Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Tolstoy Foundation Rehabilitation And Nrsg Center during CMS and state inspections, most recent first.
Inconsistent DNR Documentation and Communication: Surveyors found that staff did not have a reliable process for identifying and communicating residents’ code status. Two residents were admitted with hospital DNR paperwork that was not promptly transcribed into EMR physician orders, and several other residents had DNR orders in the EMR while door labels and wristbands were not consistently aligned with staff expectations. Interviews showed conflicting practices among the RN supervisor, DON, Social Worker, and Social Work Consultant Supervisor regarding who was responsible for entering DNR orders, updating MOLST forms, and communicating code status to bedside staff.
The facility failed to ensure CPR-certified staff were available 24/7 to provide basic life support before EMS arrival. Surveyors found that multiple LPNs and an RN lacked current or acceptable CPR certification, one LPN had an expired card, and some staff had no documented certification. Staffing records showed several shifts with no CPR-certified staff present, and interviews confirmed there was no reliable system to track CPR status or a clear process for maintaining current certification.
Insufficient nursing staffing led to delayed call bell response and unmet par levels on multiple shifts. Residents and family members reported call bells were not answered in a timely manner, and a family member said staff seemed overwhelmed and the front desk phone was not answered. The DON acknowledged staffing shortages related to sick calls and said the facility relied on overtime and schedule changes rather than agency staff or incentives. During observation, multiple call bells were ringing without response and there was a noticeable urine odor in the hall.
Advance directive and CPR policy implementation failures were identified during survey. The facility’s policy required clinical staff to review advance directives and communicate resident wishes, but the SW only reviewed DNRs on weekends and had not discussed a plan for when they were off duty. The Administrator stated they were unaware of the identifier used for advance directive/DNR status and later acknowledged the facility did not have CPR-certified staff present on every shift, despite the policy requiring all licensed nursing personnel to hold current CPR certification.
Governing body oversight and QAPI communication were not clearly established. The Board could not state its involvement with QAPI, did not confirm review of QAPI minutes or the prior survey results, and there was no documented process or frequency for administrator reporting to the Board. The Administrator did not recall sending QAPI minutes, and the management company CEO stated they were not involved in QAPI meetings or review of the minutes.
Residents were not provided clear information on how to file grievances or who the grievance officer was. Multiple residents at a council meeting said they did not know the formal grievance process, and an observation found no postings in the lobby or on resident units identifying the grievance officer or explaining the process. The Administrator said residents got grievance forms in the admission packet, but there was no Abuse Coordinator in place, and the Social Worker said they were unaware of the grievance policy.
Failure to Provide Required Transfer and Ombudsman Notices: The facility did not complete written transfer/discharge or bed-hold notices, and did not notify the ombudsman, for three residents reviewed after hospital transfers or discharge home. The affected residents had significant medical and cognitive impairments, including COPD, adult failure to thrive, pneumonia, diabetes, intellectual disability, sepsis, and cerebral palsy, and staff could not locate proof that the required notices were sent.
Nonfunctioning Resident Call System: Surveyors found that the second-floor call system did not reliably alert staff, with door lights activating in several rooms but no audible signal and the nurse station console not accurately showing room numbers. Tap bells were not available in some bathrooms, and staff, including a CNA, LPN manager, RN supervisor, DON, and maintenance director, acknowledged the system had been malfunctioning for months. Residents reported the call bells did not consistently work or get answered in a timely manner, and the facility could not provide documentation of staff rounds during the malfunction.
A resident receiving Medicare Part A services did not receive documented timely NOMNC notice before therapy ended. The resident was cognitively intact and was given the notice by therapy, but refused to sign and wanted to speak with the designated representative. Staff later stated they were unsure whether the notice had been signed and described confusion between therapy and nursing over who handled the Medicare therapy cut process.
Failure to assess and treat a sacral pressure ulcer: A resident with DM and a hospital-acquired sacral pressure ulcer returned with a Stage 4 wound, but the record showed no documented wound assessment for nearly two weeks and no documented treatment until later in the stay. Nursing notes described the wound as full-thickness with redness, bleeding, granulation tissue, and pain, while later wound rounds showed a larger wound with heavy slough and drainage. Staff stated wound rounds were weekly, but one scheduled round was missed when the wound provider was unavailable, and no weekly measurement was found in the chart.
Pharmaceutical services failed to meet resident needs when an ordered oral hypoglycemic was not available for administration during the med pass, despite the resident’s diabetes and other significant diagnoses. The facility also failed to maintain controlled drug reconciliation when two boxes of lorazepam labeled for a deceased resident were found in the refrigerator lock box without a count sheet, and staff could not account for the medication’s disposition.
Repeated blood pressure medication errors occurred for a resident with HTN, hypotension, and ESRD. Metoprolol was given when BP was below the hold parameter and Midodrine was given when BP was above the hold parameter on multiple occasions. Pharmacy reviews identified the out-of-parameter doses, but the ADON stated the facility did not use the medication incident report form, and the DON stated staff were not reading the parameters properly.
Medication Labeling and Storage Deficiencies: An open insulin pen for a resident receiving daily insulin was found in a med cart without an open date, despite manufacturer guidance that it be dated when opened. In a separate observation, a med cart on the unit was left unattended and unlocked in the hallway, and the DON stated med carts should be locked when left unsupervised.
Infection control practices were not followed for two residents. A resident on contact precautions had no precaution sign or PPE bin outside the room, and a CNA entered the room and handled dresser drawers without gloves or a gown. Another resident on EBP received incontinence care from two CNAs who wore gloves and masks but no gowns. The DON/IP also could not provide complete infection surveillance documentation, including onset of symptoms, antibiotic start dates, and ordered isolation precautions.
Surveyors found that the facility did not initiate or update care plans for a resident at high risk for falls who later experienced a fall, and for two residents involved in a physical altercation, despite existing care plans for abuse. Staff interviews confirmed that care plans were not revised to reflect these incidents or to implement new interventions as required.
A resident with cognitive impairment physically struck their roommate, who had multiple medical conditions, during a verbal altercation. Both residents had care plans addressing abuse risk and cognitive issues, but the incident still occurred, indicating a failure to protect residents from abuse as required by facility policy.
A resident with moderate cognitive impairment and mobility limitations was found with floor mats propped upright against their bed, secured by night tables, preventing movement out of bed. This setup, implemented by a CNA who believed it would prevent falls, constituted a physical restraint without a physician order or documented medical need, contrary to facility policy. Staff interviews confirmed the mats should have been placed flat on the floor, and the incident was identified during a federal survey.
The facility did not promptly report suspected abuse incidents or submit required investigation results to the state health department for two residents. In one case, a resident was physically restrained with floor mats and furniture, and in another, a resident reported being struck by a roommate. Both incidents were not reported or concluded within the required timeframes.
