Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Paramount At Somers Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, agitation, and a history of falls was placed under 1:1 supervision, but a CNA used an overbed table to block movement, then hit, pinched, and spit at the resident while the resident tried to push the table away. The resident had no behavior care plan in place before the incident, and video showed the CNA repeatedly repositioning the table and assaulting the resident while an LPN was nearby at the nurse’s station.
Failure to provide adequate supervision and fall-prevention interventions for two residents with repeated falls and injuries. One resident with severe cognitive impairment had multiple unwitnessed falls, including a head injury requiring hospitalization and staples, and staff did not document review or effectiveness of the fall plan after later falls. Another resident with dementia and agitation had repeated unwitnessed and witnessed falls, including facial injury, while the record did not show timely practitioner evaluation or effective interventions for the resident’s behaviors and fall risk.
The facility failed to maintain procedures for abuse prevention screening and training for prospective facility and agency staff. Record review found missing background checks, fingerprinting, reference checks, employment verification, and licensing/registry review for multiple CNAs and an LPN, along with no documented abuse prevention in-service training related to residents with behaviors. Interviews with HR and nursing leadership showed confusion about who was responsible for screening and maintaining records for agency staff, and the DON stated agency staff did not receive the same onboarding process as facility staff.
Facility assessment deficiencies involved failure to capture resident behavioral health needs, unit-specific census and characteristics, staffing distribution by unit and shift, third-party agency use, and leadership changes. The assessment listed staffing plans for RNs, nurse aides, and RN supervisors, but did not tie staffing to the needs of the different units, including a locked dementia unit and other units with varying bed capacities. Record review also showed inaccurate MDS behavior documentation for several residents, and the Administrator acknowledged the assessment did not include key unit and staffing details.
Inadequate staff training and tracking for abuse, dementia, and behavior management. The facility did not have an effective system to ensure new and existing staff, including agency CNAs and facility nursing staff, received and completed required in-services tied to their roles. Records showed missing documentation for abuse prevention, dementia care, and behavior management training, and interviews showed staff were unclear about who was responsible for onboarding and tracking education. During an incident involving a resident with psychiatric, mood, and dementia-related needs, staff described the resident spitting and using racial slurs, while a CNA tapped the resident on the shoulder and other staff did not intervene before the abuse event.
Failure to Report Alleged Abuse and Injuries of Unknown Origin: The DON and facility records showed multiple failures to promptly and accurately report alleged abuse and injuries of unknown origin to the State survey agency. A resident with dementia reported being hit after a visitor heard screaming, but the police report timing in the facility investigation did not match the incident timing. Another resident with severe cognitive impairment had an unwitnessed fall with a head laceration requiring hospitalization and staples, and two residents were found in bed together with no incident report or State report documented.
The facility did not thoroughly investigate multiple abuse- and injury-related incidents. A resident with severe cognitive impairment was seen on video being hit, pinched, and spit on by a CNA, but the facility’s account did not reflect the full sequence of events or identify the failures leading up to the abuse. Another resident with dementia and repeated falls developed a left wrist fracture, yet there was no documented investigation of the injury as an unknown source fracture. In a separate event, two cognitively impaired residents were found in bed together, but the facility did not investigate or report the incident to the state.
Insufficient CNA staffing and an inadequate facility assessment led to poor coverage on a unit with up to 50 residents. Staff described night shifts as unmanageable, with only two aides assigned, delayed call bell response, unfinished work carrying into the day shift, and difficulty covering residents needing close supervision. An LPN reported that a confused, agitated resident at high fall risk required rotating one-to-one monitoring after a staff-to-resident abuse incident, but staffing levels did not increase to match that need. The report also cites a pattern of falls for two residents resulting in harm.
Behavioral Health Care and Supervision Deficiencies: The facility failed to ensure behavioral health needs were addressed through individualized care plans, staff orientation, and monitoring. A resident with dementia and agitation had no documented behavior plan or psych eval, and agency CNAs said they were not trained before being assigned. Another resident with dementia and behavioral disturbance had an incomplete behavior plan despite repeated agitation and unsafe behaviors. Two residents involved in an inappropriate sexual encounter did not have care plans adequately revised to address supervision, triggers, or ongoing monitoring.
The facility did not ensure the Medical Director coordinated medical care for the Westminster unit. Surveyors found no documented evidence that the Medical Director reviewed the Facility Assessment, helped develop abuse prevention policies, or attended the most recent QA meeting. The Medical Director said they reviewed incident investigations and had assessed a resident after an abuse incident, but could not provide documentation, and were unaware the resident had not been seen by a psychiatrist as required.
Improper Use of Overbed Table as a Physical Restraint: A resident with vascular dementia and severe cognitive impairment was observed on video with an overbed table placed in front of the wheelchair to keep the resident from getting up. The resident repeatedly tried to move the table away, but a CNA kept repositioning it and lowered it to box the resident in, despite no documented restraint assessment or MD order. The CNA said an LPN directed one-to-one supervision because of a fall, and the DON later acknowledged the table could be viewed as a restraint.
Failure to develop and implement a dementia care plan for a resident with vascular dementia, agitation, and metabolic encephalopathy until after a staff-to-resident abuse incident. The resident was severely cognitively impaired, had a history of falls, and had behaviors including restlessness, agitation, and physical combativeness; the resident was placed on 1:1 supervision when the incident occurred. The CNA involved stated they were agency staff and had not received dementia management training, while the DON stated dementia management was part of required orientation and annual inservices.
A resident with cognitive impairment and a history of constipation was repeatedly flagged for not having bowel movements, but the facility failed to initiate its bowel protocol or document interventions as required. Despite ongoing alerts and care plan directives, staff did not consistently follow up or record the effectiveness of administered treatments, leading to the resident's hospital admission for severe constipation and related complications.
A resident's representative reported missing personal items to facility staff, but the grievance was not documented or followed up according to policy. Communication breakdowns and lack of staff awareness of the grievance process resulted in the resident's concern not being properly addressed.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
A resident with a documented diagnosis of constipation did not have a care plan addressing this issue initiated in a timely manner. Despite repeated documentation of constipation and related symptoms, the facility delayed implementing its bowel protocol and did not consistently administer or monitor prescribed interventions. Staff interviews confirmed that care plan initiation and review processes were not followed as required, resulting in the resident being discharged to the hospital with severe complications related to constipation.
A resident with a history of stroke and Parkinson's disease experienced a sudden onset of slurred speech, which was reported by nursing staff to an NP. The NP initially ordered rest and IV fluids, suspecting dehydration, and only arranged for hospital transfer after continued symptoms and at the request of the resident's representative. The resident was later diagnosed with bilateral scattered infarcts. Facility staff and the medical director did not immediately recognize or act on the potential for acute stroke, resulting in delayed hospital evaluation.
Surveyors found that two residents did not have physician-ordered follow-up orthopedic consultations properly documented or scheduled after initial consults for hip fractures. Staff interviews revealed that orders for follow-up visits were not consistently entered into the electronic medical record, and communication about these appointments was often verbal rather than documented. As a result, both residents were discharged without the recommended follow-up care being arranged or recorded.
