for those residents that are applicable. Audits will be performed every shift x 1 week, daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee. Audits will be conducted on all units in regards to staff use of EBP, to include signage outside of applicable rooms/Donning & Doffing of PPE. Audits will be performed every shift x 1 week, then daily x 2 weeks, then monthly x 3 months. Audits will be completed by Infection Preventionist/Unit Manager/Staff Nurse/Nurse Supervisor/Designee. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Deficiency in CNA Dementia Care Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required hours of training and annual in-services on dementia care management, as mandated by regulations. Specifically, the facility could not provide documentation that three CNAs had completed the necessary training. CNA #23, hired in July 2023, had a last recorded training in November 2024, which did not include dementia care management. CNA #24, hired in March 2019, had their most recent training documented in November 2024, also lacking evidence of dementia care management education. CNA #25, hired in May 2023, had no documentation confirming completion of the required dementia care management education. During an interview, the Assistant Director of Nursing acknowledged the absence of documentation for these CNAs.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified Required in-service training for Nurse Aides must include dementia management training and resident abuse prevention training. Certified Nurse Aides #23, #24, and #25 did not have the required hours of the mandatory training in regards to Dementia training. No residents suffered ill effects. Upon notification of this deficiency, Certified Nurses Aides #23, #24, and #25 were all contacted and provided with Dementia in-service and all now meet the standard for the 12 hours of annual in-service. Audits of the employees assigned residents and units revealed no ill effects to those or any other resident as a result of this deficiency. Residents at Risk: Any resident can be affected by this deficient practice. In-service coordinator/educator conducted an audit of all CNAs to determine if any other CNA was out of compliance with Dementia education or the annual 12 hour education, and none were noted out of compliance. The facility respectfully states that while all staff and therefore residents could have been affected, no other staff or resident was affected. Systemic Changes: All CNAs will receive mandatory training on an annual basis by Nurse Staff Educator/Designee. The Administrator has reviewed the facility’s policy on Employees Annual Mandatory Education and found it to be in compliance with all local, state and federal regulations. Monitoring of Corrective Actions: Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Infection Preventionist/Nurse Staff Educator/ADON/DNS/Designee. The DNS/Designee will be responsible for completion of this plan of correction. Audits will be completed in regards to Dementia training/Annual Mandatory for certified aides biweekly x 4 then monthly x 3 months. Audits to be completed by Human Resource Director/Nurse Staff Educator/Designee. Audits will be presented at QAPI meetings monthly by the Human Resource Director/DNS to determine continued need. The DNS/Designee will be responsible for completion of this plan of correction. The Administrator has created an audit tool to monitor compliance with CNA annual mandatory education including Dementia education. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Dignity in Dining Experience Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents during the recertification survey. Resident #2, who was admitted with severe cognitive impairment and required extensive assistance for eating, was observed being fed by a Certified Nurse Aide (CNA) who stood over the resident while assisting with their meal. The CNA acknowledged awareness of the requirement to sit at eye level with residents during feeding but chose to stand for personal comfort. Similarly, Resident #113, who also had severe cognitive decline and was totally dependent on staff for eating, was observed being fed by another CNA who stood over the resident due to the unavailability of chairs. This CNA also acknowledged the requirement to sit at eye level with residents during feeding. A Licensed Professional Nurse confirmed that CNAs should always be at eye level with residents to maintain dignity during meals.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Residents #2 and #13 Resident Rights The resident has a right to a dignified existence and respect. Residents #2 and #13 suffered no ill effects related to deficient practice. Residents will be provided with dignity and respect as evidenced by staff will be seated next to residents at eye level that require assist with meals. Resident Rights Following notification of this deficiency, resident #2 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects related to this deficient practice. Resident #13 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects as a result of this deficient practice. Aide #13 and Aide #5 were re-educated on 4/1/2025 on resident’s rights and the procedure for providing feeding assistance, the need to sit beside residents while providing assistance with feeding. Resident at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident who was affected by this deficient practice and none was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. The Administrator/Designee has conducted an audit of chairs within the facility, available for use by staff providing feeding assistance, and found that there are sufficient numbers of available chairs. Dependent residents can be affected by this deficient practice. Systemic Changes All nursing staff (CNA’s and Nurses) will be educated by Nurse Staff Educator/ADON/Designee on procedure with assisting residents with eating during meals. Specifically, staff should be seated next to resident at eye level while assisting with meal. The Administrator has reviewed the facility’s Policy on Quality of life-Dignity, and found it to be in compliance with all state and federal regulations. Education will be provided to all Nurses and CNAs on the procedure for providing feeding assistance, specifically, staff should be seated next to the resident and at eye level while assisting with meals. Monitoring for Corrective Action The DON has created a meal time audit to monitor for staff sitting while providing feeding assistance. Meal time audits will be conducted for lunch & dinner daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Failure to Maintain Prescribed Oxygen Levels for Resident