A resident with significant medical needs experienced a witnessed fall while attempting an independent transfer, despite prior instructions to seek assistance. The required accident/incident report was incomplete, lacking an investigative summary, staff statements, and documentation of family notification, contrary to facility policy. The RN involved cited short staffing and multiple duties as reasons for not completing the investigation.
A resident with severe cognitive impairment and multiple pressure ulcers did not have their care plan updated to reflect the development and progression of a sacral/buttocks pressure ulcer. The care plan only addressed a heel ulcer, omitting documentation of the additional wound, its measurements, treatments, and physician findings, despite regular wound care assessments and communication. Nursing leadership confirmed that care plan updates were expected but not completed as required.
A resident admitted with significant comorbidities was found to have a Stage 2 pressure ulcer during the admission skin check, but the physician was not notified and no treatment orders were obtained, contrary to facility policy. Nursing staff and the DON confirmed this oversight, resulting in a failure to provide necessary care and services for the pressure ulcer.
A resident with severe cognitive impairment was reportedly abused by a CNA, who was witnessed punching the resident in the head. Despite the lack of physical evidence and the resident's inability to communicate, the facility terminated the CNA to ensure safety. The incident highlighted a deficiency in the facility's abuse prevention measures, as there was no documented risk for abuse care plan for the resident.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with severe cognitive impairment. A visitor reported seeing a CNA physically assault the resident, but the facility did not obtain a written statement from the CNA or assess other residents under their care. Despite assessments by medical staff, the investigation lacked comprehensive documentation, leading to an unsubstantiated conclusion.
The facility did not complete annual performance appraisals for its Certified Nurse Aides, as required. During a survey, it was discovered that appraisals were not documented for five aides, with the most recent appraisals dating back several years. The Director of Human Resources confirmed that the Nursing Department had not completed the necessary appraisals, despite a recent initiative to update them.
The facility failed to maintain an effective infection control program, with deficiencies in linen handling, water management, and contact precautions for a resident with C. Diff. Clean linens were transported uncovered, and staff did not practice proper hand hygiene. The facility lacked a current Water Management Plan, and staff were not educated on Legionella prevention. Additionally, appropriate contact precautions were not implemented for a resident with C. Diff, with staff observed not wearing required PPE and inadequate signage and PPE availability.
The facility did not ensure proper documentation of COVID-19 vaccination status for three staff members, as identified during a recertification survey. The Assistant DON acknowledged efforts to encourage vaccination, but many staff were resistant, and records from HR did not show screening or offering of the vaccine.
A resident developed an unstageable sacral pressure ulcer, but the facility failed to notify the resident's family as required by the care plan. Despite documentation of the ulcer and treatment recommendations, there was no record of family notification, which was confirmed by the Assistant Director of Nursing.
A resident with multiple diagnoses reported an incident of sexual abuse during a shower to the facility Administrator. The Director of Nursing was informed and began an investigation but failed to report the allegation to the New York State Department of Health within the required two-hour timeframe, mistakenly believing they had 24 hours to do so.
The facility failed to develop and implement comprehensive care plans for several residents, leading to unmet needs in ADLs and specific medical conditions. Interviews revealed confusion among staff regarding responsibility for care plan initiation and updates, contributing to the deficiencies identified.
The facility did not ensure that certified nurse aides received the required training in dementia care and abuse prevention. Documentation for two nurse aides was missing, and the MDS Nurse/Staff Educator confirmed the inability to locate the necessary records.
Two residents with severe cognitive impairments were not provided a dignified dining experience. A CNA stood over one resident while assisting with meals, contrary to facility policy, and another resident was inappropriately referred to as a "feeder". Despite being advised to sit, a CNA stood over the second resident during meals, citing a lack of chairs.
A facility failed to ensure a resident's right to formulate advance directives, as there was no physician's order for such directives. The resident, with moderately impaired cognition and serious medical conditions, had a MOLST form signed by the resident but not by a physician, leading to conflicting instructions regarding life-sustaining treatments. Staff interviews revealed a lack of awareness and proper documentation of the resident's advance directives.
The facility failed to provide written notification to two residents and their representatives about hospital transfers, and did not notify the Ombudsman. Both residents had intact cognition and were transferred without documented notice. The Director of Social Work confirmed the absence of required notices in the residents' files.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during hospital transfers. Despite having intact cognition, these residents, with conditions such as diabetes and hypertension, were transferred without receiving the required notification. The Director of Social Work confirmed the absence of documentation, indicating that the responsibility lay with the nurse on duty after hours and an administrative staff person during business hours.
A resident's MDS 3.0 admission assessment was not completed within the required 14 days, as it was submitted late by the facility's MDS/Discharge Planning Coordinator. The resident, with conditions including diabetes and dementia, was admitted, but the assessment was delayed beyond the mandated timeframe.
The facility failed to ensure that PASRR assessments were signed and included digital IDs for three residents before admission. Interviews revealed confusion over responsibility for verifying these documents, with the Director of Admissions or Outreach Coordinator expected to ensure completion.
A newly admitted resident with an unstageable pressure ulcer and other conditions did not have a baseline care plan developed within 48 hours, as required by facility policy and CMS regulations. The omission was due to staffing issues, with the RN on duty unable to complete the plan due to time constraints.
The facility's designated Infection Preventionist, the Assistant DON, did not complete the required specialized training in infection prevention and control before assuming the role. The IP had outstanding training modules, including Antibiotic Stewardship and Occupational Health, and only completed the necessary training after the survey began.
Inconsistent DNR Documentation and Communication
Penalty
Summary
The facility failed to establish consistent mechanisms for documenting and communicating residents’ advance directive choices, specifically Do Not Resuscitate status, to staff responsible for resident care. During the recertification and extended survey, surveyors found that staff could not appropriately identify DNR orders for 6 of 26 residents with advance directives. The deficiency was cited as Immediate Jeopardy, and the report states the failure created the likelihood of serious adverse outcome to all 64 residents in the facility. Resident #64 was admitted with diagnoses including COVID-19, dementia, and repeated falls. The hospital paperwork included a DNR directive signed on 08/19/2025, but the admitting physician orders on 08/20/2025 did not document code status, and there were no advance directives on the EMR banner when reviewed on 08/22/2025. A DNR/DNI physician order was not entered until later that day. During observation, the resident had no identification wristband, and staff interviews showed inconsistent understanding of how code status was identified. The RN supervisor who completed the admission stated they reviewed hospital referral information, did not see code information, did not enter a code order, and did not attempt to contact the responsible party or discuss advance directives with the resident. Resident #67 was admitted with diagnoses including toxic metabolic encephalopathy, CHF, and dementia. Admission orders did not document code status, and nursing admission notes contained no evidence of code status discussion. A DNR physician order was entered the next day, and a MOLST form was completed several days later with instructions including DNR, comfort measures only, do not intubate, no feeding tube, and limits on IV fluids and antibiotics. The RN supervisor stated the resident arrived with a designated representative who said they had a MOLST and would bring it in, and that the family wanted to discuss DNR with the physician; the RN supervisor also stated CPR would be performed if arrest occurred before a DNR order was entered. The resident’s representative stated the resident had a DNR at the hospital and expected it to continue at the nursing facility. For Residents #9, #16, #28, and #36, surveyors observed black-font door labels and black-font identification wristbands while the EMR contained DNR orders. Staff interviews showed conflicting understanding of how code status was communicated, including expectations that DNR residents would have red-font labels and wristbands, while others stated they relied on the EMR banner or a MOLST book. The DON stated a MOLST form would be obtained and a DNR order placed on admission, with the code status noted on the EMR banner and a care plan created by Social Work, but the Social Worker stated DNR status needed to be addressed within 48 hours and could be missed if a resident was admitted when the Social Worker was not working. The Social Worker also stated they had not been oriented or in-serviced on DNR since starting, and the Social Work Consultant Supervisor stated the admission nurse, ADON, and DON were responsible for getting DNR orders in place and updating the record when Social Work was unavailable.