A nurse crushed and administered an extended-release Morphine tablet, clearly labeled 'do not crush,' to a resident with chronic pain and respiratory conditions. The resident became lethargic and exhibited opioid overdose symptoms, requiring Naloxone to reverse the effects. Facility policy requiring label checks and adherence to administration instructions was not followed, resulting in actual harm.
Two residents experienced falls, but their care plans were not updated to reflect the incidents as required. One resident with severe cognitive impairment fell from a Hoyer lift, and another with muscle weakness and ambulatory dysfunction had an unwitnessed fall resulting in injury. Staff interviews revealed inconsistent understanding of the need to revise care plans after such events.
A resident with severe cognitive impairment and total dependence for transfers fell from a mechanical lift during a transfer by two CNAs. The fall occurred when a strap on the Hoyer pad slipped or detached, causing the resident to strike their head on the lift. Staff interviews revealed inconsistencies in the transfer process, and the facility's investigation found that the equipment was intact but may not have been properly secured or monitored during the lift.
Two residents in an LTC facility were exposed to accident hazards due to inadequate supervision and safety protocol failures. One resident, with a pureed diet order, consumed inappropriate food and required suctioning after aspirating, while another had an uninspected electric air mattress overlay brought in by a private aide. Staff were unaware of supervision responsibilities and safety checks for personal equipment, leading to these deficiencies.
A resident's privacy was compromised due to a broken window shade and torn screen in their room, which faced the staff parking lot. Despite the resident's complaints and the facility's policy to maintain windows, the issue persisted for over a week. Staff were aware but did not report the problem, and the Director of Maintenance was only informed days later. The deficiency was noted during a recertification survey.
A resident with severe cognitive impairment did not receive necessary ADL care from facility staff, as a private duty aide, against facility policy, provided all care. The aide's involvement was not reported by staff, leading to a lack of documented evidence of care. The facility failed to ensure adherence to care plans and proper documentation.
A facility failed to maintain an adequate stock of prescribed gastrostomy tubes, leading to complications in the care of a resident with a feeding tube. The resident required an 18-gauge gastrostomy tube, but the facility ran out of stock, resulting in the use of an incorrect size and a temporary Foley catheter. The inventory management system was inadequate, and the purchasing process was delayed, contributing to the deficiency.
The facility experienced significant staffing shortages, particularly on night shifts and weekends, affecting resident care. Residents reported falls and delayed response times to call bells, while staff confirmed the lack of sufficient aides impacted care quality. Despite efforts to address the issue, including using agencies and offering incentives, the facility remained understaffed on multiple occasions.
The facility failed to maintain proper labeling and expiration management of medications. Unlabeled Ascor was found in a refrigerator on the [NAME] Unit, and expired Nexium was found in a medication cart on the Westminister Unit. Staff interviews revealed a lack of clarity on medication discontinuation and removal processes.
The facility's main kitchen failed to store food properly due to faulty insulation door seals on the walk-in freezer, leading to ice accumulation. The facility's policy required regular maintenance checks, but the seals were not functioning properly, causing a gap and ice formation. The Food Services Director acknowledged the issue and had requested repairs.
A resident with severe cognitive impairment and a history of aggression was physically abused by a CNA in a long-term care facility. The incident, captured on surveillance video, showed the CNA hitting the resident, resulting in an abrasion. The CNA had a prior disciplinary record and was the only aide on duty at the time. The facility's investigation found reasonable cause for abuse, leading to the CNA's termination.
A resident's Designated Representative was not informed about the risks and benefits of a newly prescribed medication, Depakote, or alternative treatment options before administration. The resident, who was severely cognitively impaired and had a history of aggression, began receiving Depakote following a recommendation from a Psychiatry NP. Despite the facility's policy requiring family notification for medication changes, there was no documented evidence of such communication. The Medical Doctor claimed to have discussed the medication regimen with the Designated Representative but did not document the conversation.
A facility failed to maintain a clean and homelike environment in a dementia unit, where a strong urine odor was pervasive. The unit lacked a night housekeeper, leaving nursing staff to manage accidents until morning. Carpets were cleaned weekly, but the odor persisted due to residents' incontinence and humid weather, highlighting a deficiency in environmental maintenance.
A resident with severe cognitive impairment and multiple diagnoses experienced a fall, but the facility failed to update the Comprehensive Care Plan (CCP) as required. The care plan, which included interventions for fall prevention, was not revised after the incident, despite protocols stating that care plans must be reviewed post-fall. Interviews revealed confusion over responsibilities for updating care plans, contributing to the deficiency.
A resident with dementia in an LTC facility exhibited increasing aggression and wandering behaviors, but their care plan was not updated to address these issues. Despite staff awareness and training, the care plan remained unchanged, and the medical doctor was not informed of escalating behaviors. Staffing challenges were noted by the DON.
The facility did not conduct a comprehensive assessment to determine necessary resources for the [NAME] Unit, a specialized dementia care area. The assessment failed to identify the unit's specific needs and appropriate staffing levels. Observations revealed insufficient night shift staffing, with only 2 CNAs and 1 LPN for 40 residents, some requiring two-person assistance. Despite staff concerns, no staffing changes were made.
Physical Abuse of Resident During 1:1 Supervision
Penalty
Summary
The facility failed to ensure a resident’s right to be free from physical abuse when a CNA used an overbed table to restrict a resident from getting out of a wheelchair, then hit and pinched the resident’s left arm and spit at the resident as the resident tried to move the table. Survey findings identified this as physical abuse involving one resident out of six reviewed for abuse, and the incident was determined to be Immediate Jeopardy for all residents on the behavioral unit. The resident involved had vascular dementia with agitation, a subarachnoid hemorrhage, and depression. The admission MDS documented severe impaired cognition with no documented behaviors, but the record also showed the resident had one-sided upper extremity impairment and needed moderate assistance with toileting and bed mobility. The hospital discharge summary documented the resident had attacked their spouse and needed delirium precautions. The care plan addressed falls and supervision, and a behavioral note documented the resident was restless, physically combative, and agitated in the evening, after which the resident was placed on one-to-one supervision. The resident’s Kardex contained no instructions for managing behavioral symptoms before the incident, and the comprehensive care plans showed no documented behavior care plan until after the incident. Video surveillance showed the CNA seated beside the resident with a cell phone in hand, repeatedly repositioning the overbed table in front of the resident while the resident tried to push it away. The CNA then struck the resident, pinched the resident, and later spit at and hit the resident again. An LPN was at the nurse’s station across from the incident location and responded after the second assault. The CNA stated they had been instructed to place the table in front of the resident to prevent the resident from getting out of the chair because of fall history, and the CNA also stated they had not received facility training and had to rely on other CNAs or common sense for resident care.
