Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Eleanor Nursing Care Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
The facility failed to maintain adequate nurse and CNA staffing to meet resident needs as defined in its own facility assessment, with multiple shifts where minimum nurse coverage was not met and frequent reliance on minimal CNA staffing across units. On several overnight and day shifts, too few nurses were present to cover all units, and one nurse sometimes had to function as both supervisor and direct care nurse. CNA staffing was at or below minimal levels on most days reviewed, leading to delays in getting residents out of bed, late meal service, and missed or postponed showers. Residents reported not having enough staff available at night and difficulty getting up in the morning, while CNAs and LPNs described high acuity, incomplete or delayed cares, and inconsistent documentation due to short staffing. Facility leadership acknowledged ongoing staffing challenges, open positions, and that existing minimum staffing numbers were not adequate or safe to ensure timely completion of resident care tasks.
The Governing Body failed to ensure consistent facility management, with multiple DON and Administrator changes over a short period, repeated deficiencies from prior surveys, and ongoing staffing concerns. One elevator had been out of service for years, and the other was intermittently nonfunctional, causing residents to miss appointments and contributing to late, cold meals.
Failure to Monitor Antibiotic Use: The facility did not maintain an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. The DON could not provide antibiotic surveillance or line listings, stated monthly reports had not been completed since April, and reported that unit managers were responsible for audits but had not submitted them. Unit managers said they were not aware of a formal daily surveillance process or tool, and audits were not completed because of workload and staffing issues.
The facility failed to maintain safe, clean, and homelike conditions in multiple rooms on three units. One room had stained floors, a water puddle near a radiator, peeling molding, missing closet doors, bathroom stains, missing tiles, and debris in a light fixture, with no related entries in the maintenance log. Another room had a hospital bed plugged into an electrical outlet with no cover plate and exposed wires near the bed. Additional rooms had unpacked boxes, missing closet doors, broken or missing curtains and privacy drapes, and broken dresser drawers, while a resident reported long-standing broken drapes and unassembled storage they had purchased. Maintenance staff reported they relied on work orders, did not routinely enter individual rooms during rounds, and lacked needed closet doors, contributing to these unresolved environmental issues.
Surveyors found that the facility failed to ensure necessary ADL and personal hygiene care for several dependent residents. One resident with severe cognitive impairment and incontinence had no documented showers for an entire month and multiple days without recorded dressing, hygiene, toileting, or transfer assistance despite care plan requirements. Another resident with multiple sclerosis and neurogenic bladder, fully dependent for showers, had numerous missed or undocumented scheduled baths over two months and reported that showers rarely occurred and that their hair was dirty. A third resident with cognitive and psychiatric conditions, care-planned for daily support with personal hygiene, was repeatedly observed with facial stubble despite requesting shaving, and had extensive omissions in bathing and personal hygiene documentation. Staff across roles acknowledged frequent failures in CNA documentation of ADLs, citing short staffing, high acuity, and login issues, resulting in an inability to confirm whether required hygiene care was consistently provided.
A resident with peripheral vascular disease, diabetes, osteomyelitis, multiple existing wounds, and high risk for pressure ulcers did not receive care consistent with professional standards and facility policy. Admission assessments and care plans identified the need for skin integrity interventions, weekly wound rounds, and specific wound treatments, but weekly skin checks and multiple physician-ordered treatments (including zinc oxide to buttocks, heel offloading with booties, foam dressings, betadine applications, and hydrocolloid dressings) were frequently not documented as completed over several weeks. There were no wound assessments or wound round notes for an extended period, and progress notes lacked information on the development and measurement of a sacral ulcer, which later was documented as a Stage 3 pressure injury along with pressure injuries on both heels. In interviews, an LPN reported forgetting to document treatments due to workload, the DON acknowledged poor documentation and inability to verify that treatments were done, and the Medical Director admitted an oversight in not ordering an initial wound care consult and was unaware of the undocumented wound care.
Two residents did not receive adequate supervision and assistance to prevent accidents. One resident with severe cognitive and physical impairments, care planned for two-person assist with bed mobility, was provided incontinence care by a single CNA who did not review or follow the care guide, leading to a fall from bed onto a floor mat despite another nurse being available nearby. Another cognitively impaired, fall‑risk resident experienced an unwitnessed fall with a scalp laceration and back abrasion; the Accident/Incident Report was left incomplete, lacking documentation of injuries, safety measures, new interventions, notifications, and nurse signature, and staff statements omitted last‑seen times. Although a neuro check policy required extended, scheduled monitoring after unwitnessed falls or potential head injury, neuro checks and vital signs for this resident were only documented for a few hours, with no further monitoring notes for several days.
A resident with heart failure, CKD, and cirrhosis who received hemodialysis three times weekly missed one or more scheduled dialysis sessions when a malfunctioning elevator prevented timely transport, with staff and the resident confirming that elevator breakdowns had caused missed appointments and led to the resident’s relocation to a lower floor. Review of the hemodialysis communication book over several weeks showed that on most documented dialysis days, either the pre- or post-dialysis nursing assessment was missing, and there was no corresponding documentation in the EMR, despite facility policy requiring complete pre- and post-treatment assessments for dialysis care.
Surveyors found that the facility failed to ensure meals were palatable and maintained at safe, appetizing temperatures, and did not consistently provide appropriate condiments. Policy required hot foods to be held at or above 140°F and cold foods at or below 46°F, yet a lunch tray on one unit was served with entrée items between 95.5°F and 107.6°F and milk at 63°F. The Food Service Director and RD acknowledged that food left the kitchen hot but cooled during delayed delivery due to only one working elevator, a non-functioning plate warmer, and lack of heating pellets. A resident reported that food was usually cold and disliked. On another unit, hotdogs and french fries were served without ketchup or mustard; staff stated the facility had run out after discovering a box of ketchup packets was moldy and mustard was out of stock, and residents were instead offered mayonnaise or barbeque sauce. A resident described the food as sometimes bad, and a family member observed a sandwich with a bun that was stale and hard.
Pharmacy drug regimen reviews were completed for three residents, but physician review and response to identified irregularities were not documented. One resident had multiple medication concerns, including missing lab monitoring, elevated LFTs, acetaminophen dosing issues, and psychiatric medication changes that were not addressed in the record. Two other residents also had pharmacy recommendations for lab monitoring, psychiatry follow-up, and medication review, but the chart showed continued medications without documented physician response. Interviews with the MD, DON, NP, and unit manager described a breakdown in the process for handling pharmacy consultant reports.
Food items in the kitchen were found unlabeled, undated, or unsealed, including frozen items, dry goods, and opened containers. Surveyors also observed a short emergency food supply, emergency water and other supplies stored on the floor, and damaged meal trays and cutting boards with deep cuts and nicks. The FSD stated they were unsure why items were not dated or sealed, said the emergency supply was low due to budgeted ordering, and later reported that new staff had been using food from the emergency supply racks for current meal service.
The facility failed to follow its grievance policy requiring complete documentation, timely investigation, and notification of complainants. A resident with severe cognitive impairment and incontinence had a grievance filed by a representative about being found soiled and improperly covered, but the concern form showed no investigation, follow-up, or notification. Another resident filed a grievance about an allegedly sleeping staff member; while staff response and discipline were documented, there was no documented follow-up with the resident. At a Resident Council meeting, several residents reported that the grievance process was unclear and that complaints received little or no follow-up. Staff interviews revealed confusion about who collected grievance forms from locked boxes and who was responsible for tracking them, and leadership acknowledged there was no grievance log and that the process for handling grievances was unclear.
A resident with acute UTI, Parkinson's disease, and Lewy body dementia had a care plan requiring antibiotics and a physician order for Amoxicillin 500 mg every eight hours for six days, but three of the 18 ordered doses were not administered. The MAR for the month showed omissions for specific scheduled doses with no corresponding documentation, and nurse's notes contained no explanation for the missed doses. In interviews, an LPN unit manager confirmed that lack of MAR documentation meant the medication was not given and acknowledged the omissions were preventable, while the DON stated the expectation that there be no omissions and that any non-administered medication be documented with a reason.
Missed Quarterly Care Plan Meeting: A resident with dementia, MS, and depression had a quarterly care plan meeting cancelled due to snow and not rescheduled. The resident, who had moderately impaired cognition and needed staff assistance with several ADLs, said the meetings were important for communication with family. Record review and interviews showed the SW and DON were aware quarterly care plan meetings should be held and rescheduled if needed, but no meeting note was found for the cancelled quarter.
A resident with MS, neurogenic bladder, and anxiety, who had intact cognition and needed extensive assistance with ADLs and transfers, requested a shelf and a recliner to make the room more comfortable and homelike. The shelf was stored in the office for about a month before approval and had not been assembled, and the recliner request had no documented response; staff said the recliner policy was pending and the resident was told they could not have one.
Failure to protect a resident from sexual abuse: A resident with dementia and documented sexual disorders was observed by an activity aide grabbing another resident's private areas during an outdoor activity. The other resident had severely impaired cognition and mobility limitations. Prior care plans did not include specific interventions for sexually inappropriate behavior, and the incident report noted no investigation was completed.
Failure to Report Alleged Abuse Incident: A resident with dementia and severely impaired cognition was witnessed touching another resident inappropriately while staff were present. The residents were separated immediately and the physician was notified, but the incident was not found to have been reported to the State Agency. Interviews with the RN, DON, Medical Director, and Administrator confirmed the incident should have been reported and investigated.
Failure to complete a thorough abuse investigation after a resident with dementia and cognitive impairment was observed touching another resident inappropriately. Staff separated the residents and documented the incident, but the file lacked evidence of an ongoing investigation, the Medical Director was unaware of the nature of the event, and the report was not reviewed by the DON or Medical Director as required by policy. The incident was also not reported to the State Agency.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notifications: The facility did not provide written transfer/discharge notices or bed-hold information to resident representatives and did not notify the Ombudsman for three residents who were hospitalized. One resident had intact cognition and was transferred for lethargy and hypotension, while two residents had severely impaired cognition and were transferred for possible stroke and respiratory failure. Records showed only verbal or phone notification in some cases, with no documented written notice or Ombudsman notification.
Delayed MDS transmission for a resident occurred when the completed MDS was not electronically submitted to CMS within the required timeframe. The DMS stated the delay was due to pending RN sign-off, and acknowledged responsibility for submission.
A comprehensive person-centered care plan was not in place for residents with respiratory needs, an indwelling urinary catheter, and dental issues. Two residents received oxygen without an active respiratory care plan, one resident returned from the hospital with a Foley catheter but had no catheter-care interventions in the care plan at the time, and another resident had no documented dental care plan despite concerns about missing lower partial dentures.
Failure to provide individualized activity participation for two residents. One resident with dementia, schizophrenia, and diabetes had a care plan for 1:1 visits and small-group activities, but was observed in the room with no documented group attendance or in-room visits on the observed days, and records showed very limited activity participation. Another resident with dementia, MS, and depression had a care plan for 1:1 sensory visits and event invitations, but was observed in bed with no documented in-room activities, and the record showed only one documented activity day in the month reviewed.