Lack of CPR-Certified Staff on Multiple Shifts
Penalty
Summary
The facility failed to ensure that properly trained personnel certified in CPR for Healthcare Providers were available immediately, 24 hours per day, to provide basic life support prior to the arrival of emergency medical personnel, as required by the facility’s policy. During the recertification survey, eight of 14 licensed nurses reviewed did not have current or acceptable completed standardized CPR training and certification. This included six LPNs and one RN, and one additional LPN had an expired certification card. The facility also did not have a reliable system to track staff CPR certification status. Record review showed the facility’s policy required all licensed nursing personnel to be CPR certified and to maintain current certification. When the DON provided a CPR/BLS staff list, surveyors found that some certifications were expired, some were from a course that was not an accepted standardized CPR certification course with hands-on practice and in-person assessment, and some staff had no documented certification at all. Staffing lists and schedules showed multiple shifts with no CPR-certified staff available, including five days on the 7:00 AM to 3:00 PM shift and five days on the 3:00 PM to 11:00 PM shift. Interviews with the LPN, DON, management company HR director, RN supervisor, physician, and administrator confirmed there was no clear policy or procedure for tracking certification, no identified approved CPR training organization, and staff were unaware of which personnel had active CPR certification or how the building would ensure CPR-certified staff were present on all shifts.
Insufficient Nursing Staffing and Delayed Call Bell Response
Penalty
Summary
The facility did not provide sufficient nursing staff on all shifts to meet resident needs and did not consistently meet the staffing levels identified in its facility assessment. The assessment stated the facility would have nine licensed nurses, 20 certified nurse aides, one social worker, and two activity therapy staff available each day, and also noted that 75 percent of residents were high acuity. A separate staffing document dated 8/2025 listed par levels by shift as one RN, two LPNs, and eight CNAs for days; one RN, two LPNs, and eight CNAs for evenings; and one RN, two LPNs, and four CNAs for nights. Record review showed multiple shifts between 07/24/2025 and 08/21/2025 when staffing did not meet those par levels, including several evening shifts with fewer CNAs than required, one day shift with only six CNAs, and one night shift with only two CNAs. Residents and family members reported delays in call bell response during confidential interviews and a Resident Council meeting, and several residents stated they believed insufficient staffing was the reason. A family member stated call bells were never answered and that staff seemed overwhelmed, and also reported the front desk phone was not answered. The DON acknowledged awareness of shifts where staffing levels were not met and stated sick calls were a problem; she said the facility usually filled vacancies by asking staff to work overtime and adjusting schedules, but did not offer incentives or use agency staff. During observation, multiple call bells were ringing and not being answered, and there was a noticeable urine odor in the hall. An LPN stated staffing for that day was good, but also said staffing sometimes dropped to one nurse once or twice a week.
Advance Directive and CPR Policy Implementation Failures
Penalty
Summary
The facility administration did not use its resources effectively and efficiently to maintain residents’ highest practicable physical, mental, and psychosocial well-being because advance directive policies were not properly identified, communicated, and consistently implemented. The facility policy on Advance Directives/Advance Care Planning stated that clinical team members were responsible for reviewing advance directives, incorporating the resident’s wishes into treatment and care, and communicating those wishes to involved staff. During interview, the Social Worker stated they were at the facility on weekends, met with new admissions at that time, and reviewed advance directives including DNR orders, but only worked weekends. The Social Worker also stated they had spoken to administration about MOLST forms not being updated regularly, but had not discussed a plan to address DNR orders while they were not working. The facility also failed to ensure its CPR policy was implemented and that certified staff were present on every shift. The CPR policy stated that all licensed nursing personnel were required to be certified in CPR and possess a current certificate to perform CPR. During interview, the Administrator stated they believed there was a sign behind the bed for residents with DNR orders, knew that MOLST, advance directives, and DNR were a priority, and were unaware of the identifier used for advance directive/DNR status. The Administrator further stated that the DON needed to determine how staff would identify residents’ code status, and later stated they had only been at the facility a few months and were unaware the building did not have CPR-certified staff present during all shifts.
Governing Body Lacked Clear Oversight and QAPI Communication Process
Penalty
Summary
The governing body did not establish and implement a clear process for managing communication with the facility administrator, including the frequency and method by which the administrator reported to the Board. During the recertification and extended survey, surveyors found that the governing body did not receive minutes of the facility QAPI meetings, and the facility did not provide documented evidence that QAPI minutes were shared with the Board of Directors. The Chairman of the Board stated that the Board was the governing body, that management was led by the Interim Administrator, and that an Administrator had been hired to start soon. During interviews, the Chairman stated that management handled administrative duties such as payroll, human resources, purchasing, and union dealings, but could not state the Board’s involvement with QAPI or confirm review of QAPI minutes. The Chairman also stated they had quarterly meetings with the facility but could not say whether QAPI minutes were seen, did not review the 2024 recertification survey results, and were not involved with the plan of corrections. The Administrator stated they did not recall sending QAPI minutes to the Board, and the CEO of the management company stated they were not involved in QAPI meetings, did not review the minutes, and that nobody was properly managing the process.
Residents Not Informed of Grievance Process
Penalty
Summary
The facility did not make information on how to file a grievance or complaint available to residents. During a resident council meeting, multiple residents stated they were unaware of the process for filing a formal grievance with the facility and did not know who the grievance official was. An observation of the front entrance lobby and resident units found no postings identifying the grievance officer or providing information on the grievance process. Record review showed the facility’s grievance log contained only three grievances over the prior 15 months, and the policy titled Social Services/ Complaints and Grievances dated 07/25/2024 stated the Administrator would inform the Abuse Coordinator, identified as the Director of Social Services, when a complaint was made and an investigation had begun. During interviews, the Administrator stated residents were told about the grievance process during admission and received a complaint and grievance form in the admission packet, but also stated there was no Abuse Coordinator and they were trying to hire a full-time social worker. The Administrator did not know whether the grievance process had ever been reviewed at resident council meetings. A resident and a family member also stated they were unaware of the grievance process, and the Social Worker stated they had not been instructed to handle grievances and were unaware of the grievance policy.