Failure to Provide Adequate Supervision and Fall Prevention for Two Residents
Penalty
Summary
The facility failed to ensure adequate supervision and fall-prevention interventions for two residents who experienced repeated falls with injury. The deficiency involved Resident #7, who had congestive heart failure and insomnia and was documented as severely cognitively impaired, with two or more falls since the last assessment and a need for supervision with toileting and transfers. After an unwitnessed fall on 02/22/2026 that resulted in a facial laceration and hospitalization, the resident returned with four staples to the left temporal area. The care plan was revised to include toileting every three hours, but the record did not show that the effectiveness of interventions was evaluated. Resident #7 continued to have unwitnessed falls on 05/02/2026, 05/04/2026, and 05/05/2026, and the record did not show that the fall care plan was reviewed or revised after those incidents. On 05/07/2026, the resident was found on the floor in the room with a laceration and bruising to the face, and the incident investigation stated the resident had been trying to get up and tripped and fell. During observation that day, the resident was seen with facial bruising and was grimacing in pain and grabbing the left shoulder. Staff interviews indicated the night shift had two aides for 51 beds on the unit, that the assignment was difficult to complete, and that the aide assigned to Resident #7 was not informed of the prior fall on 05/05/2026 or of any special fall-prevention interventions. Resident #1 also had repeated falls with injury. The resident had vascular dementia with agitation and metabolic encephalopathy and was documented as severely cognitively impaired. After an unwitnessed fall on 04/15/2026, the resident was found on the floor in the room with the brief half off and bed sheets tangled around the legs. Another unwitnessed fall occurred on 04/21/2026 with sheets tangled around the legs, followed by a witnessed fall on 04/24/2026 and another unwitnessed fall on 04/25/2026 that caused a right eyelid abrasion, facial bruising, and swelling. The care plan was revised multiple times with interventions such as increased supervision, keeping the bed low, keeping the resident out of bed until 11:00 PM, and using footrests appropriately, but the record did not show that the attending practitioner evaluated the resident after each fall, that the effectiveness of the interventions was evaluated, or that other effective interventions were identified for the resident's restless and agitated behaviors.
Missing abuse prevention screening and training for facility and agency staff
Penalty
Summary
The facility failed to develop and maintain procedures to prevent abuse, neglect, and theft, including screening and abuse prevention training for prospective staff. Survey review found that the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated 11/14/2024, stated that background checks were part of abuse prevention, but it did not describe procedures for screening and training prospective and current agency and facility staff. The facility assessment also listed outside contracts but did not include agency nursing staff. Employee file review showed missing screening documentation for five of five facility/agency staff reviewed. The files for two CNAs and one LPN did not contain documented evidence of fingerprinting, reference checks, review of previous and current employment, or background checks prior to hire. For one LPN, the file also lacked evidence that the facility obtained status and disciplinary actions from other licensing and registry boards. The files also did not contain documented evidence that the CNAs or LPN received in-service training related to abuse prevention for residents with behaviors, and there was no evidence the LPN received abuse prevention training to competently identify, prevent, and address staff abuse of residents with behaviors. Interviews with HR and nursing leadership showed inconsistent understanding of who was responsible for screening and maintaining records for facility and agency staff. HR staff stated they ran some agency personnel through criminal history checks, but also said they were only responsible for employee screening assigned by the former HR Director and were not familiar with some of the CNAs reviewed. The new HR Director stated they were still in training, were not involved in screening prospective nursing or agency staff, and that the staffing agency was responsible for screening agency staff. The DON stated agency staff completed forms related to behaviors and abuse prevention before scheduling shifts, but also stated agency staff did not receive the same screening and training process as facility staff and were expected to begin work immediately on the unit after report.
Facility Assessment Did Not Reflect Resident Needs, Unit Characteristics, or Staffing Resources
Penalty
Summary
The facility assessment failed to adequately identify the resources needed to care for residents competently during day-to-day operations and emergencies. The assessment for the 300-bed facility did not include the resident population’s behavioral health needs, the necessary staff competencies and skill sets, the facility’s structural needs, the use of a third-party staffing agency, staffing needs for each individual unit, or changes to nursing home leadership. It also did not reflect that the facility had a locked dementia unit or define the characteristics of the other six units, and it did not document the different bed capacities for each unit. The assessment included staffing plans for licensed nurses, nurse aides, and RN supervisors, but did not specify how staff would be distributed across the units or which shifts were covered. The facility was averaging 280 residents, including 20 residents with behavioral health needs such as wandering, fall risk, and psychiatric needs. The facility assessment documented use of a staffing shortage plan during COVID-19-related staffing loss and a rapid-onboarding system for agency staff, but did not document the facility’s use of a third-party staffing agency or significant leadership changes in the Medical Director and Human Resources Director positions. Record review also showed inaccurate MDS documentation for three residents, including entries stating no wandering, no inappropriate behavior, and no behaviors when behaviors were present. During interview, the Administrator stated they were responsible for revising the facility assessment, acknowledged that it did not include unit characteristics or census in staffing levels, and stated the facility had experienced several personnel changes.
Inadequate Staff Training and Tracking for Abuse, Dementia, and Behavior Management
Penalty
Summary
The facility did not ensure an effective training program was developed, implemented, and maintained for all new and existing staff consistent with their expected roles and based on the facility assessment. The facility assessment stated the facility admitted residents with psychiatric and mood disorders needing intervention and residents with all forms of dementia, and it referenced corporate clinical support and the Nursing Staff Educator for staff in-services. However, the assessment did not include the nurse staffing agency used by the facility in the list of vendors, and it did not include a plan to ensure mandatory and ongoing in-service education and competencies were provided to agency staff. Record review showed no documented evidence that agency Certified Nurse Aides completed abuse prevention training before their hire dates, and one agency aide also had no documented evidence of dementia training or behavior management training before hire. During interview, one agency aide stated they had recently started through a staffing agency, were reassigned to provide one-to-one supervision for a resident, were unaware of the abuse incident involving that resident, and had not been oriented to the resident’s behaviors or given behavior management training before working at the facility. The aide also stated they received abuse prevention in-service only within the prior week and had submitted a post-test. The facility incident investigation documented an event in which a CNA tapped a resident on the shoulder while trying to redirect the resident, while other staff statements described the resident spitting on the aide and staff responding to the interaction. The LPN involved had only acknowledged receipt of the employee handbook and its abuse reporting policy, but there was no documented evidence of comprehensive abuse prevention, dementia management, or behavior management training before hire. Interviews with HR, the Nursing Staff Educator, the DON, and the Administrator showed inconsistent responsibility for onboarding and tracking education, no documented system for tracking agency staff training, and no ability to provide details of in-service education for staff over the prior six months.
