Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Grand Rehabilitation And Nursing At Barnwell during CMS and state inspections, most recent first.
Food and drink were not served at palatable, appetizing temperatures on two observed meal trays. A resident’s breakfast tray included cold eggs, cold oatmeal, and milk below the facility’s stated standard, with coffee missing, and a second resident’s lunch tray had pudding and multiple hot items below required temperatures. Staff also reported resident complaints that food was cold, tough, or did not taste good, and the FSD acknowledged the temperature range was not sufficient.
A facility failed to maintain a safe, clean, comfortable, and homelike environment on Unit 3. A resident’s room had an unpainted patched wall, scratched sheetrock, and chipped paint on the bathroom door, while the Unit 3 dining room ice machine was broken and the catch basin was dirty. Staff said the room damage was not homelike and that the ice machine had been out of service for months, requiring residents to use a thermal container of ice or go to another floor for ice.
Incomplete investigation of suspicious facial bruising: A resident with dementia, aphasia, and total dependence on staff was found with extensive bruising to one side of the face after being transferred to bed by staff. The incident report was incomplete, a witness statement was missing, and staff accounts conflicted about who assisted with the transfer and whether the injury was present earlier. The DON concluded the resident struck the lift bar and ruled out neglect within two hours, despite the unclear circumstances.
A resident with schizophrenia, bilateral BKA, and a history of substance abuse was discharged without documented confirmation of a safe receiving placement, without prior notification to the county DSS, and without records showing transport details, discharge instructions, medication reconciliation, a physician discharge order, or a post-discharge summary. Social work had pursued multiple housing options after a prior supportive living facility refused readmission and an ALF referral was declined, but the chart still lacked documentation of where the resident actually went and what discharge services were arranged.
A resident who needed help with bathing and grooming missed a scheduled shower and was not shaved despite visible facial hair and stated preference to have it removed. Another resident who was dependent on 1:1 feeding was left with a meal tray while staff passed other trays, and on another occasion the resident refused to open their mouth; meal intake was not documented for multiple shifts and staff did not consistently notify the nurse.
A resident with dementia, impaired mobility, and muscle weakness had an unwitnessed fall that was not immediately reported by a CNA or assessed right away by a qualified staff member. The fall was later learned about when the resident told the spouse, and the resident had bruising to the left chest/abdomen area. The MD ordered a chest/rib x-ray to rule out fracture, but there was no documentation that the imaging was completed before the order was discontinued.
The facility failed to ensure that narcotics were consistently counted by two licensed staff members at shift changes, resulting in missing Oxycontin tablets for a resident with chronic pain. Documentation on controlled medication records and medication administration records was inconsistent, and narcotic count signature sheets across multiple units lacked required signatures from both oncoming and outgoing nurses. Staff interviews confirmed that required procedures for narcotic counts were not followed, leading to unaccounted controlled substances and incomplete records.
Surveyors found that multiple residents experienced significant medication errors involving controlled substances, including inconsistent documentation between the controlled medication record and eMAR, administration of medications at incorrect times or without proper physician orders, and failures to follow required procedures for witnessing and documenting wastage. These errors involved medications such as Clonazepam, Tramadol, Alprazolam, and Oxycodone, and were confirmed through record review and staff interviews.
Surveyors found widespread housekeeping and maintenance failures, including sticky and soiled floors, trash in corridors, soiled and stained linens, cluttered resident rooms, damaged fixtures, and evidence of mold. A resident reported that their bed linens were not changed for a week, and soiled items were left in their room, contributing to unsanitary and uncomfortable conditions.
Multiple residents and staff reported that inadequate staffing levels led to long wait times for call bells to be answered, delays in receiving care, and missed showers or baths. Staff described frequent short-staffing, increased workloads, and the need to assist with tasks outside their usual roles, while the DON acknowledged ongoing staffing challenges. These issues resulted in residents not consistently receiving timely care and attention.
Nursing staff lacked documented annual education and competencies to care for residents with mental and behavioral health needs, despite a significant population with psychiatric and mood disorders. Staff interviews confirmed the absence of training and challenges in managing residents with difficult behaviors, and the facility's process for staff education on these needs was not implemented.
Surveyors found that multiple residents consistently received meals that were cold, unappetizing, and sometimes undercooked or overcooked. Food temperatures were frequently outside required ranges, and both residents and staff reported ongoing issues with tray delivery delays, lack of insulated carts, and poor food quality. Despite repeated complaints and awareness among staff and management, no effective measures had been taken to ensure meals were served at safe and appetizing temperatures.
Multiple incidents of resident-to-resident physical abuse occurred, involving residents with cognitive and behavioral health diagnoses. Aggressive behaviors, such as entering others' rooms, physical altercations, and wandering, were documented but not consistently managed with one-to-one monitoring or updated care plans. Injuries resulted from these altercations, and staff interviews revealed challenges in supervision and care planning due to staffing limitations and incomplete behavioral histories at admission.
Several residents did not have comprehensive, person-centered care plans developed or updated to address their medical, nursing, and psychosocial needs, including missing or incomplete interventions for elopement risk, new wounds, infection management, pressure ulcers, BiPAP therapy, major depressive disorder, and psychosocial adjustment. These deficiencies were identified through record review and staff interviews, revealing a lack of timely and accurate care planning for residents with significant needs.
Surveyors found that several residents did not have their oxygen tubing labeled or dated as required, and some did not receive oxygen as ordered by their physician. Additionally, BiPAP equipment for two residents was not properly cleaned or maintained, and refusals of BiPAP therapy were not consistently documented or reported. Staff interviews confirmed that these actions did not follow facility policy or professional standards.
Surveyors found that medications scheduled for administration at a specific time were given late to three residents, with one medication not available at the scheduled time. An LPN reported being unable to administer all medications on time due to working alone, and management was aware of the staffing issue. This resulted in a medication error rate significantly above the regulatory limit.
Surveyors observed that the facility's exterior areas were not properly maintained, with crumbling retaining walls, overgrown vegetation, a damaged wooden fence, deteriorating brickwork, water-stained stucco, and littered grounds. These deficiencies resulted in an environment that was not safe, functional, sanitary, or comfortable for residents, staff, and the public.
Surveyors found that several residents were not treated with dignity or respect, as evidenced by reports of rude and unresponsive aides, insufficient staff to assist with transfers and bathing, and a resident being left uncleaned and transported through public areas in a soiled state. Staff interviews confirmed low staffing levels and lack of attention to residents' needs, resulting in compromised quality of life and failure to uphold residents' rights.
A resident alleged inappropriate touching by a physical therapist during a therapy session, which was reported internally but not to the State Survey Agency within the required two-hour window. Facility staff determined the allegation was unfounded and did not report it externally, contrary to regulatory requirements for immediate reporting of all abuse allegations.
A resident with Parkinson's Disease and mild cognitive impairment reported being physically abused by a nurse, but the facility failed to conduct a thorough investigation as required by policy. The investigation lacked interviews with the resident, staff, or witnesses, did not establish a clear timeline, and was closed based only on staffing records and an administrator's statement. Key staff were unaware of the incident, and the resident's care plan was not updated.
A resident with multiple chronic conditions who required a two-person mechanical lift was not consistently assisted out of bed or offered showers, receiving only infrequent bed baths. Staff and the resident reported that insufficient CNA staffing prevented regular transfers and bathing, and the resident's preferred chair was unavailable. The care plan interventions to maintain ADL function were not consistently followed, resulting in unmet care needs.
Surveyors found that three residents were not adequately protected from accident hazards or provided with sufficient supervision. One resident's room door was repeatedly stuck, two residents with cognitive and behavioral impairments eloped from the facility on multiple occasions without proper interventions or care plan updates, and another resident exited the building unnoticed despite being on safety checks, resulting in injury. Staff did not consistently follow facility policies or respond to alarms, and documentation and investigation of these incidents were lacking.