Failure to Provide Required Transfer, Bed-Hold, and Ombudsman Notifications
Penalty
Summary
The facility did not ensure that written transfer or discharge notification, including bed-hold notice and ombudsman notification, was completed for three residents reviewed for hospitalization or discharge home. For Resident #61, who had diagnoses including COPD and adult failure to thrive and whose admission MDS documented severely impaired cognition and substantial to maximal assistance with ADLs, a progress note documented transfer to the hospital for acute respiratory distress, but the record contained no evidence that a bed-hold notice or ombudsman notification was completed. For Resident #66, who was admitted with diagnoses including sepsis, spastic quadriplegic cerebral palsy, and [NAME] syndrome, the record also lacked documented evidence of a transfer/discharge notice, bed-hold notice, or ombudsman notification when the resident was discharged. Resident #63, who had diagnoses including pneumonia, diabetes, and an intellectual disability and whose admission MDS documented severely impaired cognition and partial assistance with all ADLs, was discharged home with group home staff after lunch and had medications and clothing given to staff, but the facility could not provide documented evidence that the ombudsman was notified of the discharge. Facility staff stated the social worker should send the bed-hold notice and ombudsman notification, but the ADON and social worker could not locate proof that these notices were completed, and the ombudsman stated they had not been receiving discharge notices consistently and had no notices for Residents #61, #63, or #66.
Nonfunctioning Resident Call System
Penalty
Summary
The facility did not ensure that residents had a working call system available in their bathrooms and bathing areas, and the second-floor call system was not functioning as intended in multiple rooms. Surveyors observed that the lights above the doors in Rooms 202A, 202B, 205B, 207B, 212B, and 217B illuminated when a call was activated, but there was no audible sound. Tap bells were also not provided or readily available for three bathrooms in Rooms 202, 207, and 212. In addition, the centralized call monitor console at the second-floor nurse station produced an audible sound when call lights were activated, but it did not accurately display the corresponding room numbers. During observations and interviews, staff acknowledged that the call bell system had been malfunctioning for an extended period. A CNA stated that some call bells lit up but did not ring in all resident rooms and believed there may have been a wiring problem. Residents in council meeting stated the call bells did not consistently work, were not answered in a timely manner, and had not been functioning properly for at least eight months. An LPN manager and the RN night supervisor both stated that some call bells were not functioning properly and that the centralized console did not accurately identify the activated room. The facility’s maintenance director stated the issue had been reported in June 2025 and that a vendor proposal for a new call bell system had been received in July 2025 but not signed. The DON stated the call bell system had not functioned properly since she started in March 2025, that temporary tap bells had been placed in rooms where call bells were broken, and that there was no documentation to confirm rounds had been conducted. The facility could not provide documentation related to staff rounds while the call light system was malfunctioning.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility did not ensure that a resident receiving Medicare Part A services was fully informed of the right to an expedited review of a service termination. Resident #71, who was admitted with diagnoses including anemia, arthritis, and cataracts, had an admission MDS dated 02/26/2025 documenting that the resident was cognitively intact and received 60 minutes of PT and 40 minutes of OT. There was no documented evidence that a signed Notice of Non-Coverage for Medicare, form CMS-10123, was issued 2 days before the last Medicare-covered day of 04/23/2025. A late-entry therapy note documented that on 04/21/2025 the resident was given a Notice of Non-Coverage, refused to sign it, and would speak to the designated representative. During interview, an OTA stated they called the designated representative to determine whether the notice had been signed, were told the resident had been cut from therapy, and stated the therapy department was supposed to obtain the signed notice while nursing was responsible for insurance cuts from therapy.
Failure to Assess and Treat a Sacral Pressure Ulcer
Penalty
Summary
The facility did not ensure that a resident with a pressure ulcer received necessary treatment and assessment consistent with professional standards of practice to promote wound healing. Resident #1 was readmitted with diagnoses including diabetes mellitus, depression, and an unstageable sacral pressure ulcer, and the admission MDS documented one Stage 3 pressure ulcer and one unstageable pressure ulcer present on admission. Hospital documentation included a wound consult recommending cleansing the sacrum with normal saline, applying a nickel-thick layer of Santyl daily, and covering with a silicone bordered foam dressing daily and as needed if soiled or dislodged. On readmission, nursing documentation noted the resident arrived from the hospital with a Stage 4 sacral pressure ulcer, and a skin check documented a new sacral pressure ulcer with full thickness skin and tissue loss, unknown duration, and signs and symptoms of infection including redness, bleeding, granulation tissue, and pain. A nursing progress note documented cleansing with normal saline and application of Santyl and a protective dressing. A physician note documented the resident had returned from the hospital with a sacral Stage 4 ulcer and would be followed by wound care. Review of nursing and physician progress notes from 08/01/2025 through 08/13/2025 found no documented evidence that the sacral pressure ulcer was assessed. The wound care rounds summary on 08/13/2025 documented the sacral wound as Stage 3, measuring 9.0 cm by 10 cm by 0.2 cm, with 90 percent slough, 10 percent granulation, and moderate serosanguineous drainage. The treatment order was documented on 08/14/2025, and the TAR showed Santyl starting on 08/15/2025, with no documented treatment prior to that date. Later wound rounds documented continued worsening measurements and tissue breakdown, and staff stated the wound rounds were not done on 08/06/2025 because the wound care provider was unavailable, with no weekly wound measurements found in the record for that date.
Medication Availability and Controlled Drug Reconciliation Failures
Penalty
Summary
Pharmaceutical services did not meet the needs of each resident because Resident #47’s ordered Metformin 1000 mg twice daily was not available for administration during the medication pass. Resident #47 had diagnoses including diabetes, post cerebral infarction, and hemiplegia, and the quarterly MDS documented intact cognition with partial to moderate assistance needed for activities of daily living. During observation, the LPN placed the resident’s medications in a cup but stated the Metformin was unavailable in the medication cart and would have to be requested from pharmacy. Later documentation noted the facility was still waiting for pharmacy to deliver the medication, and the DON stated nurses were responsible for stocking the medication cart, that pharmacy deliveries were verified and carts restocked by an RN, and that the medication was not available in the back-up box. The pharmacy representative stated the medication should have been reordered 4 to 5 days before it ran out and that delivery would occur the next afternoon, with STAT delivery available within 2 hours if needed. The facility also did not ensure a system of disposition and reconciliation for controlled drugs. Resident #68, who was admitted with subdural hemorrhage, altered mental status, and acute post procedural respiratory failure, had a physician order for Lorazepam Intensol oral concentrate 2 mg/mL, 1 mL every 8 hours for agitation, and the MDS documented discharge due to death in the facility. During observation of the medication room, two boxes of Lorazepam oral concentrate were found in the refrigerator lock box, including one sealed box and one open box labeled for the resident. Nursing Supervisor #7 stated the Lorazepam belonged to a resident who had passed away and that a count sheet could not be located. The pharmacy consultant stated the medication had been found in the refrigerator on a prior inspection and that if nurses had access to it, it should have been counted; if it was to be destroyed, it should have been removed from the refrigerator. The DON stated narcotics with nurse access should be counted every shift and that they did not know why the medication remained in the refrigerator.