Failure to Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility did not ensure that alleged abuse and injuries of unknown origin were reported immediately and accurately to the State Survey Agency. For Resident #3, who had diagnoses of dementia, depression, and unspecified mood disorder and was moderately cognitively impaired, the facility received an allegation of abuse from a visitor after the resident was heard screaming and saying, "stop, don't hit me." The Director of Nursing reported the incident to the New York State Department of Health, but the facility incident investigation documented a police report filed in the morning, while the incident itself was documented as occurring later that afternoon, and there was no documented evidence that a police report was filed after the alleged abuse incident. The facility also failed to report other incidents involving residents. Resident #7, who had congestive heart failure, insomnia, muscle weakness, severe cognitive impairment, and a history of falls, had an unwitnessed fall with a head injury, blood from the left temporal area, and a laceration that required hospitalization and four staples, but there was no documented evidence the incident was reported to the New York State Department of Health. In addition, Resident #4, who had dementia, syncope, anxiety, and moderate cognitive impairment, was observed in bed with Resident #6, who had dementia with behavioral disturbances, psychosis, anxiety, severe cognitive impairment, disorganized thinking, and no behaviors noted on assessment; there was no incident report provided and no documented evidence that the alleged sexual abuse involving Residents #4 and #6 was reported to the New York State Department of Health.
Failure to Thoroughly Investigate Abuse, Unknown Injury, and Resident-to-Resident Incident
Penalty
Summary
The facility did not thoroughly investigate allegations of abuse, neglect, exploitation, mistreatment, or injuries of unknown source for three residents. For one resident with vascular dementia and severe cognitive impairment, video surveillance showed a CNA seated beside the resident in the hallway while the resident tried to push away an overbed table; the CNA repeatedly repositioned the table, hit the resident on the left arm, pinched the resident, and later spit at and hit the resident again before an LPN responded. The facility’s report to the state described the resident as attempting to hit and spit on the CNA and said the CNA tapped the resident on the shoulder, but the record did not show a thorough investigation that identified the failures leading up to the incident. A second resident with dementia and syncope, who had moderate cognitive impairment, multiple falls, and required assistance with transfers and toileting, was found to have a left distal radius impact fracture after x-rays were ordered for an unspecified left radius fracture. The record documented the fracture and later noted a fall with a left wrist fracture, but there was no documented evidence that the facility investigated the fracture as an injury of unknown origin to rule out abuse. A third resident with dementia and syncope, also cognitively impaired and unable to consent, was observed in bed with the second resident on 02/11/2026; the note stated they were caring for each other and appeared consensual, and they were separated with the Administrator and DON notified. The facility did not conduct an investigation or report the incident to the NYSDOH, despite the residents’ cognitive impairment and the later care plan noting hypersexual behavior and no personal boundaries.
Insufficient Night Shift CNA Staffing and Inadequate Unit Assessment
Penalty
Summary
Sufficient nursing staff with the appropriate competencies and skill sets were not provided on the Westminster Unit to meet resident needs and maintain resident well-being. The facility assessment did not adequately reflect the characteristics of that unit, including its higher census of up to 50 residents and the needs of its resident population, and the staffing coordinator and DON stated they relied on acuity and census to set staffing levels but could not provide current par levels for each unit. The facility’s staffing sheets showed that only two CNAs worked the night shift on the Westminster Unit for 18 of 30 nights during the reviewed month, and the Administrator stated the facility should not have been staffed with only two aides overnight. Multiple staff interviews described the night shift workload as unmanageable. A resident stated staff took a long time to answer the call bell on the night shift. CNAs reported heavy assignments, frequent double shifts, and that new staff left after seeing the amount of work on nights. One CNA stated there was not enough aide coverage across shifts, another stated two aides for up to 50 residents on the Westminster Unit and the dementia behavioral unit was not manageable, and another stated night shift work often carried over to day shift because assignments were not completed. The DON stated the facility had difficulty staffing three aides overnight on the Westminster or another unit and that two aides was the absolute lowest level they believed could provide quality care. The staffing concerns were linked to resident events involving falls and one-to-one supervision needs. One LPN stated that after a staff-to-resident abuse incident involving a confused, agitated resident at high risk for falls, they created a one-to-one assignment and had aides rotate supervision every 30 minutes, but the number of aides on the shift did not increase to reflect that need. The report also cites a pattern of falls for two residents resulting in harm, and references deficiencies related to staffing, abuse, and falls. The Administrator stated the facility’s assessment did not account for the locked dementia unit or the Westminster Unit’s larger census, and staffing was identified as a future quality assurance performance improvement issue.
Behavioral Health Care and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure residents received necessary behavioral health care and services in accordance with their assessments and care plans. Survey findings identified deficiencies for four residents related to behavior management, care planning, supervision, and staff training. The report states that the facility did not provide documented evidence that agency staff were oriented to behavior management, that resident behavior care plans were developed or individualized as needed, or that existing plans were revised after significant behavioral incidents. Resident #1 had diagnoses of vascular dementia with agitation and depression. The record showed severe cognitive impairment, attempts to get out of bed or a wheelchair unassisted, an order for Depakote for agitation, and a physician order for psychiatry consultation, but there was no documented evidence of a psychiatric evaluation. The resident was later placed on one-to-one supervision because of restlessness, physical combativeness, and agitation. The record contained no documented behavior care plan identifying the resident’s behaviors or interventions for combativeness toward staff. The facility incident investigation also documented prior agitation and aggressive behavior, including spitting at staff, and there was no documented evidence that agency CNA #1 received behavior management education before being assigned to sit with the resident. The CNA confirmed they had not received orientation or behavior management training before working with the resident. Resident #2 had diagnoses of dementia with behavioral disturbance and altered mental status. The comprehensive care plan identified socially inappropriate behavior, yelling inappropriate words and racial slurs, and sliding to the edge of the bed despite repositioning, with a stuffed animal or baby doll used to soothe the resident during escalation. However, the care plan was not updated to reflect identified behaviors until later. The record also documented the resident ripping out an IV line, shaking vigorously on bedrails causing an IV pole to fall and hit the resident in the head, and being found on the floor on two occasions, with investigations concluding the resident had restless behaviors and placed themselves on the floor. On observation, the resident was screaming at a CNA while under one-to-one supervision for another resident, and the CNA had to seek additional aides for assistance. Agency CNA #5 stated they had worked at the facility for three weeks and had not received orientation to the resident’s behaviors or behavior management training. Resident #4 had diagnoses of unspecified psychosis, unspecified dementia, and anxiety. The record documented that Resident #4 and Resident #6 were observed lying in bed together on 02/11/2026 and the activity appeared consensual, but there was no documented account detailing the incident. A care plan created after the event identified hypersexual behavior and lack of personal boundaries, with interventions including removing the resident from triggering situations and orienting the resident to daily routines, but there was no documented evidence of what situations triggered the behavior. The care plan was not updated to address supervision and protection after the inappropriate physical contact. Resident #6’s care plan was also not developed or implemented to address the inappropriate sexual encounter. Later observation showed the two residents seated together holding hands in an alcove across from the nursing station, with no staff observed providing ongoing monitoring for potential inappropriate behavior.