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident reviewed for respiratory care. The resident, who was severely cognitively impaired and aphasic, had a physician's order for oxygen to be administered at 2 liters per minute via nasal cannula as needed for wheezing or shortness of breath. However, during observations, the oxygen concentrator was found running at incorrect levels of 3 liters per minute and 1.5 liters per minute on separate occasions, contrary to the physician's order. Licensed Practical Nurse (LPN) #6 confirmed that oxygen levels were set by licensed staff according to physician orders and were checked at the start of each shift. The LPN was unaware of why the concentrator was observed at incorrect settings and suggested that a Certified Nurse Aide might have accidentally adjusted the dial during care. Despite the LPN's assertion that the oxygen was set at 2 liters per minute daily, the observations indicated a failure to maintain the prescribed oxygen level, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified - Upon notification of this deficiency, resident #29's oxygen was immediately adjusted to the prescribed 2L/min. - An assessment revealed that resident #29 suffered no ill effects as a result of the deficient practice. - Resident #29 will be seen by the MD/NP for possible discontinuation of his oxygen therapy. - LPN #6 was provided re-education on the importance of ensuring that residents' oxygen devices were set to the recommendations ordered by the MD/NP. - Nurses to review and sign the flow of oxygen each shift. Residents at Risk - An audit of all residents with oxygen therapy was conducted to identify any other resident that may have been affected by this deficiency, and none were identified. - While all residents had the potential to be affected by this deficiency, no other resident was found to be affected. Systemic Changes - The facility reviewed Policy and Procedure Oxygen Therapy- Face Mask and Canula; no revision was needed. - Nursing staff to be in-service on the policy and procedure Oxygen Therapy- Face Mask and Canula. - The DON developed an audit tool to ensure the oxygen flow matched the doctor's order. The audit will include the residents who are on oxygen, whether nurses sign off that the correct flow is being given, and if there is a physician order [REDACTED]. Monitoring of Corrective Actions - The Director of Nursing or Designee will conduct audits daily x2 weeks, then weekly x 4 weeks, then monthly x 3 months. Any issues will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - The QAPI Committee will determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Failure to Maintain a Homelike Environment Due to Urine Odor
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the strong odor of urine in Resident #10's room and the hallways of the 2 West Unit. Observations made during the recertification survey revealed that Resident #10's room consistently had a strong smell of urine, and the hallways of the 2 West Unit were similarly affected. Resident #10, who had moderately impaired cognition and was dependent on assistance for toileting, was noted to be incontinent of bladder and bowel. The resident's care plan indicated a self-care deficit related to toileting, requiring extensive assistance. Despite daily housekeeping and laundry services, the odor persisted, suggesting inadequate handling of soiled clothing and linens. Interviews with staff revealed that Resident #10's clothing, which often smelled strongly of urine, was not consistently bagged and tied before being placed in the laundry hamper, contributing to the odor. Housekeeping staff confirmed that laundry was picked up daily, and soiled clothing should be bagged to contain odors. However, observations showed that the laundry hamper in Resident #10's room contained soiled clothing that was not properly bagged, leading to the persistent odor. Additionally, the use of pull-up style disposable briefs, which were prone to leakage, further exacerbated the issue. Staff acknowledged that the odor should not be present and that proper procedures for handling soiled clothing were not consistently followed, resulting in the deficiency.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified: - Upon notification of this deficiency, resident #10 was removed from his room to allow for terminal cleaning. - Assessment revealed that this resident suffered no ill effects as a result of the deficient practice. - Resident #10 room was terminally cleaned on - Soiled laundry bagged and removed from room down to laundry on - Hallways were mopped and cleaned to eliminate odor on 4/2/2025 and continues to be cleaned daily. - LPN #6, and CNA #12 were all reeducated on the facility’s homelike environment policy with an emphasis on how soiled clothing should be managed to ensure odor control. Residents at Risk: - A facility wide audit will be conducted to ensure a safe, clean, and homelike environment is maintained and no other issues were identified. - Although all residents had the potential to be affected by this deficient practice, no other resident was found to be affected. Systemic Changes: - The Administrator reviewed policy on Homelike Environment and no revision is needed. - All staff will be in-service on Policy and Procedure Homelike environment. - The facility utilizes a complete room schedule to do a thorough cleaning. - An audit tool was developed to ensure safe, clean, and homelike environment is maintained. Monitoring of Corrective Actions: - The Housekeeping Supervisor or designee will conduct environmental Room and hallway audits for urine odors. The audit will be conducted weekly x3 months, then monthly x3 months. Any outstanding issues will be addressed immediately and reported to the administrator. - On a monthly basis the Housekeeping Supervisor will report findings to the administrator. - On a monthly basis the Housekeeping Supervisor or designee will report audit finding to Qapi Committee. - Qapi committee to determine if further action is required based on report. Responsible: Director of Plant Operation/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Deficiency in Emergency Preparedness Communication Plan
Penalty
Summary
The facility failed to ensure that its communication plan included a method for providing necessary information to the incident command center or the authority having jurisdiction during an emergency. During a life safety recertification survey, it was discovered that the facility's emergency preparedness binder lacked a policy and procedure for sharing information about its occupancy, needs, and ability to provide assistance. This deficiency was identified through documentation review and confirmed during an interview with the Administrator, who acknowledged the absence of this critical information in the emergency preparedness binder.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Residents Identified: ò All residents, visitors and staff have the potential to be affected by the deficient practice. ò Policy for sharing information regarding occupancy, needs and the ability to provide assistance was located. Resident at Risk: ò All residents, visitors and staff have the potential to be affected by the deficient practice. Systemic Changes: ò Policy reviewed and no revision needed. ò Education to the Director of Plant Operation on the importance of having policy readily available. ò Policy added to the emergency preparedness binder. Monitoring of Corrective Actions: ò The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information regarding occupancy is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance. ò If non-compliance is found this will be reported to the administrator and the Director of Plant Operations. ò All findings will be submitted to monthly QAPI. ò QAPI Committee will determine if further action is needed. Responsible: The Director of Plant Operations or designee.