Repeated Blood Pressure Medication Errors
Penalty
Summary
Resident #3, who had diagnoses including hypertension, hypotension, and end stage renal disease, received blood pressure medications outside of ordered parameters on multiple occasions. The physician orders directed staff to hold Metoprolol when blood pressure was below 110 and to hold Midodrine when blood pressure was above 130, yet the MARs documented repeated administrations outside those limits across March through August 2025. The record identified 25 occasions in which Metoprolol or Midodrine were given despite the resident’s blood pressure being outside the ordered range. The pharmacy consultation notes repeatedly identified medication administrations outside parameters and instructed staff to inquire, address, and initiate a medication error report per facility policy. The report states there was no documented evidence of medication error reports for the 24 times the blood pressure medications were administered outside the ordered parameters, and there was no documented evidence of disciplinary actions for the medication errors for Resident #3. The facility’s medication error policy stated the nurse manager was responsible for completing a medication incident report and forwarding it to the DON, with monthly summation and QAPI review. During interviews, the Pharmacy Consultant and Pharmacist stated they reviewed medication errors, informed the ADON, and provided education, while the ADON stated they did not use the Medication Incident Report form and instead documented the errors on disciplinary action forms, but could not provide copies of reports or disciplinary actions for Resident #3. The DON stated the ADON was supposed to audit the record and complete the Medication Incident Report form, but they did not know why the form was not being used. The DON also stated the nurses were not reading the parameters properly and that the resident had a history of hypotension during dialysis, with the physician stating the resident needed Midodrine to bring the blood pressure up and Metoprolol to control heart rate.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled in accordance with currently accepted professional principles when an open insulin pen for a resident with type 2 diabetes mellitus, metabolic encephalopathy, and brief psychotic disorder was found in the medication cart without an open date. The resident’s quarterly MDS documented daily insulin injections, and the physician order directed Lantus Solo-Star 100 units/mL, 26 units every day at bedtime. During observation, the insulin pen was found with no date indicating when it had been opened, despite the manufacturer recommendation that the pen be dated when opened and considered viable for 28 days after opening. Drugs and biologicals were also not stored in a locked compartment when a medication cart on the upper-level east unit was observed unattended and unlocked in the hallway. The facility’s nursing/medication storage policy stated that medications are to be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel, and the nursing/medication administration policy stated that licensed professional nurses are responsible for knowing drug classification, action, dosage, side effects, and manufacturer recommendations. Nursing Supervisor #7 stated the day nurse must not have locked the cart when leaving for the day, and the DON stated medication carts should be locked when left unsupervised.
Infection Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a sanitary environment and prevent the development and transmission of infection for two residents reviewed for infection control. Resident #65 had diagnoses including Gram Negative Sepsis, Parkinsons Disease with Dyskinesia, and Extended Spectrum Beta Lactamase, and had a physician order for contact precautions for ESBL in urine or blood. During observation, the resident’s room had no contact precaution sign posted outside the door and no PPE bin or garbage bin for discarding PPE by or inside the room. A CNA was later observed inside the room wearing only a mask and, without gloves or a gown, opening and closing the resident’s dresser drawers. The CNA stated that because they were not providing care, they did not need to wear a gown or gloves, although they also stated that care for a resident on contact precautions required a gown, gloves, and mask. Resident #23 was on enhanced barrier precautions, and during incontinence care two CNAs wore gloves and masks but did not wear gowns. The CNA interviewed stated a gown was required when entering the room to provide care for a resident on enhanced barrier precautions. In addition, the DON/Infection Preventionist stated infection tracking sheets were used for surveillance but could not provide complete infection surveillance documentation, including onset of symptoms, antibiotic start dates, and which isolation precautions were ordered. The covering Medical Director stated that before starting antibiotics for UTI, residents would be assessed for signs and symptoms of infection, urine would be collected for culture, and antibiotics would be prescribed if needed.
Failure to Develop and Update Comprehensive Care Plans After Clinical Events
Penalty
Summary
A deficiency was identified in the facility's development and implementation of comprehensive, person-centered care plans for residents. Specifically, for three residents reviewed, the facility failed to initiate or update care plans in response to significant clinical findings and incidents. One resident, admitted with multiple diagnoses including diabetes mellitus and end stage renal disease, was assessed as high risk for falls upon admission, but there was no documented evidence that a fall risk care plan was initiated. This resident later experienced a fall when attempting to self-transfer from bed to chair. Another incident involved two residents who were roommates. One resident reported being struck by the other following a verbal disagreement. Although both residents had existing care plans noting potential for abuse, there was no documentation that these care plans were updated to reflect the incident or that new interventions were implemented. The resident who was struck was relocated for safety, but the care plan documentation did not reflect this event or any subsequent changes in interventions. Interviews with facility staff, including registered nurses and directors of nursing, confirmed that care plans should be initiated or updated when assessments trigger specific care areas or after incidents occur. However, in these cases, the required updates and documentation were not completed as per facility policy and regulatory requirements. The lack of timely and appropriate care plan development and revision was observed through record reviews and staff interviews during the survey.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident reported being physically struck by their roommate during a verbal altercation. The incident involved one resident propelling their wheelchair to the other side of the shared room and striking the other resident twice on the left chest and neck area. Documentation showed that both residents had care plans addressing potential for abuse and impaired cognitive function, with interventions such as monitoring behaviors and assessing needs. Despite these plans, the altercation occurred, and the incident was reported as required by facility policy. The resident who was struck had diagnoses including atrial fibrillation, hypotension, and cardiomegaly, and was cognitively intact but required assistance with daily activities. The other resident had acute kidney failure, hypotension, hyperlipidemia, and moderate cognitive impairment, with a history of impaired thought processes. The facility's policies required immediate reporting and individualized monitoring for residents at risk of altercations, but the event still took place, indicating a failure to protect the resident from abuse as required.