Oxygen Flow Rates Exceeded Physician Orders: Two residents received oxygen at settings above the physician order. One resident with CKD, cirrhosis, and acute respiratory failure had an order for 3 L/min PRN, but the concentrator was observed at 3.75 to 4 L/min. Another resident with MS, dementia, and respiratory failure had an order for 2 L/min continuous, but the concentrator was observed at 2.5 L/min and between 2 and 3 L/min. An LPN confirmed the incorrect settings, and the DON stated nurses were expected to set oxygen flow rates per orders.
A resident with dementia, anxiety, and sexually inappropriate behavior was placed on one-to-one supervision after an incident involving another resident, but the supervision was not documented consistently and was not supported by an order or care plan entry. Monitoring sheets and staffing records showed multiple day and evening shifts with no assigned staff for the one-to-one coverage, and staff stated that when staffing was short, 15-minute checks were used instead.
Infection control practices were not maintained during linen handling on two units. On one unit, bagged soiled linens were left on the floor in a resident room, unbagged soiled linens were placed directly on the floor while a CNA made a bed, and clean linen carts in the storage room were uncovered. On another unit, an CNA placed a personal drink cup into a clean linen and supply cart and left the cart open, exposing clean supplies to the environment.
The facility did not consistently staff each unit with both a Charge LPN and a medication nurse on the day shift as required by its own assessment, resulting in single nurses being responsible for approximately 30 residents per unit and causing delays in medication administration. Interviews and staffing records confirmed that this staffing shortfall occurred on multiple occasions and did not align with the facility's documented plan.
Multiple environmental deficiencies, including stained ceiling tiles, torn curtains, missing bathroom tiles, and noisy fixtures, were observed throughout the facility. Maintenance issues were not consistently documented or tracked, and a significant plumbing incident went unreported. The lack of a formal system for maintenance requests and follow-up contributed to an unsafe and uncomfortable environment for residents.
The facility's assessment indicated that each unit should have a Charge LPN and a medication nurse on the day shift, but staffing records showed that units were often staffed with only one nurse. This discrepancy led to late medication administration, as confirmed by staff interviews and review of assignment sheets. The issue persisted across multiple units and dates, despite the facility's documented staffing plan.
The facility did not maintain adequate nursing staff on multiple occasions, resulting in units being staffed below the minimum required number of CNAs. Staff and residents reported that this led to delayed care, incomplete tasks, and increased workload, especially for residents needing extensive assistance. Resident Council meetings documented ongoing concerns about slow call bell responses and lack of assistance, with no evidence that these issues were addressed by facility leadership.
Surveyors found that the facility failed to provide a safe, clean, and homelike environment for residents, as evidenced by unresolved maintenance issues such as a missing closet bar for a resident, lack of a lock box leading to a resident's loss of funds, dirty and damaged radiator units, missing closet doors, inadequate lighting in a dayroom, and persistent noise from a defective call bell system. The facility did not have an effective system to track or address these deficiencies.
Two residents were transferred to the hospital without timely notification to their emergency contacts or representatives, despite facility policy requiring such communication. In both cases, family members were not informed by staff and only learned of the transfers after the fact, either upon the resident's return or from the hospital directly.
Surveyors found that the facility did not provide required written notifications of transfer or discharge, including bed-hold policies and ombudsman notification, for two residents who were hospitalized. In both cases, there was no documentation of discharge notices or bed-hold notifications in the medical records, and one resident's family was not informed by the facility about the hospitalization.
Three residents experienced falls, but their care plans were not updated to reflect the incidents or to include new interventions, despite facility policy requiring such updates. Documentation and interviews confirmed that the care plans did not reflect the falls or any changes in care following these events.
The facility failed to maintain a functioning call system on Unit 3, affecting 37 residents, including one at moderate risk for falls. The centrally located call bell system was non-operational, and interim tap bells were ineffective. Staff were unaware of the issue, and there was no documented evidence of increased monitoring or care plan updates. The deficiency posed an immediate jeopardy to resident safety.
The facility failed to maintain a safe, clean, and homelike environment in two units, with issues such as broken floor molding, rusted heaters, damaged walls, and dirty floors. A strong urine odor was noted, and residents' wheelchairs were unclean. One elevator was out of service, affecting accessibility. Maintenance issues were to be logged in a book, but prioritization and renovation plans delayed repairs.
A resident with schizophrenia and bipolar disorder exhibited escalating aggressive behaviors, including physical attacks on staff and other residents. Despite documented incidents, the facility failed to implement effective interventions, resulting in multiple attacks and injuries. Interviews revealed inadequate supervision and documentation, with staff acknowledging the need for increased oversight.
The facility failed to report alleged abuse and injuries involving three residents to the State Agency within the required timeframe. A resident's injury of unknown origin was not reported, another resident's allegation of staff abuse was delayed by three days, and a resident-to-resident incident was reported over five hours late. The facility's policy requires immediate reporting, but these incidents were not communicated as mandated.
The facility failed to ensure a dignified experience for three residents. A nurse stood over two residents while feeding them, contrary to policy. Another resident lacked appropriate clothing, wearing a hospital gown and sweatshirt without pants. A CNA used the term 'feeders' for residents needing assistance, which was inappropriate. These actions violated residents' rights to dignity and respect.
The facility did not ensure regular Resident Council meetings, as residents were unaware of who should assist them, and there were no documented minutes for several months. The Administrator and DON acknowledged the issue upon starting at the facility, noting the absence of a staff liaison and a Resident Council President.
A recertification survey found that a facility lacked proper communication and documentation processes between its administration and governing body, leading to unaddressed issues such as a non-functional call bell system since April and only one working elevator for over a year. Interviews revealed that staff were unaware of the duration of these problems, and there was no formal documentation of discussions with the facility owner about these issues.
The facility failed to address a malfunctioning call bell system since April 2024, leaving residents unable to call for assistance. The QAPI committee did not develop or implement a plan to ensure resident safety, and there was no documentation of meetings or interim measures. The facility was cited for Immediate Jeopardy due to the lack of an effective plan and for not notifying the Department of Health about having only one working elevator.
The facility failed to update care plans for two residents, one at risk for falls and another requiring care plan meetings. A resident's care plan was not updated after a fall, and the call bell system was malfunctioning, leaving residents unable to call for help. Another resident did not have documented care plan meetings since early in the year, causing anxiety due to lack of support for housing needs.
The facility was found to have insufficient nursing staff, leading to delayed resident care. Residents and family members reported staff shortages, particularly on weekends, resulting in delayed responses to call bells and inadequate care. Staff interviews confirmed excessive working hours and burnout due to insufficient staffing. The facility's staffing plan was not consistently met, impacting the quality of care provided.
A resident with dementia and fragile skin experienced multiple instances of bruising, which were reported by family members. Despite this, the LTC facility did not conduct thorough investigations or update care plans as required. Interviews revealed a lack of documentation and communication regarding the injuries, and no Accident and Incident reports were found.
A resident with a history of exit-seeking behaviors eloped from the facility due to inadequate supervision and safety measures. Despite being assessed as high risk for elopement, the resident frequently removed their wander guard, and there was no physician order for the device. The resident's care plan interventions, including 15-minute checks and 1:1 supervision, were inconsistently implemented. On the night of the incident, the CNA on duty did not check the stairwell after hearing an alarm, leading to the resident's elopement. Interviews revealed systemic issues, including faulty alarms and inadequate staffing.
A resident with chronic obstructive pulmonary disease and impaired vision was inaccurately assessed in their Quarterly Minimum Data Set, which failed to reflect their need for continuous oxygen and vision impairment. Despite being cognitively intact, the resident struggled to locate food due to vision issues and required oxygen, which was inconsistently documented. The Minimum Data Set Coordinator acknowledged the oversight in the assessment process.
The facility failed to develop comprehensive care plans for two residents, one with a pressure ulcer and another on psychotropic medications. A resident with Parkinson's and Peripheral Vascular Disease developed a pressure ulcer that was not addressed in their care plan, while another resident on psychotropic drugs lacked a care plan with interventions. Observations and interviews revealed inadequate repositioning and incomplete care planning, respectively.
A resident with a pressure ulcer did not receive consistent treatment and services as per professional standards. The facility failed to document treatments and follow up on wound care recommendations for heel booties and an air mattress. Observations showed the resident was not using heel booties or an air mattress, and staff interviews revealed a lack of communication and documentation regarding the wound care team's recommendations.
A resident experienced significant weight loss due to inadequate monitoring and assistance with meals, despite having a care plan in place. The resident, with impaired vision, was not reassessed for the necessary level of assistance, leading to multiple instances of unconsumed meals. Staff interviews revealed a lack of communication and documentation regarding the resident's needs, contributing to the deficiency.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Maintain Adequate Nurse and CNA Staffing to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing and CNA staffing to meet residents’ needs as outlined in the facility assessment and care plans. The facility assessment dated 11/12/2025 set minimum staffing expectations for three units, specifying ranges of direct care nurses and CNAs for day, evening, and night shifts. Review of staffing records from 03/20/2026 through 04/20/2026 showed that on multiple dates (03/24, 04/01, 04/05, 04/07, and 04/13/2026) the facility did not meet its own minimum nurse staffing numbers for at least one shift, including overnight shifts where only two nurses covered three units and one of those also functioned as supervisor. On 04/13/2026, day shift staffing showed only two direct care nurses for three units, with one nurse covering two units. CNA staffing was also at or below the facility’s minimal numbers on at least one unit and one shift on 28 of the 30 days reviewed, including overnight shifts with as few as three CNAs for the entire facility. Residents and staff reported that this staffing pattern affected the timeliness and completeness of care. One resident stated there were not enough staff to get people up in the morning and that food arrived cold because tray delivery took too long. Another resident, observed in bed in a hospital gown in the early afternoon, reported that staffing was poor, that no one was around at night, and that there were days when they could not get out of bed. During a morning observation on Unit 200, at a time when breakfast was scheduled for 8:00 AM, the breakfast cart was still on the unit at 9:15 AM, most residents were eating in their rooms, and 28 of 39 residents remained in bed or in hospital gowns, despite four CNAs being scheduled. Multiple CNAs and nurses described difficulty completing required cares and documentation due to short staffing and high acuity. CNAs reported that working with only three CNAs on a unit was challenging and that when only two CNAs were present, showers might not be completed as scheduled and would have to be made up on better-staffed days. One CNA stated they did not always document all resident cares each shift because of lack of time and short staffing, and that some cares were performed late in the shift or left for the next shift. An LPN acknowledged awareness that CNA documentation was frequently incomplete and that short staffing delayed cares, particularly on a high-acuity unit. Another LPN reported that there were two CNAs overnight on one occasion and sometimes only one, describing those nights as very challenging. Facility leadership, including the HR/Staffing Manager, Administrator, and DON, confirmed that staffing was a challenge, that there were open nurse and CNA positions, that minimum staffing levels were sometimes not met, and that the DON did not believe the current minimum staffing numbers were adequate or safe to ensure completion of resident cares such as showers.