Medical Director Not Fully Involved in Facility Oversight
Penalty
Summary
The facility did not ensure the Medical Director was responsible for coordinating the medical care of the Westminster Unit. Survey findings showed there was no documented evidence that the Medical Director reviewed the Facility Assessment dated [DATE], participated in the development of facility policies and procedures to prevent abuse, or attended the most recent quality assurance committee meeting held on 04/23/2026. The Medical Director stated they had been involved in prior quality assurance meetings and had reviewed resident care policies when they took the role, but they did not know what topics were discussed at the most recent meeting and provided no evidence of involvement in the Facility Assessment. Interviews also showed the Medical Director had been the attending physician for the Westminster Unit until about one month before the interview, while Nurse Practitioner #1, employed through the Medical Director’s third-party staffing agency, had been assigned full-time to cover three units including Westminster and answered directly to the Medical Director. The Medical Director stated they were responsible for reviewing incident investigations and had assessed Resident #1 after an abuse incident, but they could not provide documented evidence of that assessment and were unaware that Resident #1 was not assessed by a psychiatrist as required by the facility’s incident investigation. The Administrator stated the facility would be using an outside consulting agency to help address resident care and abuse prevention and reporting policies.
Improper Use of Overbed Table as a Physical Restraint
Penalty
Summary
The facility did not ensure that a resident was free from the use of physical restraints when an overbed table was used to prevent the resident from getting up out of a wheelchair without documented evidence of a restraint assessment or a physician order. The resident had vascular dementia with agitation and depression, was severely cognitively impaired, and required moderate assistance with toileting, bed mobility, and transfers. The care plan documented multiple falls and included interventions such as increased supervision, returning the resident to bed at night, use of a footrest during propulsion, and 30-minute monitoring, but there was no documented evidence that the overbed table was assessed or ordered as a restraint for a medical condition. Video surveillance showed a CNA seated with the resident in the hallway with an overbed table positioned in front of the resident while the resident sat in a wheelchair. The resident repeatedly tried to push the table away, and the CNA repeatedly moved it back in front of the resident. The resident became increasingly agitated, and the CNA then held the resident's feet and lowered the table to the height of the wheelchair armrests, boxing the resident in and preventing free movement. The CNA stated they were instructed by an LPN to sit with the resident and make sure the resident did not get up because of a fall earlier that day. The LPN stated the CNA was assigned for one-to-one supervision due to high fall risk, while the DON and Administrator later reviewed the video and acknowledged the table could be viewed as a restraint.
Failure to Develop and Implement Dementia Care Plan
Penalty
Summary
The facility did not ensure that a resident diagnosed with dementia received appropriate treatment and services when the resident’s dementia care plan was not developed and implemented until after a staff-to-resident abuse incident involving the resident and Certified Nurse Aide #1. Resident #1 was admitted with diagnoses of vascular dementia with agitation and metabolic encephalopathy, and the hospital discharge summary documented delirium precautions. The MDS dated 04/19/2026 documented that the resident was severely cognitively impaired and had a history of falls. A nursing note dated 04/17/2026 documented that Resident #1 had behaviors, was restless, and was physically combative and agitated in the evening, and the resident was placed on one-to-one supervision. The facility incident investigation dated 04/25/2026 documented that Certified Nurse Aide #1 was monitoring the resident on one-to-one supervision when the abuse incident occurred. The comprehensive care plan related to dementia was initiated on 04/25/2026 and included interventions such as breaking tasks into simple steps, encouraging self-performance in ADLs, providing leisure activities, and using simple words or instructions. There was no documented evidence that a dementia-related care plan had been developed and implemented upon the resident’s admission to the facility.
Failure to Initiate and Document Bowel Protocol for Resident with Constipation
Penalty
Summary
A resident with moderate cognitive impairment and a history of constipation was admitted to the facility with diagnoses including constipation and sepsis. The resident was frequently incontinent of bowel and bladder, and a care plan was in place to monitor and manage bowel movements, including initiating a bowel protocol if no bowel movement occurred in two days. Despite this, the resident was repeatedly flagged on the facility's bowel list report in June, July, and August for not having bowel movements, but the facility's bowel protocol was not initiated as required by facility guidelines. The resident's medication orders for constipation were inconsistently managed. Senna was ordered and then discontinued after the resident declined it, and Colace was started later. There was no documentation that the bowel protocol was initiated during multiple periods when the resident had no bowel movements, as indicated by clinical alerts. When the resident finally received a dose of Milk of Magnesia, there was no documented evidence of its effectiveness. The lack of follow-up and documentation persisted despite the resident being seen by nurse practitioners and other staff, and despite ongoing alerts indicating the absence of bowel movements. After discharge, the resident was admitted to the hospital with severe sepsis and was found to have large amounts of stool in the rectum and rectal mural thickening on imaging, consistent with severe constipation. Interviews with staff revealed inconsistent practices regarding monitoring, documentation, and initiation of the bowel protocol. Staff acknowledged that alerts were available and discussed, but there was no evidence that appropriate interventions were consistently implemented or documented for this resident.
Failure to Document and Address Resident Grievance Regarding Missing Property
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to voice grievances and to make prompt efforts to resolve them, as required by policy. The representative of a resident with moderate cognitive impairment and multiple care needs reported several missing items, including a fleece blanket and a nail manicure kit, to the Patient Relations Concierge. Despite this report, there was no documented evidence that a grievance was filed or that any follow-up was provided to the resident's representative regarding the missing items. The facility's grievance policy requires that grievances be documented and addressed promptly, but this process was not followed in this instance. Interviews revealed that the Patient Relations Concierge received the complaint and attempted to notify the Assistant Administrator and Director of Social Services via WhatsApp, but did not receive a response and was unaware of the official grievance process. The Director of Social Services, who is designated as the grievance officer, stated they were not informed of the issue until much later and confirmed that no grievance documentation existed in the resident's chart. The Administrator acknowledged that the grievance should have been documented and processed according to policy, but this did not occur. Communication breakdowns and lack of staff awareness of the grievance process contributed to the failure to address the resident's grievance appropriately.
Failure to Provide Complete Discharge Information Delays Home Care Services
Penalty
Summary
The facility failed to ensure that all necessary resident information was conveyed to the home care agency at the time of discharge, resulting in a delay in the initiation of home care services for one resident. The resident, who had a history of right femur fracture, depression, muscle weakness, moderate cognitive impairment, and required significant assistance with activities of daily living, was scheduled for discharge with home care services. The discharge planning documentation indicated that arrangements should be made with community resources to support the resident's independence post-discharge. However, the home care agency did not receive all required documentation, including the resident's demographics and orders specifying needed disciplines, which prevented timely initiation of services. Interviews revealed that the facility typically sends discharge referrals two to three weeks before discharge, but the documentation is not maintained in the electronic medical record and is instead kept in paper form. The home care agency representative confirmed that only clinical information was received, and the absence of demographic and insurance information delayed the start of home care services. As a result, the resident's home care services were not initiated until several days after discharge, contrary to the usual practice of starting services within 48 hours.