Improper Use of Physical Restraint with Upright Floor Mats
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and multiple medical diagnoses, including metabolic encephalopathy and muscle weakness, was found in bed with floor mats propped upright against the bed and held in place by two wooden night tables. This arrangement prevented the resident from moving out of bed, effectively acting as a physical restraint. The resident required moderate assistance for bed mobility and was dependent for transfers and toileting, with no documented physician order for restraints or side rails in use. The facility's Restraint-Free Environment policy states that restraints are only to be used for the safety and well-being of residents and only after all alternatives have been tried unsuccessfully, and never for staff convenience or fall prevention. Despite this, a Certified Nurse Aide was responsible for placing the mats in this manner, believing it would prevent the resident from rolling out of bed and ensure safety. The incident was discovered during a federal survey, and interviews revealed that the mats were intentionally positioned upright and secured, rather than being placed flat on the floor as intended. Further investigation showed that the resident was bedridden, required a two-person assist for transfers, and had difficulty bearing weight. Staff interviews confirmed that the mats should not have been positioned upright, as this constituted a restraint. There was no evidence of physical harm to the resident, but the use of the mats in this way was not in accordance with facility policy or regulatory requirements, and there was no documented medical need or order for such a restraint.
Failure to Timely Report Suspected Abuse and Investigation Results
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse and the results of related investigations to the New York State Department of Health for two out of three residents reviewed for abuse. In the first instance, a resident with diagnoses including metabolic encephalopathy, depression, and muscle weakness was found in bed with floor mats propped up against the bed and held in place by two wooden night tables, preventing the resident from exiting. The responsible certified nurse aide believed this would prevent the resident from rolling out of bed. Although the facility's investigation did not substantiate a breach in quality of care, the use of mats in this manner constituted a physical restraint. The incident was not reported to the Department of Health until the following day, and the 5-day investigative conclusion was not submitted until over a year later. In the second instance, a cognitively intact resident reported being struck twice on the chest/neck area by their roommate following a verbal disagreement. The incident was unwitnessed, and a full body and skin assessment revealed no injuries. However, the 5-day investigative conclusion for this incident was not submitted to the Department of Health until six days after the event. The facility's policy required immediate reporting of suspected abuse and submission of investigative results within five business days, but these requirements were not met in either case.
Incomplete Investigation Following Resident Fall
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following a fall involving a resident with multiple diagnoses, including diabetes mellitus, end stage renal disease, and benign neoplasm of the duodenum. The resident, who was cognitively intact but required maximal assistance with transfers and had upper extremity impairments, experienced a witnessed fall while attempting to transfer independently from bed to chair, despite prior instructions to seek assistance. The accident/incident report for this event was incomplete, lacking an investigative summary and staff statements, and there was no documentation that the resident's representative was notified of the fall. According to facility policy, an investigation should be initiated for any outward event, such as a fall, and should include staff interviews and statements from those present during the incident. However, the Registered Nurse who witnessed the fall did not complete the required incident report or obtain statements from Certified Nurse Aides, citing short staffing and multiple responsibilities as reasons. The only documentation provided was a progress note, and the Assistant Director of Nursing confirmed that only the top portion of the report was completed, with no explanation for the omission.
Failure to Update Care Plan for Pressure Ulcer Progression
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed, updated, and revised for one resident with significant skin integrity issues. Specifically, the resident, who had severe cognitive impairment, hemiparesis, and was dependent for all care, developed a Stage 2 pressure ulcer to the sacrum and bilateral buttocks while in the facility, in addition to a Stage 4 pressure ulcer present on admission. The care plan in place only addressed a Stage 4 pressure ulcer on the left heel and did not include documentation of the sacral/buttocks ulcer, its measurements, treatments ordered, or updates on wound progression and physician findings, despite these being reported to the facility. Interviews with nursing leadership revealed that wound care physician notes were received weekly, and it was the expectation that nursing staff would update the care plan with any changes in wound status or treatment orders. However, the care plan was not updated to reflect the presence or progression of the sacral/buttocks ulcer, nor were physician findings consistently documented. The responsibility for updating care plans was described as belonging to unit managers, but this was not carried out as required by facility policy and regulatory standards.
Failure to Notify Physician and Obtain Treatment Orders for Pressure Ulcer on Admission
Penalty
Summary
A deficiency was identified when a resident admitted with multiple diagnoses, including diabetes mellitus and end stage renal disease, was found to have a Stage 2 pressure ulcer in the intergluteal medial cleft during the admission skin check. The ulcer measured 5 cm x 4 cm, showed no signs of infection, and the resident denied pain. Despite facility policy requiring that the physician be notified of any wounds or pressure ulcers at the time of assessment and that treatment orders be obtained, there was no documented evidence that the physician was informed of the pressure ulcer or that any treatment orders were obtained upon admission. Interviews with nursing staff and the Director of Nursing confirmed that the standard protocol was not followed in this case. The responsible RN stated that they did not receive a treatment order from the physician for the pressure injury, describing this as an oversight. The DON further clarified that while there are standing orders for different wound stages, the physician must be notified to determine the appropriate protocol. The lack of physician notification and absence of treatment orders for the pressure ulcer constituted a failure to provide necessary care and services consistent with professional standards of practice.
Resident Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident where a Certified Nurse Assistant (CNA) was reported to have physically abused a resident. A visitor witnessed the CNA punching the resident in the head while in the resident's room. The resident, who had severe cognitive impairment due to dementia, was unable to communicate details of the incident. The facility's abuse policy, revised in January 2024, mandates that all residents be free from abuse, including physical abuse such as hitting and slapping. The resident involved in the incident had a documented history of severe cognitive impairment and required maximal assistance with daily activities. Despite this, there was no documented evidence of a risk for abuse care plan in place for the resident. The facility conducted an investigation following the report of abuse, but was unable to substantiate the allegation due to the lack of physical evidence and the resident's inability to articulate the incident. However, the facility decided to terminate the CNA involved, citing the severity of the allegations and the need to ensure resident safety. Interviews with facility staff, including the Administrator and Medical Director, revealed that the CNA left the facility shortly after the incident and did not provide a statement. The Medical Director and Attending Physician examined the resident and found no physical injuries. The Administrator acknowledged the credibility of the witness and expressed belief that the CNA did abuse the resident. Despite the lack of physical evidence, the facility took the precautionary step of terminating the CNA to maintain a high standard of care and safety.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a resident with severe cognitive impairment. A visitor reported witnessing a Certified Nurse Assistant (CNA) physically assaulting the resident by punching them in the head. Despite the severity of the allegation, the facility did not obtain a written statement from the accused CNA, nor did they interview or assess other residents under the CNA's care to rule out further abuse. The resident involved in the incident had a history of Alzheimer's, diabetes, and muscle weakness, and was severely cognitively impaired, as indicated by a Brief Interview for Mental Status score of 0. The facility's investigation included assessments by the Medical Director, nursing supervisor, and Director of Nursing, but there was no documented evidence of a comprehensive medical assessment by a physician or nurse practitioner. The investigation concluded without substantiating the abuse allegation, despite a credible witness account, due to the lack of physical evidence and the resident's inability to communicate details of the incident. Interviews with facility staff revealed inconsistencies and gaps in the documentation of the incident. The Administrator acknowledged the credibility of the witness but noted the absence of a statement from the CNA. Licensed Practical Nurses involved in the post-incident care of the resident did not document their assessments, and the Director of Nursing admitted to not documenting the skin check. The facility's failure to follow its abuse policy and ensure comprehensive documentation and investigation of the incident led to the deficiency.