A resident with chronic pain conditions did not receive their scheduled Oxycodone dose on time due to a lack of timely communication between an LPN and an RN Supervisor. The resident, who was in significant pain, informed the LPN about the medication shortage, but the issue was not addressed promptly. The RN Supervisor later obtained the medication from the emergency kit after pharmacy authorization, resulting in a delay of over three hours.
A resident at high risk for falls experienced multiple falls, including one resulting in a cervical fracture, due to the facility's failure to implement and document necessary interventions. Despite being identified as high risk, the resident's care plan was not updated with preventive measures after each fall, as confirmed by interviews with nursing staff.
The facility failed to maintain resident dignity by serving meals with disposable utensils, affecting several residents with cognitive impairments and medical conditions. Staff interviews revealed a lack of awareness and coordination regarding the use of plastic utensils, with the Director of Food Service citing a shortage of real utensils and the DON unaware of the issue.
The facility failed to develop comprehensive care plans for three residents, including one with oxygen therapy needs, another with PTSD, and a third with depression. Despite documented medical conditions, the facility did not implement person-centered care plans, as confirmed by staff interviews and record reviews.
The facility failed to update comprehensive care plans for three residents, leading to unaddressed fall risks, lack of resident involvement in care planning, and outdated interventions for a discontinued feeding tube. Despite multiple falls and a serious injury, a resident's care plan was not revised. Another resident was not included in care planning, and a third resident's care plan was not updated after enteral feeding was stopped.
The facility failed to ensure proper documentation and reconciliation of controlled substances on two units. Staff did not consistently sign shift-to-shift forms for narcotic counts, and LPNs did not sign out medications when removed or immediately after administration. Discrepancies in medication counts were observed, including a mismatch in Lacosamide tablet counts and an unaccounted Fentanyl patch. The DON confirmed expectations for documentation and monitoring, despite annual competencies.
The facility failed to ensure proper labeling and storage of medications, with issues such as unlabeled open medications, unsecured controlled substances, and pre-poured medications found across multiple floors. LPNs were unaware of guidelines for expiration dates, and the DON confirmed that staff should adhere to policies for medication administration.
The facility failed to provide palatable and appropriately tempered meals to residents, with observations revealing cold and unappealing food served with plastic cutlery due to a shortage of real utensils. Residents expressed dissatisfaction, and staff interviews highlighted issues with meal delivery delays and lack of awareness about cutlery use.
The facility failed to cool ground chicken safely in the main kitchen, with the chicken found at 52°F instead of the required 41°F within the specified time. Additionally, the Unit #1 kitchenette was unclean, indicating non-compliance with food safety standards.
The facility did not ensure proper labeling of food brought in by family or visitors for residents, as well as personal food, in the kitchenette refrigerators on three resident units. Items such as deli sandwiches, lactose-free milk, and orange tonic were not labeled with the resident's name, room number, and date, despite a posted policy requiring such labeling.
A resident was found with medication at their bedside without an assessment to determine their ability to self-administer safely. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which was not conducted. An LPN admitted to leaving the medication unattended, and the DON confirmed no residents were cleared for self-administration.
A resident with a PEG tube did not receive appropriate care after tube feedings were discontinued. Despite staff awareness that the tube should be flushed and skin care provided daily, there were no orders or care plans in place for maintenance. Interviews with staff, including an LPN, RN, and DON, confirmed the lack of orders and care plans for the resident's PEG tube.
A resident with severe malnutrition and other conditions did not receive total parenteral nutrition (TPN) as ordered by their physician. The TPN was not started on time and was not taken down as scheduled, leading to a deficiency finding. Staff interviews revealed inconsistencies in documentation and recollection of events, and the resident was eventually sent to the hospital due to a decline in condition.
The facility failed to provide appropriate respiratory care for two residents. One resident, with chronic conditions, was not provided continuous oxygen therapy as ordered, and their care plan lacked documentation for oxygen and BiPAP use. Another resident received oxygen without a physician's order for several days, contrary to facility policy. Staff interviews revealed communication and documentation issues regarding oxygen therapy orders.
A resident with chronic conditions requiring dialysis did not receive consistent monitoring and documentation of their dialysis treatments. The facility failed to complete the required dialysis communications log, missing vital signs and other critical information. Staff interviews confirmed the expectation for complete documentation, which was not met.
A resident with a history of depression was not assessed by a Social Worker upon admission or readmission, contrary to facility policy. The resident, on antidepressant medication, lacked a person-centered care plan for their depression until expressing suicidal ideation, leading to an emergency room transfer. Staff interviews confirmed the absence of a required social service assessment.
Two residents with severe cognitive impairments were left unsupervised, leading to inappropriate sexual behavior. A CNA observed them together but left the room without redirecting one resident. Previous similar behavior was reported but not addressed. Staff lacked training and documentation was insufficient, resulting in immediate jeopardy and substandard care.
A facility failed to ensure residents were treated with respect and dignity, as evidenced by a CNA's verbal abuse towards a resident with severe cognitive impairment. Multiple witnesses reported the aide's inappropriate behavior, including yelling and cursing. Additionally, another resident felt scared after overhearing a loud altercation between the same CNA and an LPN. The facility's investigation revealed a history of similar issues with the aide, contributing to the deficiency.
A resident with cognitive impairment was verbally abused by a CNA, and the incident was not reported to the administrator or state authorities within the required two-hour timeframe. The abuse was overheard by another resident and reported four days later, leading to a deficiency citation for the facility.
Food Served Below Required Temperatures
Penalty
Summary
The facility failed to ensure residents were provided food and drink that were palatable, flavorful, and at an appetizing temperature for two test trays observed during breakfast and lunch meal service. During the breakfast observation, Resident #154’s tray was tested and replaced, and the food temperatures were below the facility’s stated standards: eggs were 106.9 degrees Fahrenheit, breakfast sausage was 114.6 degrees Fahrenheit, milk was 48.2 degrees Fahrenheit, and cinnamon oatmeal was 97 degrees Fahrenheit. The eggs and oatmeal were described as cold, and the oatmeal was also described as pasty. The tray was served on paper plates, and coffee was missing from the tray. During the lunch observation, Resident #51’s tray was tested in the presence of a CNA and replaced, and several items were again below the facility’s required temperatures: super pudding was 66.7 degrees Fahrenheit, brown sugar glazed ham was 112.3 degrees Fahrenheit, candied yams were 132.4 degrees Fahrenheit, and green beans were 122.4 degrees Fahrenheit. All food was served on paper plates. Interviews with staff documented ongoing resident complaints that food did not taste good, was tough, or was cold, and the Food Service Director stated the temperature range of food items was not sufficient and that hot foods should have been at least 135 degrees Fahrenheit.
Unrepaired Room Damage and Nonworking Ice Machine
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment on Unit 3 and in the Unit 3 dining room. In room [ROOM NUMBER], surveyors observed an unpainted patched wall, another wall with several long areas of scratched sheetrock, and a bathroom door with chipped and missing paint. The facility’s policy required residents to be provided with a safe, clean, comfortable, and homelike environment, and maintenance records showed prior audits identifying the room’s doors, door jambs, windows, and walls as unsatisfactory and needing painting or cleaning. The maintenance log from 12/11/2025 to 05/18/2026 did not document repairs to the walls or doors in room [ROOM NUMBER], and there were no comments on pending repairs. During interviews, nursing and maintenance staff stated that damaged walls and chipped paint were not homelike and that work orders were used to notify maintenance of needed repairs. Staff also stated the room was occupied by a resident on contact precautions who was isolated to the room, and the room was observed with the surveyor while the damaged surfaces remained visible. In the Unit 3 main dining room, the ice machine did not dispense ice during multiple observations, and the drain rack was covered with white and brown debris. Staff interviews indicated the ice machine had been broken for months, with residents routinely relying on a thermal container of ice filled by staff or by going to another floor for ice. A CNA, unit manager, unit secretary, maintenance director, and residents all described the ongoing lack of a working ice machine and the repeated need to obtain ice elsewhere for resident use.