Failure to Develop and Implement Timely Care Plan for Constipation
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address constipation for one resident. The resident was admitted with multiple diagnoses, including a documented diagnosis of constipation, but no care plan addressing constipation was in place until more than two weeks after admission. Despite the facility's policy requiring timely care plan development and the presence of a bowel protocol, the resident experienced multiple episodes without a bowel movement, as documented in the facility's bowel alert lists and medication administration records. The bowel protocol was not initiated until much later, and there was no evidence that interventions were consistently implemented or monitored for effectiveness. The resident's medical records showed repeated documentation of constipation, complaints of discomfort, and requests for stool softeners. Orders for medications such as Senna and Colace were made, but there was inconsistency in their administration and follow-up. The medication administration records did not reflect refusals or consistent use of prescribed laxatives, and there was a lack of documentation regarding the effectiveness of interventions when they were eventually provided. Nursing and medical progress notes indicated ongoing issues with constipation, but the facility did not initiate the bowel protocol in a timely manner, nor did they update the resident's diagnosis list to reflect active constipation. Interviews with facility staff, including LPNs and the DON, revealed that care plans are expected to be initiated at admission and reviewed by registered nurses and the interdisciplinary team. However, in this case, the care plan for constipation was delayed, and the diagnosis was not properly carried over or updated in the resident's records. The resident was eventually discharged and admitted to the hospital with severe sepsis, where imaging revealed significant stool retention and colitis. The deficiency was attributed to the facility's failure to ensure timely and effective care planning and intervention for constipation as required by policy and regulation.
Failure to Provide Timely Hospital Transfer for Resident with Acute Neurological Changes
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services provided met professional standards of quality for a resident with a history of stroke, peripheral vascular disease, and Parkinson's disease. The resident, who had moderate cognitive impairment and required significant assistance with activities of daily living, experienced a sudden onset of slurred speech. This change was first noted by an LPN, who notified the nursing supervisor and a nurse practitioner (NP). The NP instructed staff to place the resident in bed for rest. Despite continued slurred speech, the NP initially ordered intravenous fluids and lab work, suspecting dehydration, and later requested a speech evaluation. The resident's symptoms persisted into the following day, with ongoing slurred speech and general weakness. The NP was again notified and, after further discussion and at the request of the resident's representative, ordered the resident to be transferred to the hospital to rule out a stroke. The resident was subsequently admitted to the hospital with a diagnosis of bilateral scattered infarcts. Documentation and interviews revealed that the NP and medical director did not immediately suspect a stroke and opted to treat in place, attributing symptoms to possible dehydration or other non-stroke causes. The medical director indicated that unless symptoms worsened or failed to improve, the standard practice was to continue treatment in the facility rather than transfer to the hospital. Interviews with facility staff and the resident's representative highlighted delays in recognizing the severity of the resident's symptoms and in transferring the resident for appropriate evaluation and treatment. The NP did not consult the medical director regarding the case, and the medical director did not question the NP's decisions. The facility's approach did not align with timely intervention for potential stroke symptoms, as required by professional standards of care.
Failure to Document and Schedule Physician-Ordered Follow-Up Consultations
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians reviewed residents' total programs of care and documented progress notes and orders at each required visit for two out of three residents reviewed for follow-up consultation visits. Specifically, one resident admitted after a right hip fracture had an orthopedic consultation recommending a follow-up visit and x-ray in six weeks. However, there was no documented evidence that a physician's order for the follow-up was entered, nor was the appointment scheduled before the resident was discharged home. The resident's discharge instructions included a recommendation to follow up with orthopedics post-discharge, but the required in-facility follow-up was not arranged or documented. Another resident, admitted after a left hip fracture, was also scheduled for an orthopedic follow-up consultation. The consultation report specified a follow-up appointment, but there was no documented physician's order for this visit. The resident was discharged without having the follow-up orthopedic appointment completed. Review of the medical record and staff interviews confirmed the absence of documentation regarding the follow-up consultation, and it was noted that the resident would sometimes cancel appointments, but this was not consistently documented in the medical record. Interviews with facility staff, including the unit clerk, LPN, nurse practitioner, and medical director, revealed inconsistent practices regarding the scheduling and documentation of follow-up consultations. The nurse practitioner stated that recommendations from consultations were verbally communicated to nursing staff, but orders were not entered into the electronic medical record. The medical director acknowledged that orders and progress notes for consultations should be documented and that the current process allowed for lapses in scheduling and documentation, leading to missed appointments.
Crushed Extended-Release Morphine Administered, Resulting in Harm
Penalty
Summary
A deficiency occurred when a nurse administered a crushed extended-release Morphine Sulfate tablet to a resident, despite the medication being clearly labeled as 'do not crush.' The nurse, who was responsible for medication administration, stated that the resident was known to spit out medications and could become verbally disruptive if pain medication was not given on time. In an effort to ensure the resident received their pain medication, the nurse crushed all of the resident's medications, including the extended-release Morphine, and administered them together. The facility's policy required nurses to check pharmacy labels and follow all instructions, including not crushing medications labeled as such, but this protocol was not followed in this instance. Following administration, the resident was found lethargic in bed by a speech language pathologist, who alerted nursing staff. The resident exhibited decreased responsiveness, decreased respirations, wheezing, and pinpoint pupils. Initial assessments by nursing staff and the physician led to the administration of Solumedrol and Lasix for respiratory symptoms, as the resident had a history of chronic obstructive pulmonary disease and pulmonary hypertension. It was only after further inquiry that the nurse disclosed the error of crushing the extended-release Morphine, prompting the administration of Naloxone to reverse the effects of the opioid overdose. The resident returned to baseline shortly after receiving Naloxone, and the incident was reported to the physician and the resident's representative. Interviews with staff confirmed that the nurse was aware of the 'do not crush' instruction but proceeded due to being in a rush and wanting to address the resident's pain. The facility's policy on narcotic handling and administration was not adhered to, resulting in actual harm to the resident.
Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised following actual falls for two out of four residents reviewed for falls. For one resident with severe cognitive impairment, dementia, and total dependence for mobility and transfers, the care plan was not updated to reflect a fall from a Hoyer lift during a transfer by two CNAs. Although the care plan was later updated with staff education and a physical therapy evaluation, there was no documented evidence that the actual fall event was incorporated into the fall risk care plan as required by facility policy. Another resident, who was cognitively intact but had muscle weakness, ambulatory dysfunction, and required assistance with mobility, experienced an unwitnessed fall in their room resulting in a laceration and skin tears. The care plan for this resident, which identified fall risk due to their physical limitations, was not updated to include the details of the fall incident. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the requirement to update care plans immediately after a fall, with some staff relying on progress notes rather than revising the care plan itself.
Resident Fall During Mechanical Lift Transfer Due to Improper Supervision and Equipment Attachment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and total dependence for transfers fell from a mechanical lift during a transfer. The resident, who was bedridden and required assistance for all activities of daily living, was being transferred by two Certified Nurse Aides (CNAs) using a Hoyer lift. The facility's fall prevention policy required a comprehensive approach to safety, including environmental adjustments and individualized interventions for residents at risk of falls. During the transfer, one CNA was preparing the resident's chair while the other CNA attached the Hoyer pad to the lift. As the resident was being lifted, they fell out of the Hoyer pad and struck their head on the leg of the lift. Upon investigation, it was found that one of the straps on the Hoyer pad had slipped or become detached during the lifting process, resulting in the resident's fall. Interviews with staff revealed inconsistencies in the sequence of actions, with one CNA stating they were not in position when the transfer began and the other indicating they had attached all the necessary clips. Further interviews with nursing staff and administration indicated that the Hoyer pad and equipment were intact, but the incident may have been caused by improper attachment or shifting of the resident during the transfer. The facility's investigation concluded that the strap may have come off due to the resident's movement or contact with the bed rail, but both CNAs believed they had followed proper procedures. The event demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided during the transfer process.