Deficiency in Certified Nurse Aide Performance Appraisals
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide performance appraisals were completed at least once every 12 months, as required. During a recertification survey conducted from May 28, 2024, to June 4, 2024, it was found that performance appraisals were not documented for five certified nurse aides. Interviews with the Director of Human Resources revealed that a project to update performance appraisals had begun about a month prior, but the Nursing Department had not completed appraisals for any nurse aides. Upon request, the Director of Human Resources was unable to provide recent performance appraisals for the selected staff members, with the most recent appraisals dating back several years, and one staff member having no documentation of any appraisal.
Infection Control Deficiencies in Linen Handling, Water Management, and C. Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the recertification survey. Firstly, clean linens were transported throughout the facility without being covered, which is against infection control protocols. Maintenance staff were unaware of the requirement to cover linen carts, despite the Director of Maintenance acknowledging that staff had been previously instructed to do so. Additionally, a Certified Nurse Aide was observed handling dirty linens and then making a resident's bed without changing gloves, indicating a lapse in hand hygiene practices. The facility also lacked a current Water Management Plan, which is essential for preventing Legionella infections. The Director of Maintenance was unable to articulate a plan or next steps in the event of positive test results for Legionella, and the Assistant Director of Nursing admitted that the Director of Maintenance had not been educated on the Legionella Plan upon hiring. This lack of a comprehensive water management strategy poses a risk of Legionella growth and spread within the facility's water systems. Furthermore, the facility failed to implement appropriate contact precautions for a resident with a confirmed Clostridium Difficile infection. Despite a physician's order for contact isolation, the resident was observed outside their room without proper signage or personal protective equipment (PPE) available for staff. Multiple staff members, including a Certified Nurse Aide and the Director of Rehabilitation, were observed not wearing the required PPE while interacting with the resident. The Director of Nursing acknowledged the oversight in signage and PPE availability, and the Assistant Director of Nursing was unsure why the contact isolation sign was not posted, despite attending daily clinical meetings discussing residents on precautions.
Deficiency in COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to ensure that each staff member was screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with the vaccine. This deficiency was identified during a recertification survey conducted from May 28 to June 4, 2024, where it was found that there was no documented evidence of immunization records for three out of ten staff members reviewed for COVID-19 vaccines. Specifically, the facility lacked documentation of screening, education offering, or current COVID-19 vaccination status for these staff members. During an interview, the Assistant Director of Nursing acknowledged the issue, stating that efforts had been made to encourage staff to receive the COVID-19 vaccine, but many employees were resistant. They also mentioned that vaccine records were obtained from Human Resources and reviewed upon hire, but they were unaware that the records for these employees did not show they were screened, offered, or given an opportunity to decline the COVID-19 vaccine.
Failure to Notify Family of Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident's representative was immediately notified of the development of an unstageable sacral pressure ulcer. This deficiency was identified during a recertification and abbreviated survey, where it was found that the representative of a resident with a history of urinary tract infection, metabolic encephalopathy, and brain tumor was not informed about the pressure ulcer. The resident, who was admitted with modified independence for decision-making and required assistance with daily living activities, did not have a pressure ulcer documented upon admission. The care plan for the resident, which included an intervention to inform the resident or family of any new skin breakdown, was not followed. On 12/5/2022, a nurse's note documented a sheer injury to the sacrum, and a subsequent physician consultant wound note on 12/7/2022 described the ulcer as unstageable. Despite these developments, there was no documentation that the family was notified of the pressure ulcer. The Assistant Director of Nursing confirmed the lack of documentation regarding family notification.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the New York State Department of Health within the required two-hour timeframe. The incident involved a resident with diagnoses including amyotrophic lateral sclerosis, cerebrovascular accident, dementia, reflux, and hypertension, who had intact cognition and was dependent on staff for activities of daily living. The resident reported to the facility Administrator that during a previous shower, three women forcibly removed their clothes, dragged them down the hallway naked, and one of the women squeezed their genitals multiple times. This allegation was made known to the Administrator on 5/6/24. The Director of Nursing was informed of the allegation on the same day by the Administrator and began an investigation by reviewing the previous three showers and obtaining staff statements. However, the report to the New York State Department of Health was not submitted until the following day, 5/7/24, at 13:39 PM. The Director of Nursing admitted to not being aware of the two-hour reporting requirement, mistakenly believing they had 24 hours to report the incident. This oversight resulted in a failure to comply with the mandated reporting timeframe for allegations of abuse.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for four residents, leading to deficiencies in meeting their needs. Resident #42, who required varying levels of assistance with activities of daily living (ADLs), did not have an active care plan outlining these needs. Interviews with staff revealed confusion and lack of clarity regarding responsibility for initiating and updating care plans, with multiple staff members pointing to others as responsible for the oversight. Resident #229, admitted with a seizure disorder and other conditions, also lacked a care plan addressing ADLs and seizure management. Staff interviews indicated that care plans should be initiated upon admission, but there was a disconnect between policy and practice, as evidenced by the absence of a care plan for this resident. The Director of Nursing acknowledged the expectation for care plans to address all resident needs, including specific diagnoses and medication management. Resident #70, who experienced an alleged abuse incident, did not have a care plan addressing ADLs or abuse prevention. Despite the incident being reported, there was no follow-up in terms of care planning to prevent future occurrences or address the resident's needs. Similarly, Resident #327, who required assistance with ADLs, did not have a documented care plan, and family members reported inadequate care. Staff interviews highlighted a lack of awareness and responsibility for ensuring care plans were in place, contributing to the deficiencies identified.
Deficiency in Nurse Aide Training Documentation
Penalty
Summary
The facility failed to ensure that certified nurse aides received the required 12 hours of training and annual in-services on dementia care management and resident abuse prevention. During a recertification survey, it was found that the facility could not provide evidence of mandatory training for two of the five nurse aides reviewed. Specifically, the training documentation for Staff #8 and Staff #11 was missing. The MDS Nurse/Staff Educator, responsible for maintaining these records, confirmed the inability to locate the 'Mandatory In-Service Sign-Off Sheets' for these staff members.