Incomplete investigation of suspicious facial bruising
Penalty
Summary
The facility failed to ensure that an alleged incident involving suspicious bruising to a resident was thoroughly investigated to rule out abuse. Resident #46 had dementia, aphasia, and a seizure disorder, with severely impaired cognition and total dependence on staff for activities of daily living. The care plan identified the resident as at risk for abuse because of the inability to understand surroundings related to cognitive impairment, and the resident required a mechanical lift with assistance of two staff for transfers. On 05/09/2026, Resident #46 was later found with a large dark purple discoloration on the left side of the face. A consultant note documented extensive facial ecchymosis of unclear etiology, with nursing uncertain whether the resident had an unwitnessed fall and the resident unable to provide a history. The incident report completed by the DON documented the facial discoloration, but the report was incomplete, with sections left blank including level of consciousness, mobility, and injury type. The report also lacked a witness statement from one of the staff assigned to the unit that evening. Witness statements were inconsistent regarding who assisted with the resident’s transfer to bed and whether anyone observed an injury before the resident was found bruised. One CNA stated they helped with care and left the resident safe in bed, another CNA stated they did not assist with the resident’s care after about 8:00 PM, and an LPN stated they administered medications around 9:00 PM and did not notice a bruise because the resident’s face was turned away. The DON stated the facility concluded the resident hit their head on the bar of the mechanical lift during transfer, even though the statements did not consistently identify who assisted with the transfer. The DON also stated neglect was ruled out within two hours and therefore the event did not meet reporting requirements to the Department of Health.
Unsafe discharge without confirmed receiving placement or discharge documentation
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for one resident who had schizophrenia, bilateral below-knee amputations, and a history of psychoactive substance abuse. At admission, the resident was cognitively intact but had disorganized thinking and depression symptoms, required assistance with multiple activities of daily living, was on a therapeutic diet, and was receiving OT, PT, and medications including an antipsychotic. The care plan identified the resident’s placement as short-term with a plan to reside with Unity House upon discharge, and discharge planning was to involve the resident and/or representative. During the stay, social work documented that a supportive living facility previously used by the resident refused to take the resident back unless specific conditions were met because the resident had caused damage and police had been contacted. Additional assisted living referrals were sent, but one referral was declined because the resident was not age appropriate. The resident was later documented as medically stable and independent, and the facility issued a 30-day discharge notice listing the county Department of Social Services as the discharge destination and notifying the Ombudsman. The social worker documented that discharge planning was finalized and that the resident was to be discharged to the County Department of Social Services via medical transport, with a PCP follow-up appointment scheduled. At discharge, there was no documentation showing where the resident was actually discharged to, how the resident was transported, or whether discharge instructions or medication reconciliation information were provided. There was no physician order to discharge the resident, no documented post-discharge summary describing where the resident planned to reside or what follow-up care and services were arranged, and no medical provider discharge summary with a recapitulation of the resident’s stay. The facility later stated that it had tried to find suitable housing, that the resident was homeless, and that the resident was sent to the county Department of Social Services with a discharge packet, but the record did not show that the county Department of Social Services was notified before the resident was sent there.
Missed ADL Assistance for Bathing, Grooming, and Feeding
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the assistance needed for bathing, grooming, hygiene, and feeding. Based on observations, record review, and interviews, two residents were identified as affected: one resident with dementia and schizophrenia who required substantial to maximum assistance with bathing and partial to moderate assistance with personal hygiene, and another resident with dementia, protein calorie malnutrition, and seizure disorder who was dependent on feeding and required 1:1 meal assistance. For the resident with dementia and schizophrenia, the care plan and Kardex indicated the resident required substantial to maximum assistance for showering and bathing, with a shower scheduled on Tuesday during the day shift. During observation, the resident had greasy hair and long white hairs on the chin and upper lip, and stated they did not like the hair on their face and wanted it removed. The May 2026 CNA task record documented the resident did not receive the scheduled shower. Interviews showed the CNA responsible for showers did not complete the shower because of time constraints, did not tell the next shift the shower was missed, and intended to do it later but did not. Staff also stated they were not aware the resident wanted to be shaved, although shaving was part of personal skin care and cleanliness and the resident had facial hair visible during observations. For the resident dependent on feeding, the care plan and Kardex documented 1:1 feeding assistance. During one observation, the resident was in bed while being fed by their significant other. During a later constant observation, a CNA brought the breakfast tray into the room, prepared it, told the resident they would return to feed them, and then left the tray while passing trays to other residents; the CNA did not return to feed the resident, and another CNA later removed the untouched tray. On another day, a CNA entered the room with the breakfast tray and later left with the tray untouched, stating the resident refused to open their mouth. Interviews showed staff expected the resident to be fed when the tray arrived, to be reapproached if refusing, and to have the nurse notified, but documentation of meal intake was missing for multiple shifts and staff acknowledged they could not determine how much the resident ate on several days.
Fall Not Immediately Reported and Ordered X-Ray Not Completed
Penalty
Summary
The facility failed to ensure Resident #56 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices. Resident #56 had diagnoses including dementia, difficulty walking or moving around, and muscle weakness. The resident’s care plan identified a fall risk related to abnormalities of gait and mobility, and the resident required supervision with bed mobility and transfers. The resident had an unwitnessed fall while in bed, and the fall was not immediately reported by Certified Nurse Aide #43 or documented as having been assessed right away by a qualified individual. The fall was later reported when the resident’s spouse contacted the unit after the resident told them about the fall. The incident report documented bruising to the left rib cage/abdomen area, and the physician noted the resident had struck the chest and had three bruises to the left lower chest. The physician ordered a bilateral ribs/chest x-ray to rule out fracture and Tylenol for pain. However, there was no documented evidence that the x-ray was completed or that the diagnostic testing was no longer needed, and the order was discontinued and removed from the record. Interviews showed staff did not recall being notified of the fall at the time it occurred, and the CNA later stated they helped the resident back into bed but forgot to report the fall because the night was busy. The RN unit manager stated CNAs were expected to report falls immediately, and the physician stated they relied on nursing to ensure orders were completed and results reviewed. The assistant director of nursing stated the fall was only initiated after the spouse reported it the next day and that the CNA had witnessed the fall but did not report it to a nurse.
Failure to Maintain Accurate Narcotic Counts and Documentation
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt, disposition, and reconciliation of controlled drugs, specifically narcotics, as required by policy and regulation. On one unit, narcotics were not counted by two licensed staff members at the end of a shift, resulting in the discovery that twenty Oxycontin extended-release 10 mg tablets prescribed for a resident were missing. Documentation revealed that the required dual-nurse narcotic count was not performed, and the controlled medication record did not align with the medication administration record, indicating inconsistencies in documentation and administration practices. The resident involved had diagnoses including fibromyalgia, chronic pain syndrome, and anxiety disorder, and was cognitively intact according to the Minimum Data Set. The resident's medication order for Oxycontin was not properly accounted for, with the last documented administration showing 20 pills remaining, but the next shift discovering the entire blister pack missing. Interviews with nursing staff revealed that narcotic counts were either not performed together as required or were not performed at all, with some staff admitting to taking each other's word rather than conducting the count in person. Signature sheets for narcotic counts across multiple units were inconsistently completed, with missing signatures from both oncoming and outgoing nurses on several shifts. Further review and interviews indicated that this was not an isolated incident, as narcotic count signature sheets on all six nursing units showed similar deficiencies in documentation. Some staff reported receiving education on proper narcotic handling and documentation, while others did not recall such training. Despite the facility's policy requiring dual-nurse counts and immediate reporting of discrepancies, these procedures were not consistently followed, leading to unaccounted controlled substances and incomplete records.