Lack of Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. Resident #631, who had a physician order for a pureed diet with nectar thick liquids due to dysphagia, was able to consume thin liquids and a cookie while in a supervised area. This led to the resident requiring oral suctioning to clear their throat after aspirating. The incident occurred when the resident was left unsupervised in the common area, despite the care plan indicating the need for close supervision during meals. Staff members were unaware of who was responsible for supervising the area, leading to the resident's exposure to inappropriate food and drink. Resident #226 was found to have an electric air mattress overlay on their bed, which had not been inspected by the maintenance department for safety. The air mattress overlay was brought in by the resident's private duty aide without the facility's knowledge. The Director of Nursing and other staff members were unaware that the air mattress overlay was not provided by the facility and had not been checked for safety. The maintenance department was only informed of the equipment after the survey had begun, highlighting a lapse in the facility's protocol for inspecting electrical equipment brought in by visitors. Both incidents demonstrate a lack of adequate supervision and adherence to safety protocols within the facility. The failure to supervise Resident #631 in the common area and the oversight in inspecting Resident #226's air mattress overlay contributed to the deficiencies identified during the survey. These lapses in care and safety protocols put the residents at risk and indicate a need for improved communication and adherence to established procedures within the facility.
Failure to Maintain Resident Privacy Due to Broken Window Shade
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #66, by not maintaining the window in their room in a functional state. The window, which faced the staff parking lot, had a broken shade that could not be pulled down, and a torn insect screen. This situation persisted for over a week, during which Resident #66 expressed dissatisfaction and a desire for privacy. The resident's roommate also confirmed the issue, stating that the broken shade allowed light to shine through the room continuously, necessitating the use of a curtain between the beds for some privacy. Despite the facility's policy requiring windows to be maintained in a safe and functional order, the broken shade and screen were not addressed promptly. Certified Nurse Aide #21 acknowledged awareness of the issue but failed to report it for repair. The Director of Maintenance was unaware of the problem until several days later, at which point the shade was repaired. The Director of Nursing confirmed that residents should be provided privacy upon request, including having window shades closed during care. The deficiency was identified during a recertification survey, highlighting a failure to uphold the resident's right to a dignified existence and privacy.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. The resident, who had severe cognitive impairment and required total assistance with eating, toileting, and personal hygiene, did not receive the required ADL care on multiple shifts as documented in the October 2024 Certified Nurse Aide documentation. A private duty aide, who was not permitted to provide care according to facility guidelines, stated they provided all care for the resident during their 8-hour daily shifts. Observations and interviews revealed that the private duty aide was performing tasks such as feeding, bathing, and applying protective cream, which were supposed to be done by the facility staff. Certified Nurse Aide #27 admitted that they documented care as provided even when it was not done by them, and they did not report the private duty aide's involvement to the nurses. The Director of Nursing and Licensed Practical Nurse Manager #22 confirmed that private duty aides were not allowed to provide care and that staff should have reported any non-compliance. The facility's failure to ensure proper documentation and adherence to care plans resulted in the resident not receiving the necessary care from the facility staff. The private duty aide's involvement, despite being against facility policy, was not adequately addressed by the staff, leading to a lack of documented evidence of care being provided by the certified nurse aides. This deficiency highlights a breakdown in communication and adherence to facility policies regarding the provision of care by private duty aides.
Failure to Maintain Adequate Stock of Prescribed Gastrostomy Tubes
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not have the physician-prescribed gastrostomy tube size available for Resident #182, who was admitted with diagnoses including aphasia, respiratory failure, and gastrostomy status. The resident's care plan required a specific size of gastrostomy tube, but the facility ran out of the necessary 18-gauge gastrostomy tubes, leading to complications in the resident's care. On July 20, 2024, the resident's g-tube balloon broke, and the g-tube came out. The facility did not have the prescribed 18-gauge gastrostomy tube available, and attempts to use a 20-gauge tube were unsuccessful. As a temporary measure, an 18 French Foley catheter was inserted, and the resident was sent to the hospital for a new tube. On July 22, 2024, a 14-gauge gastrostomy tube was inserted because the facility still did not have the correct size in stock, which may have caused the resident's abdominal opening to become smaller. Interviews with facility staff revealed that the inventory management system was inadequate, as the Director of Housekeeping and Central Supply did not maintain records of inventory levels, leading to a shortage of the necessary gastrostomy tubes. The staff was unaware of how long the stock had been depleted, and the facility's purchasing process was delayed, contributing to the deficiency in care for Resident #182.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Multiple residents and staff members reported that the facility was short-staffed, particularly on night shifts and weekends. The facility's staffing sheets from October 1 to October 31, 2024, revealed that the facility was understaffed on 19 out of 31 days, with only one Certified Nurse Aide scheduled on various units during night shifts. This staffing shortage led to delayed response times to call bells, with residents experiencing falls and other care issues as a result. Interviews with residents and staff highlighted the impact of the staffing shortages. One resident reported experiencing falls due to lengthy response times to call bells, while another resident noted that staff seemed rushed and took about 15 minutes to respond. Staff members, including Certified Nurse Aides and a Licensed Practical Nurse, confirmed the staffing issues, stating that the lack of sufficient aides affected the quality of care, resulting in skin issues and longer wait times for residents. The facility attempted to address the staffing challenges by utilizing agencies, offering incentives, and running a Certified Nurse Aide Training Program, but continued to struggle with maintaining adequate staffing levels.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were maintained in accordance with accepted professional standards, specifically regarding labeling and expiration dates. During an observation of the medication storage room refrigerator on the [NAME] Unit, two boxes of Ascor were found in a plastic bag without a resident name or pharmacy label, while another bag containing three boxes of Ascor was properly labeled. A Licensed Practical Charge Nurse confirmed that all Ascor was ordered for the same resident and should have been in the labeled bag. Additionally, on the Westminister Unit, a blister pack containing 27 capsules of Nexium DR 40 mg was found in a medication cart. The blister pack was labeled for a resident who was no longer receiving the medication, and it had an expiration date of 6/6/24, with a handwritten date of 10/28/24. A Registered Nurse stated that the medication had been discontinued, but they were unsure when. They explained that discontinued or expired medications should be removed from the cart, scanned by the Director of Nursing, and returned to the pharmacy. The Director of Nursing confirmed that the Pharmacy Consultant checks medication carts monthly, and Unit Managers and Charge Nurses conduct weekly checks.