Governing Body Failed to Ensure Stable Facility Management and Repeated Deficiencies
Penalty
Summary
The Governing Body failed to ensure consistent and responsible management of the facility. The facility had seven changes in the Director of Nursing between 07/30/24 and 02/02/2026, including four hired DONs and three interim DONs, with the longest tenure lasting less than 6 months. At the time of survey, the current DON had started on 02/03/2026, and during interviews related to F600, F609, and F610, the DON stated they were not at the facility at the time of the incident. The Administrator at survey start had begun on 01/02/2026, and the prior Administrator worked from 09/25/2025 to 01/02/2026. The facility also had repeated deficiencies from prior recertification surveys, including 11 repeat citations from 05/06/2025 and 12 repeat deficiencies from 09/17/2024. These repeat citations included F725 for sufficient nursing staff, which had been cited during both prior recertification surveys. Interviews with the DON, Human Resources, and nursing staff identified low staffing and that the minimum staffing levels in the Facility Assessment were not adequate. In addition, one elevator had been out of service for at least 3 years, and a second elevator was not always functional and caused residents to miss appointments; staff and resident interviews also reported that residents complained of food being late and cold because only one elevator was working.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility did not ensure an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. During the post-survey revisit, the Director of Nursing/Infection Preventionist was unable to provide documentation of antibiotic surveillance or a line listing for the facility from 06/18/2026 through 06/25/2026. The Director of Nursing stated that unit managers were responsible for completing surveillance reports, but they had not received reports for May or June 2026, and the last full monthly antibiotic surveillance report completed in the facility was in April 2026. The Director of Nursing also stated that a full house audit of residents prescribed antibiotics was not completed as described in the plan of correction from the prior survey. They reported not receiving reports documenting missed antibiotic administrations and stated that, because no audits were completed, no corrective measures were put in place if applicable. The facility had two Assistant Directors of Nursing serving as Infection Preventionists since April 2026, but they did not remain employed long enough to complete surveillance and line listings. Unit managers stated they were not aware of an official tool such as McGeer being used, were not aware of a formal expectation for daily antibiotic surveillance or line listings, and did not complete the requested audits in May or June 2026 due to workload and time constraints. The Administrator stated they were not aware the surveillance and line listings were not being completed.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms Across Three Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment across three units, as required by its Resident Rights policy and 10NYCRR 415.15(h)(1). On Unit 2, one room had multiple unresolved environmental issues, including floor stains on both sides of the bed, a puddle of water near the radiator, a large spackle stain above the bed, spackle residue above the sink, peeling molding under the window, and a missing closet door. In the bathroom of the same room, there were brown stains on the toilet, three missing wall tiles, brown stains on the ceiling, and insect or debris accumulation inside the light fixture. Review of the Unit 2 maintenance logbook showed no documentation of needed repairs for this room, despite these conditions being present. On Unit 1, another room had a hospital bed electrical power cord plugged into an electrical outlet that lacked a cover plate, leaving exposed wires in close proximity to the resident’s bed. The Maintenance Supervisor acknowledged that the outlet cover was missing and that someone had likely changed the outlet and failed to replace the cover plate, and also acknowledged awareness that having exposed wires so close to the bed was not good. These observations showed that the facility did not ensure that electrical fixtures in resident rooms were maintained in a safe condition. On Unit 3, several rooms had environmental deficiencies related to privacy and furniture condition. One room contained unpacked cardboard boxes piled along the wall by the closet, had no closet doors so that all items in the closet were exposed, and had drapes that were not fully affixed to the track; the resident in that room stated they had many boxes and belongings they wanted to put away, had purchased a shelf that had not yet been assembled, and that the drapes had been broken since their arrival. Additional rooms on Unit 3 were observed with no curtains or blinds, curtains falling with rods loose and hems coming out, a broken privacy curtain with missing clips, window curtains falling apart, and broken dresser drawers. Maintenance leadership reported that they rounded on units daily but did not routinely go into individual rooms, relied on work orders for specific repairs, and that closet doors for at least one room were not available and would need to be ordered, indicating that these room-specific issues had not been identified or addressed through the existing process.
Failure to Provide and Document Required ADL and Hygiene Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene, as required by facility policy. For one resident with severe cognitive impairment, diabetes mellitus, Wernicke’s encephalopathy, and bowel and bladder incontinence, certified nurse aide (CNA) documentation showed that the resident did not receive a shower during an entire month and had no recorded assistance with dressing, personal hygiene, toileting, CNA care, or skin checks for many days, as well as missing transfer documentation on multiple days. The resident’s care plans required monitoring of skin during toileting and diaper changes every two to four hours, but the CNA record did not reflect consistent provision or documentation of these cares. Another resident with multiple sclerosis, neurogenic bladder, and anxiety, who was cognitively intact and dependent on staff for showers, had multiple omissions in the CNA accountability records for scheduled bathing across two consecutive months. The resident reported that showers rarely occurred as scheduled and that they often received bed baths instead, while expressing a desire to receive showers as planned. On one observation, the resident arrived for a group activity stating they had not received their shower and complained of dirty hair, which appeared greasy. Staff interviews confirmed that showers were scheduled once or twice weekly and that documentation showed numerous unsigned bathing entries for this resident on scheduled shower days. A third resident with metabolic encephalopathy, unspecified psychosis, and respiratory failure had a care plan documenting self-care deficits in personal hygiene related to cognitive status and medical condition, requiring daily staff support and supervision for personal hygiene and bathing. This resident was observed on two separate occasions with visible scruffy stubble on the face and stated a desire to be shaved. The CNA accountability record for this resident showed omissions for bathing over most of the month and omissions for personal hygiene on numerous days. Staff reported that shaving was typically offered on assigned shower days and that shaving would be documented under personal hygiene, but the record reflected extensive lack of documentation for both bathing and personal hygiene tasks. Across these cases, multiple staff, including CNAs, LPNs, a registered nurse supervisor, and the director of nursing, acknowledged ongoing problems with CNA documentation of ADL care in the electronic medical record. CNAs reported not always documenting all resident care each shift due to lack of time, short staffing, high acuity, and login/password issues, and stated that some cares were performed late or left for the next shift. Nursing staff and leadership stated they were aware that CNA tasks were frequently not documented, that when tasks were not documented it could not be determined if they were completed, and that this issue had been a known problem within the facility. These observations and records demonstrated that residents dependent on staff for ADLs did not consistently receive or have documented showers, personal hygiene, toileting, and related care as required by facility policy and resident care plans. The facility’s written policies required that residents be maintained at the highest practicable level of well-being and receive hygienic care at routine intervals and as needed, and that CNAs document ADL performance each shift in the electronic medical record, including bathing/showers, personal hygiene, toileting, dressing, transfers, skin condition, and safety interventions. The policies also assigned oversight of CNA documentation to nursing leadership. Despite these policies, the survey findings showed repeated omissions in ADL care documentation for multiple residents, resident reports of missed showers and desired shaving not being provided as requested, and staff acknowledgment that short staffing and other barriers interfered with both the provision and documentation of required ADL and hygiene care.
Failure to Provide and Document Ordered Pressure Ulcer Care
Penalty
Summary
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards and its own policies for a resident at high risk for skin breakdown. On admission, the resident had peripheral vascular disease with a nonhealing right transmetatarsal amputation, diabetes mellitus, osteomyelitis, deep tissue injuries to both heels, a right groin wound, a right foot/toe amputation wound, and coccyx excoriation. The admission assessment and MDS identified the resident as at risk for pressure ulcers, with care plans calling for skin integrity interventions such as daily CNA skin checks, pressure-reducing devices, turning and repositioning, offloading extremities, and weekly wound rounds. Hospital discharge instructions also required timely follow-up with primary care, wound care center, infectious disease, and vascular surgery. Despite these identified risks and orders, multiple physician-ordered treatments and monitoring interventions were not documented as completed. Weekly skin checks ordered starting 04/21/2025 had no documentation on the April and May Treatment Administration Records (TARs). Orders dated 04/25/2025 for zinc oxide to the buttocks every shift and bilateral heel booties with offloading every shift were missing documentation on 7 of 42 shifts in April and 48 of 93 shifts in May. An order to apply foam dressing to the left heel every other day lacked documentation from 05/01/2025 to 05/14/2025. Later wound care orders dated 05/28/2025 for daily betadine and dressing to the left heel and hydrocolloid to the sacral ulcer every other day were also not documented as completed for multiple days in June, including 06/01/2025–06/06/2025 and on 5 of 16 days after 06/14/2025. In addition to missing treatment documentation, there was a lack of wound assessments and wound round documentation over an extended period. From 04/21/2025 until 06/18/2025, there were no documented wound assessments or evidence that the resident was seen on wound rounds, and nursing and medical progress notes from 04/29/2025 to 06/06/2025 lacked information about the sacral ulcer, including when it developed or any wound measurements. When the resident was reassessed after a hospital stay, the re-entry MDS documented two Stage 3 and one unstageable pressure ulcers present upon admission, and a 06/18/2025 wound care note described a Stage 3 sacral wound and pressure injuries on both heels. During interviews, an LPN Unit Manager acknowledged numerous dates where ordered wound treatments were not documented and could not confirm whether care was provided, citing workload and being the only nurse on the unit. The DON confirmed awareness of poor documentation and could not verify that ordered wound care was completed, and the Medical Director acknowledged not ordering an initial wound care consult and was unaware that wound treatments were not documented as completed.
Failure to Follow Care Plans and Post-Fall Protocols Resulting in Inadequate Supervision and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for two residents with significant cognitive and physical impairments. One resident with diabetes mellitus, cerebrovascular accident, adult failure to thrive, severe cognitive impairment, and physical limitations on one side required total assistance for bed mobility and was care planned for two-person assistance with bed mobility and transfers. The resident’s CNA care guide and care plans documented a need for two staff for bed mobility and total dependence for toileting hygiene. Despite these documented requirements, a CNA provided incontinence care alone, without obtaining a second staff member, and the resident slipped off the bed while on their side and fell onto a floor mat. The CNA did not check the care guide or follow the care plan, even though another nurse was immediately available outside the room who could have assisted. The second resident had diagnoses including diabetes mellitus, Wernicke’s encephalopathy, and cognitive communication deficit, with a quarterly MDS documenting severe cognitive impairment, fall risk, and a need for supervision/touch assistance for chair-to-bed transfers. This resident sustained an unwitnessed fall in their room and was found on the floor beside the bed, unable to describe the event due to poor cognition. The Accident/Incident Report for this fall was incomplete: it did not document the injuries sustained, did not record whether safety or preventive measures were in place, did not list new interventions to minimize recurrence, did not document notification of the resident representative or physician/NP, and lacked a nurse’s signature. Staff statements did not include the time the resident was last seen or when care was last provided, and there were no additional statements beyond those of three CNAs. Facility policies required thorough investigation and documentation of all accidents/incidents, including evaluation for injury, physician notification, and forwarding of the Accident/Incident Report to the Medical Director and Administrator for review and signatures. A separate neurological check policy required immediate and ongoing neuro checks after any unwitnessed fall or potential head injury, with a specific schedule and minimum monitoring duration. For the second resident, neuro checks and vital signs were documented only from late afternoon through mid-evening on the day of the fall, with no documentation after that time despite the policy’s extended monitoring requirements. The resident’s blood pressure was not recorded after the early part of the monitoring period, and there were no nursing notes or evidence of continued monitoring for several days following the fall, despite the resident having a scalp laceration, abrasion, and complaint of head pain at the time of the incident.