Significant Medication Errors in Controlled Substance Administration and Documentation
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically regarding the administration and documentation of controlled substances for seven residents. The facility's own Controlled Substance/Narcotic Management Protocol required accurate prescribing, administration, storage, destruction, and documentation of all controlled substances, including dual documentation in both the controlled substance logbook and the electronic medication administration record (eMAR). However, multiple instances were found where the documentation on the controlled medication record was inconsistent with the eMAR, and medications were administered at incorrect times or without proper physician orders. For example, one resident with anxiety and depression received Clonazepam at the wrong time of day on several occasions, with the medication being administered in the morning instead of at bedtime as ordered. The medication was signed out on the narcotic sheet but not properly documented in the eMAR, and the nurse responsible did not have a physician order for those administrations. Another resident with schizophrenia and anxiety received Clonazepam and Tramadol with similar inconsistencies, including doses given outside the prescribed schedule, undocumented administrations, and lack of required witness signatures for wasted medications. In some cases, medications were administered when there was no active physician order, and the records between the controlled substance log and the eMAR did not match. Additional deficiencies were noted with the administration of Oxycodone for pain management, where doses were given and documented on the controlled medication record but not reflected in the eMAR, and vice versa. There were also instances where a resident was told they had received medication when they had not, according to their own account and therapy schedule. Interviews with nursing staff and administration confirmed awareness of these discrepancies, and staff described the required procedures for documentation and witnessing of controlled substance administration and wastage, which were not consistently followed in practice.
Failure to Maintain Clean and Homelike Environment Across All Resident Units
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and comfortable environment across all six resident units. Specific findings included sticky floors in multiple corridors and resident rooms, trash left in corridors, soiled bathroom toilets and floors, littered bathroom floors with used toilet paper, improperly patched wallpaper, warped baseboards, and stained privacy curtains. In one resident room, the soap dispenser was found ripped off the wall and lying on the floor. Additionally, the surface of a wall near the west stairwell was crumbling and soiled with a black mold-like substance, and a moldy odor was detected on one unit. The floors where door frames met the floor were also soiled in several units. In one resident's room, surveyors found a top bed sheet with dried blood stains, a bottom sheet with a large visible stain that was partially covered, and a soiled brief draped over the waste receptacle. The bed table and nightstand were cluttered with empty and unopened beverage bottles, and the room floor was sticky. The resident reported that the bottom sheet had not been changed all week and was covered with a folded blanket by staff. These observations and resident interviews demonstrate a lack of effective housekeeping and maintenance services, resulting in unsanitary and uncomfortable living conditions.
Insufficient Nursing Staff Resulting in Delays and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from both residents and staff regarding inadequate staffing levels. The facility assessment outlined required staffing numbers for each shift, but interviews revealed that actual staffing often fell below these levels, particularly on certain units and during specific shifts such as evenings, nights, and weekends. Residents consistently reported long wait times for call bells to be answered, delays in receiving care, and instances where staff would turn off call lights without providing the requested assistance. Some residents indicated that they were unable to get out of bed or receive full showers or baths due to the lack of available staff. Staff interviews corroborated these concerns, with certified nurse aides and nurses describing frequent short-staffing, increased workloads, and the inability to provide extra attention to residents who required it. Staff reported that, at times, only two aides were available to care for up to 40 residents on a unit, including several residents who required two-person assistance and mechanical lifts. Nursing staff also reported that short-staffing led to delays in medication administration and required them to assist with direct care tasks outside their usual responsibilities, sometimes resulting in staying late to complete their work. The Director of Nursing acknowledged ongoing staffing challenges, particularly on the most demanding units, and confirmed that staffing was reviewed daily and incentives were being used to attract additional staff. Despite these efforts, both staff and residents reported that insufficient staffing persisted, leading to delays in care and unmet needs. The deficiency was cited under 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) for failing to ensure adequate nursing staff to assure resident safety and well-being.
Lack of Staff Competency in Mental and Behavioral Health Care
Penalty
Summary
Nursing staff, including licensed nurses and Certified Nurse Aides, did not possess the necessary competencies and skills to care for residents with mental and behavioral health needs. The facility assessment documented a significant population of residents with psychiatric and mood disorders, including anxiety, bipolar disorder, depression, schizophrenia, schizoaffective disorder, borderline personality disorder, traumatic brain injury, and psychosis. Despite this, there was no documented evidence of annual educational competencies or training for staff regarding the care of residents with mental health or behavioral needs. The facility's process for assessing and addressing the needs of residents with such conditions included referral to the Nursing Educator for staff education, but this was not implemented in practice. Interviews with staff confirmed the lack of training and education on mental and behavioral health care. A Certified Nurse Aide reported insufficient staffing to monitor and provide care for residents with difficult behaviors. The Director of Social Work acknowledged the challenge of managing a large population of residents with behavioral and mental health issues, making care planning and supervision difficult. The Administrator noted the high number of residents with mental health diagnoses and the need for staff education in de-escalation and behavior management, which had not been provided. The Nurse Educator confirmed that no orientation or annual education on mental or behavioral health needs was in place.