Deficiency in Emergency Preparedness Communication
Penalty
Summary
The facility was found deficient in ensuring a method for sharing information from the emergency preparedness plan with residents and their families or representatives, as required by Section 483.73. During the Life Safety recertification survey, it was observed that the facility's Emergency Preparedness plan lacked a policy and procedure for communicating components of the emergency plan to residents, their families, or representatives in the event of an emergency. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of such a policy and procedure in the plan.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 All residents, visitors, and staff have the potential to be affected by the deficient practice. Policy for sharing components of the emergency preparedness plan with residents, families, and representatives was located. Resident at Risk: All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - Policy reviewed and no revision needed. - Education to the Director of Plant Operations on the importance of having policy readily available. - Policy added to emergency preparedness binder. Monitoring of Corrective Actions: - The Director of Plant Operations or Designee will conduct a monthly audit to ensure that the policy for sharing information is in the Emergency Preparedness plan for each location weekly x4 monthly x3, or until 100% compliance. - If non-compliance is found, this will be reported to the administrator and the Director of Plant Operations. - All findings will be submitted to monthly QAPI. - QAPI Committee will determine if further action is needed. Responsible: Director of Plant Operations or Designee.
Deficiency in Hand-Free Operation of Kitchen Sinks
Penalty
Summary
The facility failed to ensure that hand washing fixtures in the food preparation areas of the kitchen could be operated without the use of hands, as required by local building codes. During a life safety recertification survey, it was observed that all three food prep sinks in one of the kitchen's food prep locations lacked the necessary 4-inch wrist blades. This deficiency was noted during an inspection conducted at 3:20 PM, and the Director of Plant Operations acknowledged the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved May 1, 2025 Corrective Actions for Resident Identified: All residents, visitors, and staff have the potential to be affected by the deficient practice. Kitchin wrist blades ordered for the sink. Wrist blades were installed on 4/16/2025. Residents at Risk: All residents, visitors, and staff have the potential to be affected by the deficient practice. Systemic Changes: - All kitchen staff will be educated on the wrist blade and putting in work orders to ensure the kitchen is in compliance with the standards of construction. - If the wrist blade is missing, the kitchen staff will notify the maintenance department by putting in a work order. Monitoring of Corrective Action: - Food Service Director or Designee audit will be created to ensure there are no deficient sinks in the kitchen. - Audit will be done Monthly x3 to ensure kitchen sinks remain in compliance with standards of construction. - All audits will be reviewed at monthly QAPI. - QAPI committee will determine if further action is required. Responsible: Director of Food Service
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving inappropriate behavior and physical harm. In the first incident, a resident with severe cognitive impairment and a history of wandering was found in another resident's room, where they were being inappropriately touched by the other resident. The resident who committed the act had a history of sexually inappropriate behavior and was known to have behavioral symptoms directed towards others. Despite the facility's policy against abuse, the incident occurred, and the victim was unable to verbalize the event due to their cognitive condition. In the second incident, a resident with dementia and rheumatoid arthritis reported being roughly handled by a certified nurse assistant while their shirt was being changed. The resident sustained a bruise on their forearm, which was confirmed by a skin assessment. The resident expressed that the staff member did not heed their request to stop when they were being hurt. The facility's investigation initially found cause to believe abuse occurred, but later documentation was altered to state the incident was not substantiated, despite the resident's continued anxiety and fear of being hurt again. Both incidents highlight a failure in the facility's duty to ensure residents' safety and freedom from abuse. The facility's policies were not effectively implemented, leading to situations where residents were either physically harmed or subjected to inappropriate behavior. The lack of a care plan to address potential abuse victims and the inadequate response to the residents' complaints contributed to the deficiencies observed during the survey.
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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 Newburgh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fishkill Center For Rehabilitation And Nursing | 5.4 mi | ★★★★★ | 3 | 0 |
| Taconic Rehabilitation And Nursing At Beacon | 6.3 mi | ★★★★★ | 0 | 0 |
| Montgomery Nursing And Rehabilitation Center | 8.5 mi | ★★★★★ | 0 | 0 |
| Sapphire Nursing At Wappingers | 10.1 mi | ★★★★★ | 3 | 0 |
| Taconic Rehabilitation And Nursing At Hopewell | 10.1 mi | ★★★★★ | 15 | 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.