Missed Dialysis Sessions and Incomplete Hemodialysis Assessments Due to Elevator Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide dialysis services consistent with professional standards of practice for a resident receiving hemodialysis. The facility’s policy on care of residents receiving hemodialysis, last reviewed in May 2025, required nursing staff to complete pre- and post-dialysis assessments, including documenting pretreatment information and post-treatment vital signs and access site assessments in a hemodialysis communication book. For a resident with heart failure, chronic kidney disease, and cirrhosis who received dialysis three times per week, surveyors found that from mid-March to late April 2026, only fifteen days had dialysis sheets in the communication book, and ten of those were incomplete, missing either the pre- or post-dialysis assessment. There was no documentation elsewhere in the electronic medical record to show that these required assessments had been completed. The facility also failed to ensure that the resident consistently attended scheduled dialysis treatments due to an ongoing elevator problem. Dialysis treatment records from September through October 2025 showed that the resident was scheduled but absent on at least one occasion due to a “facility issue,” and an elevator repair invoice documented repair work on the second and third floor elevator doors in October 2025. Interviews with a former employee, the resident, nursing staff, and the receptionist/transportation scheduler indicated that the elevator frequently malfunctioned, causing residents, including this hemodialysis resident, to miss one or more dialysis appointments. The resident reported missing dialysis sessions because the elevator was down and then having to attend dialysis on consecutive days, and staff confirmed that the resident was moved from an upper floor to a first-floor unit specifically because of missed dialysis appointments related to the elevator being out of service.
Failure to Maintain Food Palatability, Temperature, and Condiment Availability
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with food and drink that were palatable and maintained at safe, appetizing temperatures, as required by facility policy. The facility’s dietary policy specified that hot foods should be held at or above 140°F and cold foods at or below 46°F. During a lunch observation on Unit 1, surveyors measured the temperature of the last tray served and found the chicken parmesan at 107.6°F, pasta at 95.5°F, green beans at 105°F, and milk at 63°F, all outside the facility’s stated standards. The Food Service Director acknowledged that food was hot in the kitchen but cooled during delayed delivery to the units due to having only one working elevator, a non-functioning plate warmer, and the absence of heating pellets under plates. A resident reported that most of the food served was always cold and that they did not like it but felt they had to eat it. The deficiency also includes failure to provide appropriate condiments for a meal, affecting the palatability of the food. During a lunch meal on Unit 3, residents were served hotdogs and french fries without ketchup or mustard, and multiple residents requested these condiments. Staff reported the facility was out of ketchup and mustard, offering mayonnaise or barbeque sauce instead. The Food Service Director stated that a box of ketchup packets had been opened before tray line and found to be moldy, with no additional ketchup available, and that mustard packets were out of stock when an order was placed. The Director also stated they had to follow a budget and did not maintain an extra supply of condiments. A resident stated the food was sometimes bad, and a family member reported seeing a sandwich by a resident’s bed with a bun that was stale and rock hard. The Registered Dietitian noted that while food quality was generally good, they knew the food was cold due to slow delivery, and the Administrator stated the facility had no problem obtaining needed food items.
Failure to Document Physician Review of Pharmacy Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacist drug regimen reviews were consistently reviewed by the attending physician or medical director, and that identified irregularities were documented in the medical record with any actions taken. The deficiency involved three residents: one resident with diabetes, dementia, and bipolar disorder; one resident with dementia, anxiety, and depression; and one resident with bipolar disorder, seizure disorder, and anxiety. The report states that pharmacy reviews were completed for each resident, but the required physician review and response were not documented for multiple recommendations. For the resident with diabetes, dementia, and bipolar disorder, pharmacy reviews identified several concerns, including no documented rationale for fluoxetine, a recommendation for carbamazepine levels, missing pulse and blood pressure monitoring related to carvedilol and antipsychotic use, hepatic impairment with elevated liver enzymes, acetaminophen dosing concerns, and psychiatric recommendations to change multiple medications. The record review found no documentation that the attending physician addressed these recommendations, and the medical director stated the psychiatric recommendations were being seen for the first time during the survey interview. The DON also confirmed there was no documented physician follow-up for the psychiatric consultation. For the resident with dementia, anxiety, and depression, pharmacy notes documented irregularities and recommendations for lab monitoring and psychiatry follow-up, including review of antipsychotic use and gradual dose reduction considerations. Physician progress notes continued medications but did not document review or response to the pharmacy recommendations, and there was no documented evidence that several later pharmacy reviews were reviewed by the physician. For the resident with bipolar disorder, seizure disorder, and anxiety, pharmacy progress notes documented medication review completed with irregularities noted, but there was no documented evidence of the recommendations or physician response. Interviews with the medical director, DON, nurse practitioner, and unit manager described a breakdown in the process for handling pharmacy consultant recommendations and stated that reports were not consistently forwarded or addressed.
Food Storage and Equipment Maintenance Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, or served in accordance with professional standards in the kitchen. During the initial kitchen tour with the Food Service Director, surveyors observed frozen hashbrowns, a box of farina, a pan of thickener, a pan of instant potato, and a pan of sugar that were all unlabeled and undated. An opened box of cornstarch was also undated, and an open box of salt was unsealed. The facility policy titled Dietary Department stated that no boxes of food shall be stored on the floor, food must be covered when stored, and cutting boards should be inspected frequently for wear and replaced as needed. Surveyors also observed that the emergency food supply was short on cans of tuna, beef stew, mixed vegetables, and canned fruit. The emergency water supply was stored directly on the floor, along with a rack of food in the freezer, six 5-gallon buckets of detergent, and a box of napkins in the main kitchen. Three damaged meal service trays with sharp edges and two cutting boards with deep cuts and nicks were also observed. The Food Service Director stated they were not sure why the food items were not dated, labeled, and sealed, and said the emergency food supply was low because they could only order within budget and replenished it a little at a time. The Food Service Director later stated that new staff had been using food from the emergency supply racks on the weekend for current meal service, which caused the deficiency in supplies.
Failure to Maintain Clear, Consistent, and Tracked Grievance Process
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clear, consistent, and promptly implemented grievance process, as required by its own policy and state regulations. The facility’s undated Grievance/Complaint Procedure policy designates the Administrator as the Grievance Officer and requires that grievances be fully documented, investigated, and that complainants be informed orally and in writing of the results within ten working days. Surveyors found that this process was not followed, and that there was no effective system to track grievances or demonstrate the facility’s response and rationale. One resident involved, Resident #114, had diagnoses including type 2 diabetes mellitus without complications, Wernicke’s encephalopathy, and cognitive communication deficit, and was documented as having severe cognitive impairment and needing partial to moderate assistance with toileting, bathing, and dressing, with bowel incontinence. A Concern Form dated 06/16/2025 recorded that the resident’s representative reported finding the resident the previous day in a soiled brief, in a gown, with no sheets on the bed, wrapped in a throw cover, and with a wheelchair containing a towel soiled with feces. The form contained only the description of the concern and no documentation of investigation, follow-up, resolution, notification to the representative, or staff signatures. The Director of Social Work and the Director of Nursing each confirmed that this concern was not completed, investigated, or resolved, and could not explain why, noting they were not employed at the facility at that time. Additional deficiencies were identified through resident interviews and record review. One resident reported filing a grievance about a staff member allegedly sleeping on an overnight shift; the corresponding grievance form showed a staff response and an undated disciplinary action, but there was no documentation of any follow-up with the resident who filed the grievance. At a Resident Council meeting, multiple residents stated that they were unaware of the grievance process, that there was poor or little follow-up when complaints were made, and that they did not know what happened after submitting grievances. Staff interviews revealed confusion about who collected grievance forms from locked boxes and who was responsible for tracking and resolving grievances. The Director of Social Work acknowledged that the grievance policy needed review, that there was no log to track grievances, and that the grievance binder contained grievances only from 2025 and none from 2026. The Administrator and Director of Nursing both indicated that the process for collecting, tracking, and responding to grievances was unclear and that no tracking system was in place.
Omitted Antibiotic Doses Without Documentation
Penalty
Summary
The facility failed to ensure that a resident received antibiotic treatment in accordance with physician orders, professional standards of practice, and the comprehensive care plan. A resident admitted with acute urinary tract infection, Parkinson's disease, and Lewy body dementia had a care plan for urinary tract infection that included administering medications as ordered. The physician ordered Amoxicillin 500 mg to be given every eight hours for six days (at 6 AM, 2 PM, and 10 PM), for a total of 18 doses. Review of the February 2025 Medication Administration Record showed that three scheduled doses of Amoxicillin were omitted on 2/16 at 2 PM and on 2/17 at 2 PM and 10 PM, resulting in only 15 of 18 doses being administered. There was no documentation on the Medication Administration Record or in the nurse's notes explaining why these doses were not given. During interviews, the LPN Unit Manager stated that if there was no documentation on the MAR, the medication was not given, acknowledged that the omissions were preventable, and noted that nurses were expected to check at the end of their shift to ensure medications were signed or that a note was entered if a medication was refused. The DON stated that the expectation was that there be no omissions on the medication or treatment administration records and that, if a medication was not administered, the medication nurse should document the reason in a progress note or on the MAR or treatment administration record.
Missed Quarterly Care Plan Meeting
Penalty
Summary
The facility did not ensure that Resident #68 participated in the development and implementation of the person-centered plan of care because the resident’s quarterly care plan meeting was cancelled due to snow in January 2026 and was not rescheduled. Resident #68 had diagnoses including non-Alzheimer’s dementia, multiple sclerosis, and depression. The Minimum Data Set assessment documented moderately impaired cognition, set-up assistance needed for eating, and dependence on staff for rolling, sit-to-lying, and transfers. During interview, Resident #68 stated the care plan meeting had been cancelled because of snow and not rescheduled, and said these meetings were important for communication with family members. Record review showed a care plan meeting note from 09/17/2025, a quarterly assessment note from 01/20/2026 with no corresponding meeting note, and an invitation sent to a family member for an upcoming care plan meeting dated 04/20/2026. The Social Worker stated there was an upcoming quarterly care plan meeting scheduled for 04/29/2026 and the family member had been invited, but they did not recall why the January 2026 meeting was not rescheduled. The DON stated quarterly care plan meetings should be held for all residents and rescheduled if needed.