Failure to Provide Palatable and Safe Temperature Meals
Penalty
Summary
Surveyors identified that the facility failed to provide food and drink that was palatable, attractive, and at safe and appetizing temperatures for all residents reviewed. Multiple residents and their family members reported that meals were frequently served cold, unappetizing, and sometimes appeared undercooked or overcooked. During a resident council meeting, residents described food as cold, hard, and uncooked, and noted that staff did not always reheat food when requested. There were also complaints about inconsistencies between the meal ticket and what was actually received on the tray. Direct observations and tray testing confirmed that food temperatures were often outside the required ranges, with hot foods below 135°F and cold foods above 41°F. For example, one resident's lunch tray included a beef taco at 114.1°F, vegetables at 108°F, and jello at 56.5°F, with the ice cream already liquefied. Another test tray showed beef tacos at 112.6°F and 113.5°F, peas and carrots at 103.1°F, and several cold items such as yogurt, cottage cheese, and salad dressing well above the safe cold temperature threshold. Staff interviews corroborated these findings, with several CNAs and LPNs stating that food was often cold by the time it reached residents, and that delays in tray delivery were common due to slow elevators and staffing issues. Residents with various medical conditions, including chronic obstructive pulmonary disease, congestive heart failure, diabetes, end stage renal disease, and cognitive impairments, were affected by these deficiencies. Some residents reported that they often ate cold food rather than wait for a replacement, while others relied on family members to bring in outside food. Staff and management acknowledged ongoing complaints about food temperature and quality, citing issues with open carts, lack of insulated delivery systems, and logistical challenges in distributing trays promptly. Despite awareness of these problems, no effective changes had been implemented to ensure meals were consistently served at safe and appetizing temperatures.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents of resident-to-resident physical altercations involving four residents. One resident with diagnoses including schizophrenia, traumatic brain injury, and epilepsy exhibited repeated aggressive behaviors, including entering other residents' rooms, physical altercations, and wandering. Despite documentation of these behaviors in nursing progress notes and care plans, the resident was not consistently placed on one-to-one monitoring at the time of the incidents, and interventions were not sufficiently updated to address the ongoing risk. Several specific incidents were documented: one resident was injured after being struck in the face by another resident who entered their room, resulting in lacerations that required emergency medical care. Another incident involved a resident being punched in the face while an item was taken from their walker, causing injury. Additional altercations included a resident being punched after attempting to prevent another from entering their room, and a forceful push that resulted in two residents falling to the floor. These events occurred despite existing care plans that identified behavioral symptoms and interventions such as medication management, safety checks, and environmental modifications. The facility's policies required immediate action to stop abuse and prompt reporting, as well as comprehensive care planning for residents at risk. However, there was no documented evidence of a care plan specifically addressing risk for abuse for at least one resident before or after a significant incident. Staff interviews indicated challenges in providing adequate supervision due to staffing issues and a high population of residents with behavioral health needs. The facility also faced difficulties in discharging residents to more appropriate settings, and there were gaps in communication regarding residents' behavioral histories upon admission.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulation. In multiple cases, care plans were either missing, incomplete, or not updated to reflect changes in residents' conditions. For example, one resident at high risk for elopement did not have their electronic monitoring device checks reinstated or documented after returning from a hospital stay, despite a continued high risk assessment. The care plan was not revised to address this change, and there was no evidence of ongoing monitoring as previously required. Another resident developed a new open area on the coccyx, but the care plan was not updated to document this wound or to include specific interventions for its treatment. Although staff provided wound care and interventions such as turning, positioning, and topical treatments, these actions were not reflected in the resident's care plan. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the care plan should have been updated to address the new wound, but this was not done. Additional deficiencies included a resident with an infection on intravenous antibiotics whose care plan did not include any interventions, and a resident with a stage III pressure ulcer whose care plan was delayed and incorrectly documented the ulcer as stage II. Other residents lacked care plans for significant issues such as BiPAP therapy, major depressive disorder, and adjustment to the facility following admission with complex psychosocial needs. These omissions were identified through record review and staff interviews, demonstrating a pattern of incomplete or missing care plans for residents with identified needs.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received services in accordance with professional standards of practice. Surveyors observed that for several residents receiving supplemental oxygen, the oxygen tubing was not labeled or dated to indicate when it had last been changed, despite facility policy and physician orders requiring weekly changes and labeling. This was noted repeatedly for multiple residents during different observations, and staff interviews confirmed that labeling was expected but not consistently performed. In addition, one resident did not receive supplemental oxygen as ordered by the physician, with discrepancies noted between the prescribed oxygen flow rate and the amount actually being delivered. Documentation was also incomplete, with missing records for oxygen administration on certain shifts. Staff interviews acknowledged that the delivery of oxygen must match physician orders and that documentation lapses could indicate missed care. Furthermore, the facility did not ensure that BiPAP equipment used by two residents was appropriately cleaned and maintained to prevent respiratory infections. There were no documented interventions or orders for cleaning and maintenance of the BiPAP equipment until after surveyor observations, and refusals of BiPAP therapy by a resident were not consistently documented or communicated to the physician. Staff interviews confirmed that cleaning protocols and documentation were required but not followed as per facility policy.
Medication Error Rate Exceeds Regulatory Threshold Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5%, as required by policy and regulation. During a recertification survey, observations, record reviews, and interviews revealed that three out of four residents observed during a medication pass experienced medication administration errors, resulting in an error rate of 59.26%. Specifically, medications scheduled for administration at 9:00 AM were instead given between 10:23 AM and 10:55 AM. In one instance, a prescribed medication was not available for administration at the scheduled time. The facility's policy required medications to be administered within one hour of the prescribed time unless otherwise specified. The residents involved had various medical conditions, including epilepsy, chronic obstructive pulmonary disease, hypertension, orthopedic aftercare, anemia, atherosclerosis, schizoaffective disorder, and chronic pain syndrome. The LPN responsible for administering the medications acknowledged being aware that the medications were late but stated that it was not possible to pass all medications on time while working alone on the unit. The LPN also indicated that management staff were aware of the need for additional help. These findings were based on direct observation and interviews conducted by surveyors.
Failure to Maintain Safe and Sanitary Facility Grounds
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed multiple deficiencies in the exterior areas, including crumbling blocks in the retaining wall on the west end of the property, an overgrown propane tank area with a wooden fence in disrepair, crumbling brickwork in the loading dock wall, black water staining on the east exterior wall stucco, and grounds along the west exterior wall that were littered and had a build-up of leaves and overgrown vegetation. These conditions were directly observed during the recertification survey and confirmed through interviews.
Failure to Ensure Resident Dignity and Adequate Assistance Due to Staff Conduct and Insufficient Staffing
Penalty
Summary
Surveyors identified deficiencies in the facility's compliance with resident rights to dignity, respect, and quality of life, as evidenced by observations, record reviews, and interviews with residents and staff. One resident, who was cognitively intact, reported that several certified nurse aides were rude, had 'sharp' tongues, and sometimes ignored requests for help. The resident also stated that after complaining about a nurse's behavior, the nurse was terminated, but other staff continued to display similar negative attitudes and lack of care. Another resident, with chronic medical conditions and requiring a two-person mechanical lift for transfers, reported that due to insufficient staffing, they were rarely able to get out of bed and had not been offered the opportunity to do so for about ten days. The resident also stated that staff no longer asked if they wanted to get out of bed and that showers or tub baths were not provided due to the lack of available staff, resulting in infrequent bed baths instead. Staff interviews confirmed that only two to three aides were available for 40 residents, and that several residents did not get out of bed as a result. A third resident, with Parkinson's disease and mild cognitive impairment, was observed in a lethargic state, drooling, and with food smeared on their face, hands, and clothing while eating in a common area. The resident was not cleaned up after eating and was subsequently transported through public areas in this condition. Staff confirmed that care instructions were available to aides, and the DON stated that all residents should be treated with dignity and respect, but the observed care did not reflect this standard.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that an alleged violation involving abuse was reported to the appropriate authorities within the required timeframe. Specifically, a resident reported to an occupational therapist that a physical therapist had inappropriately touched them during a therapy session. The occupational therapist relayed this allegation to the Director of Physical Therapy, who then informed the Director of Nursing. The Director of Nursing conducted an internal investigation and determined the allegation was unfounded, documenting that no abuse had occurred within the two-hour reporting window. However, the facility did not report the allegation to the New York State Department of Health within two hours as required by regulation, based on their internal conclusion that the claim was false. Interviews with facility staff confirmed that the abuse allegation was not reported to the State Survey Agency because the internal investigation concluded it was unsubstantiated. The Director of Nursing stated that, since the allegation was determined to be untrue within the two-hour window, they believed reporting was unnecessary. This action was not in accordance with facility policy and state regulations, which require all alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation is made, regardless of the outcome of the initial internal investigation.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with Parkinson's Disease, major depressive disorder, and bipolar disorder, who was assessed as having mild cognitive impairment and being able to communicate effectively. The resident reported that a staff member was rough with them in September 2024, and later alleged being hit in the face three times by a registered nurse. The initial investigation was closed without interviewing the resident, staff, other residents, family, or visitors, and without establishing a clear timeline of the event. The specific date of the alleged incident was not determined, and there was no documentation in the electronic medical record regarding the allegation. The facility's policy required that all allegations of abuse or neglect be promptly reported and thoroughly investigated, including interviews with the resident, staff, witnesses, and others who may have relevant information. However, the investigation consisted only of reviewing staffing sheets and a statement from the administrator, which concluded the allegation was unsubstantiated because the accused nurse was not scheduled to work at the time. No supporting interviews or statements were obtained, and the resident's care plan was not updated to reflect the alleged incident. Interviews with facility staff revealed that key personnel, including the DON and Activities Director, were not aware of the incident, and the administrator acknowledged that the investigation was not thorough and should have been reported to the state health department. The lack of a comprehensive investigation and failure to follow facility policy resulted in the deficiency cited by surveyors.