Failure to Ensure Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents during a recertification survey. Resident #328, who has severe cognitive impairment and requires extensive assistance with eating due to conditions such as dementia and Parkinson's disease, was observed being assisted with their meal by a certified nurse aide who stood over them instead of sitting. This action was contrary to the facility's feeding program policy, which aims to promote residents' self-esteem and well-being. The staff member acknowledged knowing the correct protocol but did not follow it during the observation. Similarly, Resident #46, who also has severe cognitive impairment and requires moderate assistance with eating, was addressed inappropriately as a "feeder" by a certified nurse aide. Additionally, this resident was fed by another aide who stood over them during meals, despite being advised to sit by a licensed practical nurse. The aide cited a lack of available chairs as the reason for standing. These actions were inconsistent with the facility's policy and compromised the residents' right to a dignified dining experience.
Failure to Ensure Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate advance directives, as evidenced by the lack of a physician's order for such directives. Resident #334, who was admitted with diagnoses including anemia, malignant neoplasm of the prostate, and occlusion and stenosis of precerebral arteries, had moderately impaired cognition. During a record review, it was found that there were no advance directives in the electronic medical records or a hard copy of Medical Orders for Life Sustaining Treatment (MOLST) for the resident. Interviews with staff revealed that in the event of a medical emergency, the facility would contact the family and physician and send the resident out for evaluation. A review of the resident's MOLST form showed it was signed by the resident but not by a physician, and it included conflicting instructions regarding CPR and other life-sustaining treatments. A physician's order indicated the resident was Full Code, but there was no evidence the physician was aware of the resident's other advance directives. The Director of Social Services acknowledged the need for a physician's signature on the MOLST form.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, as well as failing to notify the Ombudsman, for two residents. Resident #18, who had diagnoses including diabetes mellitus, chronic kidney disease stage 3, and protein calorie malnutrition, was transferred to the hospital on 3/19/24. Despite having intact cognition, there was no documentation that Resident #18 or their representative received a written notice of the transfer, nor was there evidence that the Ombudsman was notified. The Director of Social Work confirmed that no notice of transfer was found in the resident's file, and it was noted that the responsibility for completing the form varied depending on the time of transfer. Similarly, Resident #24, with diagnoses including diabetes mellitus, hemiplegia and hemiparesis affecting the right side, and hypertension, was transferred to the hospital on 4/1/24. The resident also had intact cognition, yet there was no documentation of written notification to the resident or their representative, nor was there a record of notification to the Ombudsman. The Director of Social Work acknowledged the absence of the notice in the resident's file. The facility's policy, revised in February 2018, mandates issuing a valid notice of discharge/transfer to residents, their representatives, and the Ombudsman, which was not adhered to in these cases.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers, as required by regulations. This deficiency was identified during a recertification survey conducted from May 28, 2024, to June 4, 2024, affecting two out of three residents reviewed for hospitalization. Specifically, the facility could not provide evidence of written notification for Residents #18 and #24, who were transferred to the hospital with the anticipation of return. Resident #18, who had diagnoses including diabetes mellitus, chronic kidney disease stage 3, and protein-calorie malnutrition, was transferred to the hospital on March 19, 2024. Despite having intact cognition, there was no documentation that the resident or their representative received a written notice of the bed hold policy. Similarly, Resident #24, with diagnoses including diabetes mellitus, hemiplegia, and hypertension, was transferred to the hospital on April 1, 2024, and also did not receive the required notification. Interviews with the Director of Social Work confirmed the absence of these notifications, attributing the responsibility to the nurse on duty after hours and an administrative staff person during business hours.
Delayed MDS Assessment for Resident
Penalty
Summary
The facility failed to complete the Minimum Data Set (MDS) 3.0 comprehensive assessment for a resident in a timely manner, as required by federal and state regulations. Specifically, the MDS admission assessment for a resident with diagnoses including diabetes, hypertension, and dementia was not completed within the mandated 14 calendar days from the date of admission. The resident was admitted on January 7, 2024, and the assessment was scheduled for January 9, 2024, but was not completed until January 24, 2024, exceeding the required timeframe. The facility's policy, revised in January 2024, mandates that the Resident Assessment Instrument (RAI) be used to ensure optimal care planning and quality of care, with the assessment coordinator responsible for timely completion. During an interview, the MDS/Discharge Planning Coordinator acknowledged the delay, stating that the admission assessment was submitted late. This deficiency was identified during a recertification survey conducted from May 28, 2024, through June 4, 2024.
Deficiency in PASRR Documentation
Penalty
Summary
The facility failed to ensure that each resident's Pre-Admission Screening and Resident Review (PASRR) assessment was signed and included the required digital ID prior to admission. This deficiency was identified during a recertification survey, where it was found that three out of twenty-five residents reviewed did not have the necessary documentation. Specifically, the electronic medical records for these residents lacked evidence of a signed and digitally identified PASRR assessment, which is required to assess for mental illness, dementia, and intellectual disabilities. Interviews conducted during the survey revealed a lack of clarity regarding responsibility for ensuring the completion and documentation of PASRR assessments. The Director of Social Work was unaware of who was responsible for verifying the signatures and digital IDs. The facility Administrator indicated that the Director of Admissions or the Outreach Coordinator should ensure the completion of these assessments before admission. However, the Outreach Coordinator, who was temporarily filling in for the Director of Admissions, confirmed that they were responsible for this task during the interim period.
Failure to Develop Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours of admission, as required by their policy and CMS regulations. The resident, who was admitted with diagnoses including an unstageable pressure ulcer, local skin infection, and darkened skin, did not have a baseline care plan documented in their electronic record. This omission was identified during a recertification survey. Interviews with facility staff revealed that the baseline care plan was not completed due to staffing issues. The Assistant Director of Nursing acknowledged the absence of the care plan and stated that it should have been completed by a Registered Nurse within the first 48 hours. A Registered Nurse Supervisor admitted to not completing the care plan, citing a lack of time as they were the only RN on the floor at the time.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), who was the Assistant Director of Nursing, completed specialized training in infection prevention and control before assuming the role. During the recertification survey, it was found that the IP had not completed the necessary training modules, including those on Antibiotic Stewardship and Occupational Health, until after the survey had commenced. The IP had been in the role since March 2024 but only completed the required Centers for Disease Control training course and presented the certificate on 5/29/24, after the survey began on 5/28/24.
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Illustrative
What surveyors actually found near you
We read the 968 citations issued within 25 miles in the last 12 months — including the 10 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Valley Cottage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nyack Ridge Rehabilitation And Nursing Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Northern Manor Geriatric Center Inc | 4.3 mi | ★★★★★ | 0 | 0 |
| Tarrytown Hall Care Center | 4.7 mi | ★★★★★ | 0 | 0 |
| Cedar Manor Nursing & Rehabilitation Center | 4.8 mi | ★★★★★ | 2 | 0 |
| Briarcliff Manor Center For Rehab And Nursing Care | 4.9 mi | ★★★★★ | 0 | 0 |
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