Failure to Consider Resident Requests for Personal Room Items
Penalty
Summary
The facility did not ensure that Resident #6’s needs and preferences were considered in creating an individualized home-like room environment. Resident #6 had diagnoses including multiple sclerosis, neurogenic bladder, and anxiety, and the Quarterly MDS documented intact cognition, maximal assistance with most ADLs, and dependence on staff for transfers. The resident purchased a shelf for the room and asked about purchasing a recliner so there would be somewhere to sit other than the wheelchair and bed, but the shelf was still awaiting approval and the recliner request had not been approved or documented as responded to. During observation, cardboard boxes were piled along the wall by the closet in the resident’s private room, and the room appeared large enough to accommodate a recliner. An email from the DOR to the Regional Nursing Coordinator documented a request for the policy on recliners because Resident #6 was requesting one for the room. During interviews, the DON stated the shelf had been stored in the office for about a month, was only approved a couple of weeks earlier, and had not been assembled because no one had time. The DON also stated the recliner policy had been pending and residents were not supposed to have recliners, though the reason was uncertain. The Administrator stated they were aware of the shelf but were not sure of its status, knew staff were concerned about hoarding, and said residents were allowed to bring in personal items if deemed safe; the Administrator was not aware of the recliner request. The DOR stated the recliner policy had been requested in December but never received, and that the chair would be evaluated prior to purchase if permitted.
Failure to Protect a Resident from Sexual Abuse
Penalty
Summary
The facility did not ensure that residents remained free from abuse when Resident #23 was observed touching Resident #37's breast during an outdoor activity. Resident #37 had diagnoses including dementia, anxiety, and bipolar disorder, and the MDS documented severely impaired cognition with use of a walker and wheelchair. Resident #23 had diagnoses including dementia, hydrocephalus, anxiety, and psychiatric conditions that included frontotemporal neurocognitive disorder with speech/language deficits, major depressive disorder, and sexual disorders; a physician order dated 02/06/2025 showed naltrexone was prescribed for sexual disorders, and the psychiatric consultation also identified sexual disorders. Prior to the incident, Resident #23's care plan identified risk for unsafe behavior due to cognitive deficit, but the earlier plan documented no related diagnoses, behaviors, or interventions. The later care plan dated 07/03/2025 listed general safety interventions such as maintaining safety devices, anticipating needs, and observing for mood or temperament changes, but there were no interventions in place before the incident that specifically addressed sexually inappropriate behavior toward other residents. During the incident, an activity aide and a coworker were taking residents outside when they observed Resident #23 walking around Resident #37 and then grabbing Resident #37's private areas; Resident #37 screamed for Resident #23 to stop. The incident report documented that the residents were separated immediately and that no injuries were noted. The report also stated that no investigation was completed. Nursing documentation noted the event and that Resident #23 was educated on appropriate behavior, but there were no nursing notes or evidence of monitoring from 08/23/2025 to 08/29/2025. Subsequent notes later documented sexually inappropriate behavior and added supervision and medication-related interventions, but these were entered after the incident occurred.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an alleged abuse incident was reported no later than two hours after it occurred. Resident #23, who had diagnoses including dementia, hydrocephalus, and anxiety and whose quarterly MDS documented severely impaired cognition, was observed touching another resident inappropriately while outside on the back patio. The incident report documented that Resident #23 touched a female resident's breast, the residents were separated immediately, no injuries were noted, and the physician was notified. The report was signed by the supervising nurse and the Administrator, but there was no signature from the DON or Medical Director. A staff statement described that Resident #23 was seen grabbing another resident's private areas while residents were being brought back inside, and the other resident screamed for the behavior to stop. A RN note documented that activities staff witnessed Resident #23 touching another resident's breast and that the resident was immediately separated and redirected. During interviews, the Regional Nursing Coordinator could not recall whether the incident was reported and could not find documentation of reporting to the State Agency. The DON and Medical Director stated the incident should have been reported, and the Administrator stated a more thorough investigation should have been conducted and that the incident needed to be reported and investigated due to the inappropriate touching.
Failure to Complete Thorough Abuse Investigation After Inappropriate Resident Contact
Penalty
Summary
The facility did not ensure that it initiated and completed a thorough investigation after Resident #23 was observed touching another resident inappropriately. The incident occurred while Resident #23 was in a supervised area on the back patio, and staff separated the residents immediately. The Accident/Incident report documented that the physician was notified, but it did not include a thorough investigation showing actions taken to determine whether the alleged abuse could have been prevented or to protect other residents while the investigation was ongoing. Resident #23 had diagnoses including dementia, hydrocephalus, anxiety, and cognitive communication impairment, and the care plan documented impaired decision making and risk for unsafe behavior due to cognitive deficits and significant mental health and neurological diagnoses. The incident documentation included observations that Resident #23 touched another resident's breast and later grabbed the resident's private areas. The report was signed by the supervising nurse and reviewed by the Administrator, but there was no signature from the DON or Medical Director, and the Medical Director was not aware of the nature of the incident. The facility's abuse policy required supervisory or administrative staff to immediately initiate an investigation and document actions taken throughout the investigation, with review by the Administrator, Medical Director, and DON. However, the investigation file contained only the incident report, a staff statement, and an inservice sign-in sheet about supervising residents with behaviors, with no documented evidence of a thorough investigation. The incident was also not reported to the State Agency, and interviews with the DON, Medical Director, and Administrator confirmed that a more thorough investigation should have been completed.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notifications
Penalty
Summary
The facility did not ensure that written transfer/discharge notices, including bed-hold information, were provided to resident representatives, and did not ensure that the Office of the State Long-Term Care Ombudsman was notified of hospital transfers for three residents reviewed for hospitalization. The deficiency was identified during interviews and record review and involved residents who were transferred to the hospital from the facility or from a facility area, with no documented evidence that the required notices were completed or that the ombudsman received notification. Resident #111 had diagnoses including cardiac arrest, breast cancer, and chronic kidney disease, and a Minimum Data Set assessment documented intact cognition and minimal assistance needs. A nursing progress note documented transfer to the hospital for lethargy and hypotension, but there was no documented evidence that Resident #111 or the resident representative received a discharge notice or bed-hold notification, and no documented evidence that the ombudsman was notified. During interview, the Director of Social Work stated the resident was transferred directly from the Heart Center to the hospital and that the ombudsman was not notified, the transfer/discharge notice was not mailed, and the resident representative was not notified of the bed-hold policy. Resident #3 had diagnoses including Alzheimer's dementia, schizophrenia, and diabetes mellitus, with severely impaired cognition and need for assistance with transfers and ambulation. A nursing progress note documented possible stroke symptoms and transfer to the hospital, and a social work note documented that the spouse was notified by phone; however, there was no documented evidence that the representative received a discharge notice or bed-hold notification, and no documented evidence that the ombudsman was notified. Resident #5 had diagnoses including lung cancer, respiratory failure, and diabetes mellitus, with severely impaired cognition and dependence for transfers. A nursing progress note documented a decline in status with respiratory failure and transfer to the hospital, and a transfer/discharge note documented verbal notification to the designated representative, but there was no documented evidence of a written discharge notice, bed-hold notification, or ombudsman notification.
Delayed MDS Transmission
Penalty
Summary
The facility failed to electronically transmit completed MDS assessments to the CMS system within the required timeframe for Resident #101. Record review showed the resident’s discharge MDS had a completion date of 04/22/2026 and a transmission date of 04/25/2026, which was documented as 89 days past the required submission timeframe. The facility policy titled Minimum Data Set required each resident to have a comprehensive functional capacity assessment recorded on the designated MDS form and electronically submitted in accordance with federal and state regulations. During an interview on 04/27/2026, the Director of MDS stated the delay in completion occurred because a registered nurse sign-off was pending and acknowledged responsibility for submission.
Incomplete Care Plans for Respiratory, Catheter, and Dental Needs
Penalty
Summary
A comprehensive person-centered care plan was not developed and/or implemented to meet residents’ needs for respiratory care, urinary catheter care, and dental care. Resident #46 had diagnoses including chronic kidney disease stage four, liver cirrhosis, and acute respiratory failure with hypercapnia, and the annual MDS documented shortness of breath when lying flat. A physician ordered oxygen at 3 liters per minute via nasal cannula as needed, and the resident was observed receiving oxygen on multiple occasions, but the care plan review showed no active respiratory care plan in place. The DON stated there was no active care plan for respiratory care or oxygen therapy for this resident. Resident #29 had diagnoses including benign prostatic hyperplasia and neurogenic bladder causing urinary retention. After ongoing difficulty voiding, the resident went to a urology appointment and then to the hospital emergency department, and returned to the facility with an indwelling catheter placed due to urinary complications/retention. At the time of review, there were no interventions for indwelling catheter care in the care plan, and the care plan was not updated until after the catheter had already been placed. Resident #98, who had diagnoses including non-Alzheimer's dementia, anxiety disorder, and cancer, was noted by the resident and family to have lost or not have a lower partial denture, and the speech therapist stated the resident did not have a lower partial denture on admission; however, there was no documented dental care plan for the resident.
Failure to Provide Individualized Activity Participation
Penalty
Summary
Activities were not provided based on each resident’s comprehensive assessment, care plan, and preferences for two residents reviewed. Resident #3 had diagnoses including Alzheimer’s disease, dementia, schizophrenia, and diabetes mellitus, and the MDS documented severely impaired cognition with moderate assistance needed for transfers and walker use. The activities record showed a preference for small group or 1:1 activities, religious services, TV animal shows, and encouragement to attend patio activities, with a care plan goal for 1:1 visits and small group participation 5 times per week. However, Resident #3 was observed in the room on 04/20/2026 and 04/21/2026, and there was no documented evidence of group attendance or in-room visits on those days. The Activity Director stated Resident #3 had attended only five activities out of 22 opportunities in April 2026, and there were no room visits documented for February, March, or April 2026. Staff also stated they were trying to see Resident #3 in the morning to inform them of daily activities, but had not yet done so at the time of the interview. Resident #68 had diagnoses including non-Alzheimer’s dementia, multiple sclerosis, and depression, with the annual MDS documenting moderately impaired cognition, dependence for rolling, sit-to-lying, and transfers, and that going outside when weather permitted was very important. The care plan noted limited participation due to choice, enjoyment of TV, and a goal for 1:1 sensory visits and invitations to facility events. Resident #68 stated staff did not come in often to ask about attending activities and did not care for the activities offered. The Director of Activities stated Resident #68 preferred to stay in the room and watch TV but should have received 1:1 visits, and reported only one documented activity attendance day out of 22 in April 2026 and none in March 2026. Resident #68 was observed in bed on 04/21/2026 and 04/24/2026, with no documented evidence of in-room activities on those days.