Failure to Provide Necessary ADL Assistance Due to Staffing and Equipment Limitations
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, congestive heart failure, and morbid obesity was not provided with the necessary care and services to prevent avoidable decline in activities of daily living (ADLs). The resident required a two-person mechanical lift for transfers and was dependent on staff assistance to get out of bed and for bathing. Over multiple observed dates, the resident was not assisted out of bed and was not offered showers, only receiving infrequent bed baths. The resident reported that staff did not ask if they wanted to get out of bed due to insufficient staffing, and that they had not been out of bed for approximately ten days. The care plan indicated the need to encourage participation in ADLs and to use assistive devices, but these interventions were not consistently implemented. Staff interviews confirmed that there were typically only two to three Certified Nurse Aides available for 40 residents, making it difficult to provide the required assistance for residents needing two-person transfers. The resident's preferred seating option, a Broda chair, was no longer available, and therapy services were being provided at bedside due to the resident not being transferred out of bed. The facility's policy emphasized promoting dignity and quality of life, but the lack of staff and resources resulted in the resident not receiving care in accordance with their needs and preferences.
Failure to Prevent Accident Hazards and Provide Adequate Supervision
Penalty
Summary
Surveyors identified deficiencies in the facility's ability to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for three residents. For one resident with peripheral vascular disease, hypertension, and glaucoma, the corridor door to their room was repeatedly observed to be stuck or unable to be freely opened or closed while the resident was present in the room. Multiple staff interviews confirmed the issue was not previously noticed, but the door was later found to be functioning properly after the observations. Another resident with schizophrenia, traumatic brain injury, and epilepsy, who was identified as an elopement risk, experienced two separate elopement incidents. The resident was not wearing a wander guard and was able to leave the facility on both occasions. Staff failed to update the care plan or document interventions after these incidents, and interviews revealed that the resident would not keep a wander guard on and required close monitoring, which was not consistently provided due to staffing challenges. The facility's own policies for elopement were not followed, and the incidents were not properly investigated or documented at the time. A third resident with hemiplegia, major depressive disorder, and severe cognitive impairment eloped from the facility while on 30-minute safety checks. The resident exited through a side door by holding the release for fifteen seconds, triggering an alarm that was not responded to by unit staff. The resident was found outside by staff, sustained a laceration after a fall, and was sent to the hospital. There was no documented investigation into how the resident was able to exit unnoticed, and staff interviews indicated a lack of awareness and follow-up regarding the alarm and the resident's absence.
Delayed Pain Management for Resident
Penalty
Summary
The facility failed to provide timely pain management for a resident, leading to a deficiency in care. On 3/31/2024, a resident with chronic pain conditions, including inflammatory spondylopathies and hidradenitis suppurativa, did not receive their scheduled dose of Oxycodone at 12:00 PM. The resident, who was cognitively intact, reported their pain level as 7 or 8 on a scale of 0-10 due to the delay in medication administration. The resident informed the assigned LPN before 12:00 PM that they were out of Oxycodone and that previous doses had been obtained from the emergency kit. The LPN, who was not regularly assigned to the resident's unit, did not notify the RN Supervisor in a timely manner about the unavailability of the medication. Consequently, the RN Supervisor only became aware of the issue later and had to obtain authorization from the pharmacy to dispense the medication from the electronic medication dispensing system. The resident eventually received their medication at 3:15 PM, over three hours past the scheduled time, causing significant discomfort. Interviews with staff revealed systemic issues in the medication ordering process. The RN Supervisor noted that the physician had renewed the Oxycodone order on 3/29/2024, but it was not signed, leading to a delay in pharmacy authorization. Additionally, the charge nurse on the night shift was responsible for ensuring narcotic medications were ordered and available, a task that was not consistently performed. This lack of coordination and communication among staff contributed to the delay in pain management for the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of assistive devices to prevent accidents for a resident identified as high risk for falls. The resident, who had a history of multiple falls, experienced a witnessed fall on July 1, 2023, while ambulating without a walker. Despite being identified as high risk for falls, no interventions were documented or implemented following this incident to prevent further accidents. Subsequently, the resident experienced another fall on September 26, 2023, resulting in a cervical 1 vertebrae fracture. The fall occurred when the resident tripped on an intravenous pole and struck their head. The resident was transported to the hospital and returned with a cervical collar. Despite these incidents, there was no documented evidence that the resident's care plan was updated with interventions to prevent further falls. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that interventions were expected to be added to the care plan after each fall. However, they acknowledged that interventions were not documented for the falls on July 1, 2023, and September 26, 2023. The lack of documented interventions and updates to the care plan contributed to the resident's repeated falls and subsequent injury.
Deficiency in Resident Dignity Due to Use of Disposable Utensils
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the use of disposable utensils during meals for several residents. This deficiency was observed in multiple dining rooms, affecting five residents with varying degrees of cognitive impairment and medical conditions, such as chronic obstructive pulmonary disease, metabolic encephalopathy, and Alzheimer's disease. The facility's policy stated that residents should be provided with a diet that considers their preferences, yet observations showed meals served on plastic trays with plastic utensils, lacking knives, which hindered residents' ability to eat comfortably. Interviews with staff revealed a lack of awareness and understanding regarding the use of plastic utensils. A resident expressed confusion about the consistent use of plastic utensils, and a Licensed Practical Nurse was unaware of any care plans or safety risks necessitating their use. The Director of Food Service admitted that the facility ran out of real utensils and had to order them frequently, while the Director of Nursing was unaware of the issue and assumed it was due to safety concerns. This lack of coordination and communication among staff contributed to the deficiency in maintaining residents' dignity during meals.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, as identified during a recertification survey. Resident #108, who was admitted with chronic osteomyelitis, morbid obesity, and paraplegia, was receiving oxygen therapy and BiPAP for sleep apnea. Despite these needs, there was no comprehensive care plan addressing the resident's oxygen use, as confirmed by interviews with the resident, a registered nurse unit manager, and the director of nursing. Resident #118, diagnosed with post-traumatic stress disorder (PTSD), did not have a care plan addressing this condition. The director of social work acknowledged that a trauma-centered care plan should have been developed, given the resident's PTSD diagnosis. The absence of such a plan was confirmed by the director of nursing, who stated that a person-centered care plan should have been implemented for the resident's PTSD. Resident #376, who had a history of depression and was on antidepressant medication, did not have a person-centered care plan for their depression until after they expressed suicidal ideation. The resident's depression was documented in the medical provider's admission history, yet the care plan only addressed psychotropic medication administration without a focus on the resident's psychosocial needs. Interviews with the director of social work and social worker revealed a lack of awareness of the resident's depression diagnosis, which contributed to the deficiency.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs by the interdisciplinary team after each assessment for three residents. Resident #64, who was identified as high risk for falls, experienced multiple falls, including a witnessed fall on 7/01/2023 and another on 9/26/2023, which resulted in a cervical vertebra fracture. Despite these incidents, the care plan for falls was not updated to include new interventions to prevent further accidents. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that interventions were not documented in the care plan following these falls, contrary to the facility's policy. Resident #75 was admitted with chronic systolic heart failure, end-stage renal failure, and type 2 diabetes mellitus. Despite having no cognitive impairment, the resident was not involved in care planning and did not have a care plan meeting during the comprehensive assessment. The Director of Social Work acknowledged that the resident should have had a care plan meeting by the time of the survey and was unsure why there was a delay in the initial meeting with the social worker. Resident #200, who had a history of dysphagia following a stroke and was previously on enteral feeding, had their tube feeding discontinued on 5/02/2024. However, the comprehensive care plan was not updated to reflect the discontinuation of enteral feedings, and there were no current care plan interventions for the maintenance and care of the feeding tube. Interviews with an LPN and the Director of Nursing confirmed that the care plan was not updated, and the existing interventions were resolved instead of being revised.