Improper Food Storage Due to Faulty Freezer Seals
Penalty
Summary
The facility failed to ensure proper storage of food in accordance with professional standards for food service safety in the main kitchen. During a recertification survey, it was observed that the walk-in freezer had ice accumulation on the inside door surface, the freezer's floor, and the inner plastic curtain. The facility's policy, dated 8/21/20, required daily maintenance tasks, including door seal inspections to ensure proper functioning, and monthly insulation inspections. However, the freezer's insulation door seals were not attaching properly, leaving a gap between the door and the door's frame, which led to the formation of ice inside the freezer. The Food Services Director confirmed the issue and stated that a request had been placed with a contractor to fix the door seals.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as evidenced by an incident captured on surveillance video. On the night of the incident, a Certified Nursing Assistant (CNA) was observed approaching a resident from behind and subsequently hitting the resident on the shoulder, which led to a physical altercation between the two. The CNA continued to hit the resident with a closed fist, causing the resident to fall to the floor and sustain an abrasion to the nose. This incident resulted in actual harm to the resident, although it was not deemed immediate jeopardy. The resident involved in the incident was admitted to the facility with diagnoses of Lyme disease and unspecified dementia without behavioral disturbance. The resident was assessed as severely cognitively impaired and had a history of physical aggression towards others. The facility had a comprehensive care plan in place for the resident, which included interventions for managing physical aggression and wandering behavior. However, on the night of the incident, the resident was agitated and wandering into other residents' rooms, requiring constant redirection. The CNA involved in the incident had a previous disciplinary record for not appropriately handling a resident-to-resident altercation. On the night of the incident, the CNA was the only aide on the floor, as the other CNA was on break. The Licensed Practical Nurse (LPN) on duty had informed the Nursing Supervisor about the resident's escalating behavior but did not receive a timely response. The LPN later activated a code to request assistance, but by that time, the altercation had already occurred. The facility's investigation concluded that there was reasonable cause to believe that abuse had occurred, leading to the termination of the CNA involved.
Failure to Inform Designated Representative of Medication Changes
Penalty
Summary
The facility failed to ensure that a resident's Designated Representative was informed in advance about the risks and benefits of a newly prescribed medication, Depakote, and alternative treatment options. This deficiency was identified during a survey conducted from July 23, 2024, to July 24, 2024. The resident, who was severely cognitively impaired and had a history of physical aggression, was administered Depakote without the Designated Representative being notified. The facility's policy required family notification regarding changes in medication, but there was no documented evidence that this occurred prior to the administration of Depakote. The Designated Representative had previously expressed concerns about medication changes and had refused an antidepressant due to inadequate explanation from the Psychiatrist. Despite this, the resident began receiving Depakote on July 13, 2024, following a recommendation from a Psychiatry Nurse Practitioner. The Medical Doctor involved stated they discussed the medication regimen with the Designated Representative but did not document the conversation or recall the exact date. The Assistant Director of Nursing indicated that both the Medical Doctor and the unit nurse should notify the Designated Representative of medication changes, but this did not happen in this case.
Deficiency in Maintaining a Clean Environment in Dementia Unit
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents in the [NAME] Unit, as evidenced by a strong pervasive odor of urine throughout the unit, including in resident rooms. Observations were made on multiple occasions, noting the intense odor upon entering the unit and specific rooms, as well as a sticky wooden floor and a musty damp smell in each resident room. The unit, which houses residents with dementia, had both carpeted and wooden floors, and the odor was particularly strong in certain rooms. Interviews with staff revealed that the unit did not have a housekeeper at night, and nursing staff attempted to clean floors when residents had accidents. However, deep cleaning was only performed when housekeeping staff arrived in the morning. The carpets were cleaned weekly, but the unit's condition was exacerbated by the residents' incontinence and the humid weather. The housekeeping director noted that the unit required constant cleaning due to the residents' conditions, and the administrator stated that carpets were shampooed weekly, with spot cleaning available as needed. Despite these efforts, the odor persisted, indicating a deficiency in maintaining a clean and homelike environment.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner for a resident who was at risk for falls. Specifically, the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and Bipolar Disorder, was not updated following a fall incident. The resident had a history of falls, and the care plan included interventions such as encouraging the resident to stay in supervised settings, wearing non-skid footwear, and providing reality orientation. However, after a fall on April 2, 2024, where the resident hit their head, there was no documented evidence that the care plan was reviewed or revised. Interviews conducted during the survey revealed a lack of clarity regarding responsibilities for updating care plans. A Licensed Practical Nurse (LPN) stated that they were not responsible for initiating or updating care plans, which was the responsibility of the unit managers. The Assistant Director of Nursing confirmed that LPN Unit Managers are responsible for initiating and updating care plans, but they must be reviewed and signed by a Registered Nurse. Despite this protocol, the care plan for the resident in question was not updated following the fall incident, indicating a lapse in the facility's adherence to its care plan policy.
Failure to Update Dementia Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency was identified during a survey, where it was found that the resident's comprehensive care plan was not reviewed and revised to address increasing dementia-related behaviors. The resident, who was admitted with diagnoses of Lyme disease and unspecified dementia, exhibited physical aggression and wandering behaviors, which were not adequately addressed in their care plan. The resident's care plan, initiated in May and updated in July, included goals and interventions to manage behavioral symptoms and impaired cognition. However, despite documented episodes of aggression, wandering, and agitation, there was no evidence that the care plan was reviewed or revised to include individualized approaches to these behaviors. Nursing notes and psychiatric consultations documented the resident's ongoing agitation, restlessness, and exit-seeking behaviors, yet the care plan remained unchanged. Interviews with staff revealed that while they were aware of the resident's behaviors and had received dementia care training, they were not responsible for updating care plans. The medical doctor responsible for the unit was not alerted to any escalation of behaviors, and the facility's staffing issues were acknowledged by the Director of Nursing. Despite these challenges, the facility did not take the necessary steps to update the resident's care plan to address their changing needs.
Inadequate Facility Assessment and Staffing on Dementia Unit
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care, particularly on the [NAME] Unit, a specialized dementia unit. The assessment did not identify the unit as a specialized dementia care area nor did it define the staffing assignments required for its day-to-day operations. The facility's policy on facility assessment was intended to guide decisions on budget, staffing, training, equipment, and supplies, but there was no documented evidence that these needs were addressed for the [NAME] Unit. During the survey, it was observed that the night shift staffing on the [NAME] Unit was insufficient, with only 2 Certified Nursing Assistants and 1 Licensed Practical Nurse for 40 residents, some of whom required two-person assistance and others who wandered at night. The lack of housekeeping staff during the night shift led to nursing staff having to manage cleaning tasks, which was not ideal. Despite concerns raised by staff about the need for more personnel, no changes were made to the staffing schedule. The Administrator acknowledged responsibility for managing the Facility Assessment but relied on the Director of Nursing for insights into resident acuity and staffing needs.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 364 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Somers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waterview Hills Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Salem Hills Rehabilitation And Nursing Center | 1.9 mi | ★★★★★ | 1 | 0 |
| North Westchester Restorative Therapy & Nrsg Crt | 8.7 mi | ★★★★★ | 1 | 0 |
| Yorktown Rehabilitation & Nursing Center | 8.9 mi | ★★★★★ | 3 | 0 |
| Putnam Ridge | 9.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.