Oxygen Flow Rates Exceeded Physician Orders
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents when oxygen was administered at a liter flow greater than the physician order. Resident #46 had diagnoses including chronic kidney disease stage 4, cirrhosis of the liver, and acute respiratory failure with hypercapnia. The annual MDS documented intact cognition and shortness of breath when lying flat. A physician order dated 03/11/2026 specified oxygen at 3 liters per minute via nasal cannula as needed, but observations on 04/23/2026 and 04/24/2026 found the oxygen concentrator set at 3.75 liters per minute, and another observation on 04/27/2026 found it set at 4 liters per minute. An LPN stated the oxygen flow rate was at 4 liters per minute and said they would check the orders and adjust it. Resident #106 had diagnoses including Multiple Sclerosis, non-Alzheimer's dementia, and respiratory failure. The annual MDS documented the resident was not assessed for cognition due to rarely/never understood, shortness of breath when lying flat, and oxygen therapy. A renewed physician order dated 02/14/2026 specified nasal cannula oxygen at 2 liters per minute continuous. Observations on 04/20/2026 and 04/21/2026 found the concentrator set between 2 and 3 liters and then at 2.5 liters. An LPN observed the setting at 2.5 liters, corrected it to 2 liters, and stated it should be checked at least once per shift and only nurses should adjust oxygen settings. The DON stated nurses were expected to set oxygen flow rates per physician orders and that only nurses were to adjust oxygen because it was considered a medication.
Insufficient Staffing for Resident One-to-One Behavioral Supervision
Penalty
Summary
The facility did not ensure sufficient staff were available to provide one-to-one supervision for a resident with behavioral health needs. Resident #23 had diagnoses including dementia, hydrocephalus, anxiety, frontotemporal neurocognitive disorder with speech/language deficits, major depressive disorder, and sexual disorders. After an incident on 08/23/2025 in which the resident was observed touching another resident’s breast, the Sexual Disorders Care Plan documented sexually inappropriate behavior and included interventions such as psychiatric follow-up, psychoactive and sexually suppressive medication, and sight supervision when out of bed. Although calendar assignment sheets from 09/16/2025 through 11/30/2025 documented varying one-to-one supervision times, there was no documented evidence of one-to-one supervision from 12/1/2025 to 04/01/2026. For 04/01/2026 through 04/27/2026, monitoring sheets for Resident #23 showed omissions for one-to-one supervision on multiple day and evening shifts. Cross-referenced staffing sheets showed no assigned staff to provide the one-to-one supervision on several of those shifts, and the staffing manager stated there were days when there were not enough staff to provide it. The record also showed no documented order for one-to-one supervision and no evidence that it was included on the care plan. Staff interviews confirmed that Resident #23 was receiving one-to-one supervision during day and evening shifts, while overnight monitoring consisted of 15-minute checks. The DON stated the one-to-one supervision was being documented on log sheets kept at the nurses’ station rather than in the electronic medical record, and the medical director stated they had not ordered one-to-one supervision and were unaware the resident was receiving it.
Infection Control Lapses in Linen Handling and Clean Supply Storage
Penalty
Summary
Infection prevention and control practices were not maintained when handling linens on Unit 1 and Unit 2. On Unit 2, bagged soiled linens were observed on the floor in a resident room and were reported by CNA #13 to have been left there from the overnight shift. In the same room, CNA #14 was observed making a bed while the soiled linens were left unbagged directly on the floor and were not bagged until after the bed was made. The clean linen storage room was also observed with carts holding linens that did not have covers, and CNA #14 stated they were unsure whether the carts ever had covers. On Unit 1, CNA #15 was observed drinking from a personal cup and placing it into the clean linen and supply cart in the hallway, then leaving the cart area with the flaps open and the clean supplies exposed. CNA #15 stated they knew they were not supposed to keep the personal drink cup in the clean supply cart, but they drank a lot of water and knew to close the flaps when leaving. The DON stated that soiled linens should not be placed on the floor, should be bagged immediately after removal from the bed, and that clean linens should be covered when transported and stored; the DON also stated personal drink cups were not supposed to be placed in clean linen or supply carts.
Failure to Provide Sufficient Nursing Staff per Facility Assessment
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents as outlined in its own facility assessment. The assessment, reviewed by Quality Assurance and Performance Improvement, specified that each unit should have a Charge LPN and a medication nurse on the day shift. However, staffing assignment sheets and direct observations revealed that on multiple dates, including the observed date, only one nurse was assigned per unit, each responsible for approximately 30 residents. This staffing pattern was consistent across several dates within a one-month period for all units, including the rehabilitation, long-term, and dementia units. As a result, there were instances where medications were administered late due to the insufficient number of nurses available to provide timely care. Interviews with nursing staff, the staffing coordinator, the interim DON, and the administrator confirmed the discrepancy between the facility's staffing plan and actual staffing practices. Staff reported frequently working alone on units, and the staffing coordinator acknowledged that units were sometimes staffed with only one nurse if additional staff were unavailable. The interim DON and administrator both agreed that the facility assessment required two nurses per unit on the day shift, but staffing records showed this was not consistently achieved. There was no indication that staff were aware of habitual lateness among nurses, but the lack of adequate staffing directly contributed to delays in medication administration and did not align with the facility's documented plan.
Failure to Maintain Safe and Homelike Environment Due to Poor Maintenance Tracking
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents, as evidenced by multiple observations of environmental deficiencies across several units. Surveyors noted visible dark water stains on ceiling tiles in numerous resident rooms, community areas, and bathrooms. Additional issues included torn window curtains, missing ceramic tiles under bathroom sinks, and makeshift repairs with sheet rock that did not adequately cover gaps. Noisy exhaust fans and sinks producing banging and rattling noises were also observed. These deficiencies were not systematically tracked or documented, and the maintenance binders intended for reporting such issues were inconsistently used, with entries often lacking specifics, dates, or resolution information. Interviews with the Director of Maintenance revealed the absence of a formal system to track or prioritize maintenance needs, relying instead on informal verbal reports and personal recollection. During a walkthrough, the Director of Maintenance was unable to specify the extent of needed repairs or provide timelines for completion. Furthermore, a significant plumbing incident involving a burst pipe in the Physical Therapy room was not formally documented, and the Director of Maintenance was unaware of the event, its cause, or its resolution. These lapses in maintenance reporting and follow-through contributed to the ongoing unsafe and uncomfortable environment for residents.
Facility Assessment Failed to Reflect Actual Staffing, Leading to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure that its facility-wide assessment accurately reflected the resources and staffing needed to care for residents, as required. The assessment, reviewed by Quality Assurance and Performance Improvement, documented that each unit should have a Charge LPN and a medication nurse on the day shift. However, staffing assignment sheets for multiple dates over approximately one month showed that several units, including the rehabilitation, long-term, and dementia units, were often staffed with only one nurse per unit during the day shift, despite each unit housing about 30 residents. This staffing pattern was observed repeatedly, and on several occasions, a single nurse was responsible for medication administration and resident care, which led to medications being administered late. Interviews with nursing staff, the staffing coordinator, the interim DON, and the administrator confirmed that the actual staffing did not match the facility assessment. Staff reported frequently working alone on units, and the staffing coordinator acknowledged that units were sometimes staffed with only one nurse if additional staff were unavailable. The interim DON and administrator both agreed that the facility assessment called for two nurses per unit on the day shift, but staffing records showed this was not consistently achieved. There was no indication that staff were aware of any habitual lateness among nurses, but the discrepancy between the assessment and actual staffing contributed to delays in medication administration.
Insufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as required by their own Facility Assessment and staffing policy. Review of staffing schedules over a two-month period revealed multiple instances across all three shifts and units where the number of certified nurse aides (CNAs) fell below the facility's minimum requirements. Staff interviews confirmed that callouts were frequent, and the facility did not utilize agency staff, relying instead on internal pools and offering bonuses to cover gaps. Despite these efforts, there were repeated occasions when units operated with fewer CNAs than needed, particularly on weekends and during evening shifts. Staff reported having to work double shifts, skip breaks, and work into the next shift to complete resident care tasks, with some units experiencing only one CNA on duty at times. Resident acuity data indicated a high number of residents requiring extensive assistance, including mechanical lifts, help with eating, and total or extensive assistance with toileting. Staff consistently reported that the workload was heavy and that the reduction in CNA staffing from four to three per unit made it difficult to complete all required cares. Staff also noted that tasks were rushed, and resident care was sometimes incomplete, especially when callouts reduced staffing below even the minimum guideline. Supervisory staff acknowledged that low staffing levels could negatively affect resident care and that complaints about staffing had been raised by both staff and residents. Resident Council meeting minutes documented ongoing concerns from residents about delayed call bell responses, insufficient assistance with activities of daily living, and staff inattentiveness, particularly on weekends. These concerns were raised repeatedly over several months, with no documented evidence that the facility addressed or responded to them. During interviews, residents confirmed that they had to wait a long time for care and that their concerns about staffing had been expressed in previous meetings. The Administrator acknowledged awareness of these concerns and stated that incentives were offered to attract and retain staff.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents across all three residential units. One resident was unable to hang clothing in their closet for over six months due to a missing closet bar, despite repeated requests by the resident's family representative to both the Director of Social Work and the Director of Maintenance. The Director of Social Work recalled discussing the issue at a care plan meeting and with maintenance, but could not confirm if a formal work order was submitted, while the Director of Maintenance did not recall the request. Another resident reported the loss of approximately $45 from their wallet, which was kept on their bedside table. This resident was not provided with a lock box and was unaware of what a lock box was, although the Director of Social Work stated that lock boxes were offered and discussed at resident council meetings, but could not confirm if this resident had been offered one. Environmental observations revealed that heating and air conditioning radiator units throughout the facility were heavily soiled with dust, debris, and black stains, and had bent, crushed, and rusty conductor fins. Several rooms and dayrooms on all floors were affected. Additionally, one room was missing closet doors, leaving clothing exposed. The 3rd Floor dayroom was found to have inadequate lighting, with only a portion of ceiling fixtures illuminated during resident activities and meals, resulting in a dim environment. The 3rd Floor was also noted to be noisy due to a defective call bell system that emitted a continuous beeping noise, which was audible throughout the unit and originated from a wall-mounted intercom near the medication room. The Director of Plant Operations confirmed the beeping was constant and had not been resolved by the call bell vendor. The facility lacked a formal system to track maintenance and repair requests, relying instead on logbooks and verbal communication between staff and the Director of Plant Operations. Maintenance staff were responsible for addressing issues, but there was no documentation to indicate when repairs were completed or if outside vendors were needed. Housekeeping was responsible for cleaning radiator units quarterly, but observations indicated this was not sufficient to maintain cleanliness. The ongoing environmental and safety issues were not addressed in a timely or effective manner, resulting in a failure to uphold residents' rights to a safe and homelike environment.
Failure to Notify Resident Representatives of Hospital Transfers
Penalty
Summary
The facility failed to ensure timely notification of resident representatives or emergency contacts when two residents were transferred to the hospital. In the first case, a resident with end stage renal disease, respiratory failure, and atrial fibrillation was sent to the hospital for perma-catheter placement and later admitted for hypotension and end stage renal disease. Although the resident's family member was listed as the emergency contact, there was no documented evidence that the representative was notified at the time of transfer. The resident reported that their family was not contacted until days later, and documentation showed that the family member was only called after the resident returned to the facility. In the second case, another resident with diagnoses including sepsis, viral encephalitis, and chronic lymphocytic leukemia was admitted to the hospital for medical issues. The family member, listed as the emergency contact, stated they were not notified by the facility and only learned of the hospitalization from the hospital itself. There was no documentation of representative notification in the medical record. Facility policy required timely notification of residents and their representatives regarding transfers or discharges, but this was not followed in these instances.