Controlled Substance Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper documentation and reconciliation of controlled substances on Units #5 and #6, as observed during a recertification survey. The shift-to-shift staff signature form for controlled drugs was not consistently signed by staff members at each shift change, which is necessary to validate the correct narcotic count. Specifically, on Unit #6, there were three consecutive days with missing staff reconciliation for controlled drugs. Additionally, during medication administration observations, two Licensed Practical Nurses (LPNs) failed to sign out controlled medications when removed from the blister pack and did not immediately sign the administration record after administering the medication. Further discrepancies were noted in the medication administration documentation. One LPN administered a Lacosamide tablet to a resident without signing the controlled substance log, resulting in a mismatch between the blister pack count and the logbook. Another LPN documented an incorrect count of Fentanyl patches, with one patch unaccounted for in the medication cart. The Director of Nursing confirmed that nurses are expected to sign the shift-to-shift documentation form at each shift change and that unit managers are responsible for monitoring narcotic count sheets and resolving discrepancies. Despite annual competencies for medication administration and controlled substance handling, these deficiencies were observed.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards of practice. During the recertification survey, it was observed that six out of six medication carts and two out of three medication storage rooms did not comply with labeling and storage requirements. Specifically, opened medications lacked open and expiration dates, controlled substances were not secured in a double-locked cabinet, loose pills were found in medication carts, and medications were pre-poured on one medication cart. Observations revealed several instances of non-compliance. On the 5th floor, medication cart B contained loose pills and multiple opened medications without proper labeling, including eye drops, nasal spray, and insulin pens. The narcotic lock box in the 5th floor medication room was found unlocked. Similar issues were noted on the 6th floor, where medication cart A had opened medications without open and expiration dates, and the medication room refrigerator contained an open vial of tuberculin without an open date. Further observations on the 2nd, 3rd, and 4th floors showed similar deficiencies, with medication carts containing unlabeled pre-poured medications and insulin vials without expiration dates. Interviews with LPNs revealed a lack of awareness regarding pharmacy or manufacturer guidelines for expiration dates, and the Director of Nursing confirmed that staff should follow policy and procedure when administering medications. The facility's policies required labeling of medications upon opening and prohibited pre-pouring of medications.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for several residents. During a recertification survey, it was observed that residents on multiple floors received meals that were cold, unattractive, and not palatable. Specifically, residents expressed dissatisfaction during a resident council meeting, noting that their meals were often cold and unappealing. Observations confirmed that food temperatures were below acceptable levels, with items such as hamburgers and baked beans served at temperatures significantly lower than recommended. The facility's policy on Food and Nutrition Services, dated January 2024, stated that residents should receive a nourishing, palatable, well-balanced diet that meets their nutritional and dietary needs. However, during meal observations, it was noted that staff served beverages without wearing gloves, and residents were provided with plastic cutlery, lacking knives, which was not in line with any care plan or safety assessment. Interviews with staff revealed that the use of plastic utensils was due to a shortage of real cutlery, which was not being returned to the kitchen after meals. Additionally, the facility's elevator system contributed to delays in meal delivery, resulting in cold food. Residents with various medical conditions, such as sepsis, chronic obstructive pulmonary disease, and orthopedic aftercare, were affected by these deficiencies. For instance, one resident reported that their breakfast was cold upon delivery, with congealed fat on the ham slices, and temperatures of the food items were recorded well below the desired levels. Interviews with the Director of Food Service and the Director of Nursing indicated a lack of awareness and communication regarding the issues with cutlery and meal temperatures, contributing to the ongoing problem.
Improper Food Cooling and Unclean Kitchenette
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the recertification survey. Specifically, ground chicken was not cooled safely in the main kitchen. Observations revealed that the ground chicken, which was cooked on the previous day, was found in the walk-in refrigerator at a temperature of 52 degrees Fahrenheit, which is above the safe cooling temperature. According to the facility's Hazard Analysis Critical Control Points (HACCP) Cooling Step by Step Process, cooked food should be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours and then to 41 degrees Fahrenheit within 4 hours. However, the chicken had been placed in the refrigerator at 7:00 AM and had not reached the required temperature by 10:54 AM. Additionally, the Unit #1 kitchenette was found to be unclean, further indicating a lack of adherence to food safety standards. Interviews with the Assistant Director of Food Service and the Chef confirmed the timeline of events, and the Director of Food Service acknowledged the issue, leading to the disposal of the improperly cooled chicken. The Regional Manager of the food service vendor and the facility Administrator were informed of the deficiency, highlighting the need for staff training on proper food cooling procedures.
Improper Labeling of Resident and Personal Food
Penalty
Summary
The facility failed to ensure that food brought in by family or visitors for residents was stored safely and properly labeled in the kitchenette refrigerators on three of six resident units. Specifically, deli sandwiches for a resident were not dated, and lactose-free milk and orange tonic brought in by family members were not labeled with the resident's name, room number, and date. Additionally, personal food found in a green reusable lunch bag was not labeled. The facility had a posted document on the refrigerators stating that all food must be labeled with the resident's name and date, but this policy was not followed.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that an interdisciplinary team assessed a resident's ability to safely self-administer medication, as required by their policy. Resident #35, who was cognitively intact and had diagnoses including chronic diastolic congestive heart failure, morbid obesity, and bipolar disorder, was observed with a cup containing seven pills and a cup of medicine mixed in water at their bedside. There was no documented evidence in the resident's electronic medical record that an assessment had been conducted to determine their ability to self-administer medications safely, nor was there a physician order or care plan in place for self-administration. During interviews, it was revealed that the facility's protocol was not followed. A Licensed Practical Nurse (LPN) admitted to mistakenly leaving the medications at the resident's bedside when they left the room to answer a call light. Another LPN and the Director of Nursing confirmed that no residents on the floor were cleared to self-administer medications, and that a physician's assessment and order were required for a resident to self-medicate. The facility's policy stated that residents had the right to self-administer medications if deemed clinically appropriate and safe by an interdisciplinary team, but this process was not followed for Resident #35.
Failure to Maintain Care for Resident with Discontinued PEG Tube
Penalty
Summary
The facility failed to ensure appropriate care and maintenance for a resident with a percutaneous endoscopic gastrostomy (PEG) tube after enteral feedings were discontinued. The resident, who had a history of dysphagia following a stroke and moderate cognitive impairment, was initially receiving tube feedings as per a physician's order. However, the order for tube feeding was discontinued, and there were no subsequent orders for the maintenance of the PEG tube or skin care at the insertion site. This lack of orders and care plan led to the deficiency identified during the survey. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, revealed that they were aware that a PEG tube not in use should still be flushed daily and require skin care. Despite this knowledge, there were no current orders or care plans in place for the resident's PEG tube maintenance. The Director of Nursing acknowledged that the order for flushes was discontinued along with the feeding order, and there were no policies addressing the care of an unused feeding tube.