Failure to Provide Required Transfer/Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required written notifications of transfer or discharge, including bed-hold policies and appeal rights, to residents, their representatives, or the ombudsman for two residents who were hospitalized. For one resident with end stage renal disease, respiratory failure, and atrial fibrillation, there was no documented evidence of discharge notices or bed-hold notifications for three separate hospitalizations, nor was there evidence that the ombudsman was notified of one of these hospitalizations. The facility's policy requires that such notifications be provided in writing and in a language and manner understood by the resident and their representative, and that the ombudsman be notified at the same time as the resident and representative. For another resident with diagnoses including sepsis, viral encephalitis, and chronic lymphocytic leukemia, there was no documented evidence of a discharge notice or bed-hold notification when the resident was sent to the hospital. Additionally, the resident's family member, listed as the emergency contact, reported not being contacted by the facility regarding the hospitalization and only learned of it from the hospital. These findings were confirmed through interviews and record reviews, which revealed the absence of required documentation in the medical records for both residents.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans for three residents were updated to reflect their current condition following falls, as required by facility policy and state regulations. Specifically, after each resident experienced a fall, there was no documented evidence that the care plans were revised to include the details of the incident or to add new interventions to address the increased risk or to evaluate the effectiveness of existing interventions. The facility's own policies require care plans to be updated after significant changes in a resident's condition, including falls, and to document any new or modified interventions. One resident with end stage renal disease, atrial fibrillation, and peripheral vascular disease experienced a fall while being transported to hemodialysis. Although the incident was documented in progress notes and an accident report, the resident's care plan was not updated to reflect the fall or any new interventions. Another resident with peripheral vascular disease, anxiety disorder, and a history of cerebrovascular accident had an unwitnessed fall from bed, but the care plan last reviewed several months prior did not include this event or any new interventions. A third resident with chronic obstructive pulmonary disease, iron deficiency anemia, and an aneurysm also experienced an unwitnessed fall out of bed, and while the fall risk score was updated, there was no evidence of new interventions or a revised care plan following the incident. Interviews with facility leadership, including the acting DON, Regional Director of Operations, and Regional Nursing Coordinator, confirmed that care plans were not updated after the falls for these residents. The staff were unable to provide any documentation showing that the care plans reflected the falls or any subsequent changes in interventions, despite facility policy requiring such updates.
Failure to Maintain Functioning Call System on Unit 3
Penalty
Summary
The facility failed to provide a functioning call system for residents on Unit 3, which includes the Dementia/Long Term Care Unit. On 9/10/2024, it was observed that the centrally located audible call bell system was not operational, and the interim system using tap bells was ineffective. The tap bells were not audible at the central nursing station or throughout the hall, affecting 37 residents. Specifically, Resident #31, who was at moderate risk for falls, was found sitting on the toilet without access to a functioning call bell, as the bathroom call bell was neither audible nor visual, and the tap bell was out of reach. The facility's policy required that each resident have a call bell within reach, but this was not adhered to. The issue with the call bell system began in April 2024, and despite a contract proposal being signed, the contractor did not receive the necessary down payment until late August 2024, delaying repairs. Interviews with staff revealed a lack of awareness about the non-functioning call bell system, and there was no documented evidence of increased monitoring or updated care plans to address the residents' ability to contact staff during this period. The deficiency was further highlighted by the lack of documented evidence of tap bell function and placement logs, as well as care plan updates from April to September 2024. Interviews with various staff members, including CNAs, LPNs, and the Director of Maintenance, confirmed the ongoing issues with the call bell system and the absence of effective interim measures. The facility's failure to ensure a working call system posed an immediate jeopardy to the health and safety of residents on Unit 3.
Removal Plan
- The facility assigned two to four staff members as monitors to make continuous rounds on Unit 3.
- Monitoring logs for room rounds were presented to the survey team by the facility with no negative findings.
- Staff education regarding room rounds on Unit 3 was conducted with 90.2% completion.
- Unit 3 residents were assessed for the ability to use the call bell system. Three residents were assessed by therapy as not being able to use a call bell.
- The Policy and Procedure titled Alternate Call Bell System for use during a Partial or Full Call Bell System Downtime was initiated.
- The Temporary Alternative Call Bell System was installed in Unit 3 rooms with a receiver located at the desk.
Environmental Deficiencies in Facility Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in two of its three units during a recertification survey. Observations revealed several environmental deficiencies, including missing or broken floor molding, rusted and scratched heaters, damaged sheetrock with large gouges, and dirty, dusty floor tiles. Additionally, there was a strong odor of urine in the Unit 3 hallway, and residents' wheelchairs were found to be dusty, with ripped armrests and caked-on food. One of the two passenger elevators was out of service, limiting accessibility for residents and staff. Interviews with facility staff revealed that maintenance issues were supposed to be recorded in a maintenance book checked three times daily. However, the Maintenance Director indicated that they had to prioritize repairs and were working with contractors on a renovation plan. The wheelchairs were supposed to be cleaned by nursing staff at night, but no cleaning schedule was provided despite requests. The Administrator confirmed that the facility was undergoing renovations, with the first floor completed and the second floor pending. Staff were expected to update the maintenance book with needed repairs.
Failure to Protect Residents from Abuse Due to Inadequate Interventions
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving Resident #84, who exhibited escalating aggressive behaviors. Despite documented incidents of aggression starting on 9/16/23, including physical attacks on staff and other residents, the facility did not implement effective interventions to manage these behaviors. Resident #84, who was admitted with schizophrenia, bipolar disorder, and other conditions, was noted to have moderate cognitive impairment and a history of physical aggression. The care plans in place included maintaining a daily routine and providing emotional support, but these measures were insufficient to prevent further incidents. On 9/22/23, Resident #84 punched a staff member and another resident, leading to their hospitalization. Upon return, no new interventions were implemented, and the resident continued to exhibit aggressive behaviors, including hitting and scratching other residents. On 10/7/23, Resident #84 attacked multiple residents, causing injuries and necessitating hospitalization for both Resident #84 and one of the victims. The facility's records lacked evidence of interventions to address these aggressive behaviors effectively. Interviews with staff revealed a lack of adequate supervision and documentation of interventions. The Corporate LPN mentioned possible undocumented interventions, while the Director of Nursing acknowledged the need for increased supervision. The Medical Director was unaware of Resident #84's psychiatric history and noted staffing limitations that prevented 1:1 supervision. These deficiencies highlight the facility's failure to protect residents from abuse and implement necessary interventions to manage aggressive behaviors.
Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to report alleged violations of abuse, neglect, or mistreatment involving three residents to the State Agency within the required two-hour timeframe. For Resident #104, there was no documented evidence that an injury of unknown origin, reported by the family as bruises on the resident's hands, was communicated to the state agency. The facility's policy mandates immediate reporting of such incidents, but the necessary Accident and Incident report was not found, and the injury was not reported as required. Resident #45 reported an allegation of staff-to-resident abuse, which was not communicated to the State Agency until three days after the incident. The resident described being pulled by a nurse aide, resulting in bruises, and informed their son, who contacted the police. Despite the initiation of an investigation by the facility, there was no evidence of timely reporting to the state agency, as confirmed by interviews with the current Director of Nursing and the Administrator. For Resident #73, an incident of resident-to-resident abuse was reported late to the State Agency. The resident reported being hit by their roommate, resulting in visible injuries, but the report was not sent to the Department of Health until over five hours after the incident occurred. The Director of Nursing, who was not employed at the time of the incident, acknowledged that the report should have been made within the two-hour timeframe.
Dignity and Respect Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure a dignified experience for three residents during a recertification survey. A Registered Nurse was observed standing over two residents, who required assistance with eating, while feeding them their meals. This action was contrary to the facility's policy and staff interviews, which indicated that staff should be seated and facing residents during mealtime to provide a personal experience. Another resident was observed in the dining room wearing a hospital gown and a sweatshirt without pants, indicating a lack of appropriate clothing. The resident expressed a desire to wear their own clothes but did not have any available. The facility's policy was to provide clothing from a donation box within 24 hours of admission, but there was no record of this being offered to the resident. Staff interviews revealed that the resident had been without proper clothing since admission, and the issue was not addressed promptly. Additionally, a Certified Nurse Aide referred to residents needing assistance with eating as 'feeders,' which was deemed inappropriate by the Director of Nursing. The aide was unaware that such terminology was not allowed, highlighting a lack of awareness and training regarding respectful communication with residents.
Failure to Facilitate Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents had the right to organize and participate in resident groups, specifically the Resident Council meetings. During a Resident Council meeting, several residents reported that it had been months since they last attended a meeting because they were unaware of who should be assisting them. The facility lacked documented Resident Council minutes for several months, from April to July 2024, indicating that meetings were not held regularly during this period. The Administrator and Director of Nursing acknowledged that they were aware of the irregularity in holding Resident Council meetings when they started working at the facility. They confirmed that there was no staff liaison assigned to assist with the meetings, and there was no President of the Resident Council prior to the survey. A meeting was scheduled in August 2024 to introduce the new administration to the Resident Council members, but the absence of regular meetings and proper documentation led to the deficiency.
Deficiencies in Communication and Maintenance at LTC Facility
Penalty
Summary
The facility was found to have significant deficiencies during a recertification survey, primarily due to a lack of communication and documentation between the facility's administration and its governing body. The survey revealed that there was no established process or frequency for the administrator to report to the governing body, and the method of communication was not recorded. This lack of communication led to the governing body being unaware of critical issues, such as the non-functional call bell system on the third floor, which had been out of service since April 2024, and the absence of a plan to address this issue. Additionally, the facility failed to document any Quality Assurance Performance Improvement (QAPI) meetings or actions taken to resolve the call bell system problem. The survey also uncovered that the facility had only one working elevator for over a year, and this issue was not reported to the Department of Health. The QAPI meeting agendas from March and July 2024 did not mention the non-working elevator or call bells. Interviews with the facility's staff, including the Administrator, Director of Maintenance, and Corporate Director of Nursing, revealed a lack of awareness and documentation regarding these issues. The Administrator, who had been in the position for about a month, was unaware of the duration of the elevator problem and whether it had been reported to the Department of Health. Further interviews with the Corporate Administrator and Regional Director of Maintenance indicated that there were informal weekly calls with the facility owner to discuss issues, but no formal documentation of these discussions existed. The Regional Director of Maintenance did not consider the elevator issue as a loss of service since one elevator was operational. Attempts to contact the facility owner were unsuccessful, and the Assistant Chief Operating Officer, who worked closely with the facility operator, was also unaware of the exact timeline of the call bell system failure.
Failure to Address Call Bell System Malfunction
Penalty
Summary
The facility failed to ensure the Quality Assurance Performance Improvement (QAPI) committee developed and implemented an appropriate plan of action to address issues impacting resident safety, specifically regarding the malfunctioning centralized call bell system. Since April 2024, the call bell system had been out of service, leaving residents on the 3rd Floor Unit unable to call for assistance from their rooms or bathrooms. This deficiency also affected family members visiting residents and staff working in shower rooms, as they were unable to summon help when needed. Despite the ongoing issue, there was no documentation of meetings or plans to address the problem until September 2024. The facility was cited for Immediate Jeopardy at F919 due to the lack of an effective plan to ensure resident safety in the absence of a functioning call bell system. Additionally, the facility was cited for having only one working elevator and failing to notify the Department of Health about this ongoing issue. The QAPI meeting agendas from March and July 2024 did not mention the non-working elevator or the call bell system, and there was no evidence of monitoring the interim plan using tap bells for effectiveness and safety. The facility also did not document any input from residents, representatives, or direct care staff, nor did they inform the Governing Body or facility operator about the call bell system issues. Interviews with facility staff revealed that the Corporate Director of Nursing and the Corporate LPN were aware of the call bell issue in April 2024 and had implemented temporary measures such as tap bells and increased rounding. However, they were unsure if these measures were documented or if ongoing education and assessments were conducted. The call bell contractor confirmed that the facility first contacted them in April 2024, but work did not begin until September 2024 due to delays in receiving a deposit. The Corporate Administrator and Assistant Chief Operating Officer were also interviewed, revealing a lack of formal documentation and communication regarding the call bell issue with the facility owner.
Deficiencies in Care Plan Updates and Documentation
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised as required. Resident #31, who was at moderate risk for falls, did not have their care plan updated to reflect current interventions to prevent falls. Despite the resident's fall on 8/27/24, there was no documented evidence that the care plan was updated to address the resident's ability to contact staff while the call light system was not functioning. The facility's call bell system had been malfunctioning since mid-April, and temporary tap bells were provided, but these were not placed in bathrooms, leaving residents without a means to call for help when needed. Resident #88, who was admitted with diagnoses including type II Diabetes Mellitus and absence of leg below the knee, did not have documented evidence of quarterly care plan meetings or updates since 2/27/24. The resident expressed anxiety due to the lack of a Social Worker to assist with housing needs and had not attended a care plan meeting in a long time. The Corporate Social Worker confirmed that the resident should have had two additional care plan meetings, but there was no documentation of these meetings or invitations to the resident or their representative. The facility's failure to update care plans and ensure proper communication and documentation of care plan meetings led to deficiencies in the care provided to these residents. The lack of updated interventions for Resident #31's fall risk and the absence of care plan meetings for Resident #88 highlight the facility's non-compliance with regulatory requirements for comprehensive care planning.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents on all shifts, as revealed during the Recertification and Abbreviated Survey. Residents reported during a Resident Council meeting that the facility was short-staffed, particularly on weekends and various shifts, leading to delayed responses to call bells. Family members also noted the absence of staff during visits, and an analysis of staffing schedules from June to September 2024 showed the facility frequently fell below its minimum staffing levels. The Facility Assessment documentation confirmed that the staffing levels were inadequate for the facility's capacity of 120 residents. Interviews with staff further corroborated the deficiency in staffing. Several Certified Nurse Aides (CNAs) and Licensed Practical Nurses (LPNs) reported working excessive hours, often covering double shifts due to the lack of sufficient staff. The Director of Nursing and the Staffing Coordinator acknowledged the staffing challenges, noting that the facility did not have contracts with outside agencies and faced difficulties retaining staff due to its location. Despite offering bonuses, the facility struggled to maintain adequate staffing levels, leading to burnout among current staff. The deficiency in staffing resulted in residents experiencing delays in receiving care, such as infrequent bed linen changes, limited access to ice, and extended wait times for pain medication. The facility's staffing plan, which aimed for 3-4 CNAs on the day shift, 2-3 on the evening shift, and 1-2 on the night shift, was not consistently met. This inadequacy was highlighted by multiple instances where the actual staffing fell short of these targets, impacting the quality of care provided to residents.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate alleged violations involving abuse, mistreatment, or neglect for a resident with severely impaired cognition and multiple diagnoses, including anxiety disorder and dementia. The resident's family reported observing bruises on the resident's hands on multiple occasions, which led to x-rays being performed. However, there was no documented evidence that the facility initiated an investigation into the injuries of unknown origin, as required by their policy. Additionally, the resident's Skin Integrity Care Plan was not updated to address the bruising, and there was no Abuse/Victim Care Plan in place. Interviews with facility staff, including the Administrator and Director of Nursing, revealed that no Accident and Incident reports were located for the resident, despite the requirement to report and investigate injuries of unknown origin immediately. The Medical Director noted that the resident was combative and had fragile skin, which could lead to bruising during care. However, there was no documented evidence that regular skin assessments were conducted as per physician orders, and the facility failed to communicate with the family about the resident's bruising.
Resident Elopement Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for Resident #102, who had a history of exit-seeking behaviors and was at risk for elopement. Despite being assessed as high risk for elopement and having a wander guard placed on their wrist, Resident #102 frequently removed the device. There was no documented physician order for the wander guard, and the resident's behaviors and safety measures were inconsistently documented by the nursing staff. The resident's care plan included interventions such as 15-minute checks and 1:1 supervision, but these were not consistently implemented or documented. On the night of the incident, Resident #102 eloped from the facility and was found by the police at an address away from the facility. The nursing supervisor had observed the resident in bed during rounds, but later, the Certified Nurse Aide (CNA) on duty heard an alarm and assumed it was the supervisor. The CNA did not check the stairwell due to being the only staff on the unit and did not realize the resident was missing until informed by the supervisor. The facility's alarm system was reportedly faulty, and the resident was not adequately monitored despite their known risk for elopement. Interviews with staff revealed systemic issues, including the lack of a physician's order for the wander guard, inadequate staffing, and failure to follow protocols for monitoring high-risk residents. The Medical Director and Corporate Director of Nursing acknowledged that residents assessed as high risk for elopement should not be placed near exit doors and should have proper safety measures in place. The facility's failure to implement and document appropriate interventions and supervision contributed to the resident's elopement.
Inaccurate Resident Assessment for Vision and Oxygen Use
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment reflective of their status, as evidenced by the case of a resident with chronic obstructive pulmonary disease and neuromuscular dysfunction of the bladder. The resident's 8/8/24 Quarterly Minimum Data Set Assessment inaccurately documented their vision and oxygen use. Despite being cognitively intact, the resident was noted to have highly impaired vision and required continuous oxygen, as per the 5/27/24 Physician Order and the 8/24 Administration Record. However, the assessment incorrectly indicated that the resident could see fine details and did not use oxygen. During an observation on 9/06/24, the resident was found in bed with oxygen administered at 3 liters via nasal cannula, struggling to locate food on their tray and calling for help due to their impaired vision. The Minimum Data Set Coordinator admitted to overlooking the resident's vision impairment and oxygen use in the assessment, despite the administration record showing inconsistent documentation of oxygen use. This oversight led to the inaccurate coding of the resident's assessment, highlighting a deficiency in the facility's assessment process.
Deficiencies in Care Planning for Pressure Ulcer and Psychotropic Drug Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their medical needs. Resident #40, who was admitted with conditions including Parkinson's Disease and Peripheral Vascular Disease, developed a pressure ulcer that was not adequately documented or addressed in their care plan. Despite being readmitted with an unstageable pressure ulcer, there was no evidence in the medical record of a care plan to manage this condition. Observations and interviews revealed that the resident was not being repositioned frequently enough, and the care plan should have been initiated by the Registered Nurse upon the resident's return from the hospital. Resident #19, diagnosed with Type II Diabetes Mellitus, Major Depressive Disorder, and Atrial Fibrillation, was prescribed psychotropic medications but lacked a care plan with interventions to address the use of these medications. The nursing care plan for psychiatric drug use had a goal for maintaining the resident's psychosocial well-being but did not include specific interventions. The Minimum Data Set Coordinator acknowledged the absence of interventions, attributing it to being called away and not completing the plan. These deficiencies highlight a lack of comprehensive care planning for residents with specific medical needs.
Failure to Implement Pressure Ulcer Care Recommendations
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as required by professional standards of practice. Resident #401, who was admitted with a diagnosis of pressure ulcer on the left heel, did not receive consistent documentation of treatments and weekly skin checks as per the physician's order and care plan. The physician's order for Santyl application to the left foot wound was not documented on several occasions, and there was no evidence of follow-up on the wound care team's recommendations for heel booties and an air mattress. Observations revealed that Resident #401 was not consistently using heel booties or an air mattress, as recommended by the wound care team. The resident was seen with an air heel lift boot, which was not ordered by a physician, and the boot was often not secured properly, leading to inadequate offloading of pressure from the heel. Interviews with staff, including a physical therapist and a licensed practical nurse, confirmed that the recommendations for offloading and the use of an air mattress were not implemented, and there was a lack of awareness and follow-up on the wound care team's notes. The deficiency was further highlighted by the lack of communication and documentation within the facility. The wound care team's recommendations were not entered into the electronic medical record in a timely manner, leading to a delay in implementing necessary interventions. Staff interviews indicated a lack of clarity on who was responsible for updating care plans and ensuring that physician orders were followed, contributing to the failure to provide adequate care for Resident #401's pressure ulcer.
Failure to Provide Adequate Nutrition and Hydration Care
Penalty
Summary
The facility failed to ensure proper nutrition and hydration care for a resident with a significant weight loss of 9.79% over six months. The resident, who was admitted with conditions such as Chronic Obstructive Pulmonary Disease and Adult Failure to Thrive, had a care plan that required meal intake monitoring and assistance due to impaired vision. However, the facility did not consistently monitor the resident's meal intake as per the care plan, and the resident was not reassessed to determine the necessary level of assistance during meals. Observations revealed that the resident often did not consume food on multiple days, and there were instances where the resident was left unattended during meals, leading to inadequate nutrition intake. Interviews with staff, including a Registered Dietician, Occupational Therapist, and Certified Nurse Assistants, highlighted a lack of communication and documentation regarding the resident's needs and meal consumption. The staff were unaware of the resident's visual impairment, which affected their ability to feed themselves. The Occupational Therapist acknowledged the resident's vision problems and suggested methods like the clock method or divided plate, but these recommendations were not documented or communicated effectively to the nursing staff. The lack of consistent assistance and monitoring contributed to the resident's continued weight loss and inadequate nutrition management.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hyde Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Renaissance Rehabilitation And Nursing Care Center | 4.4 mi | ★★★★★ | 12 | 0 |
| Lutheran Center At Poughkeepsie Inc | 6 mi | ★★★★★ | 5 | 0 |
| The Grand Rehabilitation And Nrsg At River Valley | 7.2 mi | ★★★★★ | 12 | 0 |
| The Pines At Poughkeepsie Ctr For Nursing & Rehab | 7.7 mi | ★★★★★ | 0 | 0 |
| Hudson Valley Rehabilitation & Extended Care Ctr | 8.7 mi | ★★★★★ | 37 | 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 August 2026) and official state health department websites.