Failure to Administer TPN as Ordered
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards and physician orders for a resident who was admitted with pneumonia, severe malnutrition, and a stroke. The resident was cognitively intact and had a physician's order for total parenteral nutrition (TPN) to be administered in a 16-hour cycle starting at 5:00 PM and ending at 9:00 AM. However, the TPN was not started on time on one occasion and was not taken down as ordered the following morning. This deviation from the physician's order was documented in a late entry by a Nurse Practitioner, who noted that the TPN was not removed at the scheduled time, and advised the Registered Nurse to contact the pharmacy for the next infusion. Interviews with facility staff revealed inconsistencies in the documentation and recollection of events. The Assistant Director of Nursing acknowledged that the physician's orders should have been followed, and any deviation should have been communicated to the provider. The Director of Nursing noted a problem with documentation, suggesting that the incident likely occurred on a different date than initially reported. The resident's condition deteriorated, and they were sent to the hospital, further complicating the timeline of events. The failure to adhere to the physician's orders for TPN administration was identified as a deficiency during the survey.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, Resident #108 and Resident #473, as observed during a recertification survey. Resident #108, who was admitted with chronic osteomyelitis, morbid obesity, and paraplegia, was ordered to receive continuous oxygen therapy at 4 liters per minute via nasal cannula and BiPAP at bedtime. However, observations on multiple dates revealed that Resident #108 was not wearing supplemental oxygen as ordered. Interviews with the resident and staff indicated that the resident only wore oxygen at night or when in bed and rarely used the BiPAP due to discomfort. The care plans for Resident #108 did not document the use of oxygen or BiPAP, and there was no evidence of a care plan addressing non-compliance or refusal to wear oxygen. Resident #473, diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, and emphysema, was observed wearing 3 liters of oxygen via nasal cannula on several occasions without a physician's order documented in the medical record. The comprehensive care plan for Resident #473 indicated a need for oxygen, but there was no order in the medical record until after the surveyor's inquiry. Interviews with staff revealed a lack of communication and documentation regarding the oxygen therapy, with staff expressing uncertainty about the orders and the need to verify them in the system. The facility's policy on oxygen administration required verification of physician orders before initiating oxygen therapy, except in emergencies. However, this policy was not followed for Resident #473, who received oxygen without an order for at least five days. The lack of proper documentation and adherence to physician orders for both residents highlights deficiencies in the facility's respiratory care practices, as evidenced by the observations and interviews conducted during the survey.
Inadequate Dialysis Care Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards. Specifically, the resident, who had multiple diagnoses including chronic systolic heart failure, end-stage renal failure, and type 2 diabetes mellitus, was not consistently monitored for complications before and after dialysis treatments. The facility's policy required the use of a communications log to document the resident's needs and response to dialysis treatments, but this was not adhered to. The dialysis communications log was found to be incomplete on multiple occasions, with missing entries for pre- and post-dialysis vital signs, dialysis access site condition, medication changes, infections, acute condition documentation, and nurse signatures. Interviews with facility staff, including a Registered Nurse Unit Manager and the Director of Nursing, confirmed that the expectation was for these forms to be completed and documented, but they were not consistently filled out. This lack of documentation and communication with the dialysis center represents a deficiency in the care provided to the resident.
Failure to Provide Social Services Assessment for Resident with Depression
Penalty
Summary
The facility failed to provide medically related social services to a resident with a documented history of depression, as required to maintain their mental and psychosocial well-being. The resident, who was admitted with diagnoses including depression, did not receive an assessment by a Social Worker upon admission or during subsequent readmissions. This lack of assessment was contrary to the facility's policy, which mandates that the Care Planning/Interdisciplinary Team, including a Social Worker, develop an individualized comprehensive care plan based on a comprehensive assessment. The resident was on an antidepressant medication, but there was no documented person-centered care plan addressing their depression until after they expressed suicidal ideation. The deficiency was highlighted when the resident verbalized suicidal thoughts and a plan to harm themselves, leading to their transfer to the emergency room for psychiatric evaluation. Interviews with facility staff revealed that the initial social service assessment, which includes screening for depression, was not completed for the resident. The Director of Social Work and the Director of Nursing confirmed that a Social Worker should have conducted an assessment around the time of admission, but this did not occur, resulting in a failure to address the resident's mental health needs adequately.
Inadequate Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents with severe cognitive impairments from abuse, specifically inappropriate sexual behavior, due to inadequate supervision. On the day of the incident, a Certified Nurse Aide (CNA) observed the two residents sitting together on a bed in one of the resident's rooms. Despite noticing the situation, the CNA left the room to gather cleaning supplies without redirecting one of the residents out of the room. Upon returning approximately 7 to 8 minutes later, the CNA found the residents engaged in inappropriate sexual behavior, with one resident partially undressed. Prior to this incident, there were indications of inappropriate interactions between the two residents, as reported by another CNA who had observed similar behavior and informed a manager. However, there was no documented evidence of any follow-up or intervention to prevent further occurrences. The facility's policies on abuse prevention and reporting were not effectively implemented, as the care plans for the residents were not updated to reflect the need for increased supervision or interventions to prevent such incidents. Interviews with various staff members revealed a lack of consistent training and awareness regarding the handling of residents with wandering behaviors and potential for inappropriate interactions. The staff did not receive specific training following the incident, and there was a general lack of communication and documentation regarding the residents' behaviors and the necessary precautions to prevent abuse. This oversight resulted in a situation that posed immediate jeopardy and substandard quality of care for the residents involved.
Verbal Abuse and Disrespectful Behavior by Staff
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of Certified Nurse Aide #8 towards Resident #2. Resident #2, who had severe cognitive impairment, was subjected to verbal abuse by the aide. Multiple witnesses reported that the aide yelled and cursed at the resident, telling them to "get the fuck away" and "get into your room," among other disrespectful remarks. This incident was corroborated by several staff and residents who overheard the altercation, indicating a pattern of inappropriate behavior by the aide. Additionally, Resident #6 reported feeling scared after overhearing a loud verbal altercation between Certified Nurse Aide #8 and an LPN during a night shift. The altercation involved shouting and aggressive language, which was confirmed by other staff members who witnessed the incident. This behavior contributed to an environment that was not conducive to the residents' right to a dignified existence and self-determination. The facility's investigation revealed that Certified Nurse Aide #8 had a history of inappropriate interactions with residents and staff, including being moved between units due to similar issues. Despite these known issues, the aide continued to exhibit behavior that violated the residents' rights to be treated with respect and dignity. The facility's failure to address these ongoing issues in a timely manner led to the deficiencies identified during the survey.
Failure to Timely Report Verbal Abuse Incident
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident and a Certified Nurse Aide (CNA) within the required two-hour timeframe. The incident occurred during the night shift when a resident, who was cognitively impaired and had a history of cerebral infarction, anxiety disorder, and major depressive disorder, was verbally abused by a CNA. The abuse was overheard by another resident, who reported it to a Licensed Practical Nurse (LPN) four days later. The LPN then informed the Assistant Director of Nursing, who subsequently reported it to the Director of Nursing and the Administrator. The facility's policy mandates immediate reporting of abuse allegations to the administrator and state authorities, defined as within two hours. However, the incident was not reported to the New York State Department of Health until four days after it occurred. Multiple staff members, including another CNA and a Resident Assistant, witnessed or were aware of the incident but did not report it immediately. Some staff members cited fear of job loss or perceived the CNA's behavior as typical, which contributed to the delay in reporting. Interviews with staff revealed that the CNA involved had a history of similar behavior, and the incident was not considered unusual by some staff members. The Director of Nursing confirmed that they were unaware of the incident until four days later, at which point it was reported to the necessary authorities. The facility's failure to adhere to its abuse reporting policy resulted in a deficiency citation.
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 155 citations issued within 25 miles in the last 12 months — including the 4 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 Valatie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Center For Rehabilitation And Nursing | 8.4 mi | ★★★★★ | 10 | 0 |
| Ghent Rehabilitation & Nursing Center | 8.6 mi | ★★★★★ | 0 | 0 |
| Pine Haven Home | 11.7 mi | ★★★★★ | 0 | 0 |
| Evergreen Commons Rehabilitation And Nursing Ctr | 14.1 mi | ★★★★★ | 4 | 0 |
| Rosewood Rehabilitation And Nursing Center | 15.5 mi | ★★★★★ | 55 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Grand Rehabilitation And Nursing At Barnwell.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.