Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Van Duyn Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with chronic anemia, AFib, and anxiety had a hematology consult ordered and repeated CBC/Mg labs entered, but the consult was not completed and the bloodwork was delayed for 14 days. Staff described breakdowns in the lab-order process between the NP, ward clerk, and phlebotomy, while the resident and family reported repeated concerns about fatigue, weakness, and the need for timely bloodwork. The resident later had critical Hgb values, was sent to the hospital for emergency transfusion, and the hospital documented acute on chronic anemia.
A resident with chronic anemia, AFib, and anxiety had ordered CBC and magnesium labs repeatedly discontinued and re-entered before the specimen was finally collected. The tests were not completed when first ordered, and there was no documented evidence of the earlier lab results or nursing follow-up. When the labs were eventually drawn, the resident’s hemoglobin was critically low, prompting transfer to the hospital for emergency blood transfusion.
Surveyors found multiple food safety lapses in the kitchen, including opened and unlabeled food items in the walk-in refrigerator and freezer, dirty food prep and sink areas, and a nonfunctioning handwashing sink with grime and a spoon in it. The automatic dishwasher’s final rinse temperature was observed below the required level, and records showed repeated low rinse temperatures across multiple meal services. Staff and leadership acknowledged the labeling and equipment issues, and vendor records documented prior dishwasher repairs and ongoing maintenance problems.
A facility failed to maintain a clean and homelike environment when surveyors observed sticky floors in resident and common areas, dirty room walls, and a full, odorous urinal left on an overbed table. A cognitively intact resident also reported missing and nonworking light bulbs leaving the room dimly lit, while residents told surveyors housekeeping often only removed trash and did not complete full room cleaning.
Failure to develop and implement comprehensive person-centered care plans for a resident’s anemia, iron deficiency, and dry eye, and for another resident’s resident-to-resident altercation and oral surgery. One resident was receiving ferrous sulfate and artificial tears without documented care plans for the related diagnoses. Another resident had a documented physical altercation after being startled awake and later returned from dental surgery with pain management and soft diet needs, but the record did not show updated care plans for either event.
The facility failed to ensure timely dental evaluation and treatment for two residents. One resident had a broken front tooth reported by family, but staff documented conflicting assessments and no clear dental referral or follow-up. Another resident was missing upper dentures for an extended period; the diet was not promptly adjusted, impressions were delayed, and the resident was observed eating regular food without dentures and reporting difficulty chewing.
Failure to Document Resident Meal Consumption: A resident with osteomyelitis, infective endocarditis, and Type 2 DM had missing meal documentation for breakfast, lunch, and dinner across the month. The facility policy required nursing staff to document meal consumption, and both an LPN and CNA stated meal intakes were to be charted in the EHR for every resident.
Failure to provide water and ice to a resident with hydration needs. A cognitively intact resident with anemia, UTI, and adult failure to thrive had a care plan for hydration and preferred water and ice, but observations showed an empty pitcher without a lid and the resident reported staff did not refill it or bring fluids unless asked. The resident said they had to drink bathroom water and walk to the kitchenette for water and ice, while CNA and LPN interviews showed inconsistent understanding of hydration rounds and responsibilities.
Meals were not served at regular times, and nourishing snacks were not available for residents waiting to eat. On the 4th floor, dinner service ran for more than 2 hours, with residents at tables waiting while others ate and room trays delivered much later. Staff were observed standing around rather than helping with meal service, and a resident needed help unwrapping food before an aide intervened. A CNA reported the snack pantry was not consistently stocked, and staff described problems with the new tray line and staffing.
A resident with CKD, diabetes, and prior UTIs developed acute dysuria, new urinary incontinence, fever, and systemic symptoms, but an initial urinalysis order resulted in an unsuitable specimen that was never re‑collected, and later urinalysis and culture results showing pyuria and recommending recollection were not documented as reviewed by providers. Over several weeks, the resident had persistent fevers, nausea, vomiting, lethargy, poor intake, and abnormal labs, while being repeatedly treated with Rocephin without obtaining an adequate urine culture and sensitivity. A urology consult with cystoscopy for hematuria and urge incontinence recommended nightly vaginal estrogen for recurrent UTIs, but there was no evidence that a physician or NP reviewed or implemented this recommendation. The resident continued to decline and was ultimately hospitalized in critical condition with severe sepsis due to UTI, metabolic acidosis, and acute kidney injury, and hospital urine culture showed resistance to cephalosporins.
A resident with traumatic brain injury, severe cognitive impairment, and known aggressive behaviors had a care plan requiring two caregivers, no male caregivers, and 1:1 night supervision. Despite this, a male CNA assisted with incontinence care after the resident verbally refused to be touched. During the brief change, the resident became combative and spat at the CNA, who then forcefully pushed the resident’s head/face down, as witnessed by another CNA. The resident was later found by an LPN and RN/ADON to have multiple facial abrasions and redness and was agitated, reporting being scratched and disrespected by staff. There was no clear documentation or confirmation that the CNA accused of abuse was immediately removed from the premises after the incident.
A resident with traumatic brain injury, anxiety, severely impaired cognition, and documented behavioral issues had a comprehensive care plan specifying two staff for care, no male caregivers, and 1:1 supervision at night due to falls. Despite this, male CNAs were repeatedly assigned to the resident, including as a 1:1 on a night shift. During care at the end of that shift, the resident became combative and spat at the male CNA, who was then witnessed forcefully pushing the resident’s face into a pillow, causing facial and neck scratches. Multiple staff, including the ADON, LPNs, RN supervisor, NP, and Medical Director, confirmed that the resident was care planned to have no male caregivers and that this information was available on the care plan and care card, but it was not followed.
A resident with traumatic brain injury, severe cognitive impairment, and behavioral symptoms became agitated during incontinence care and attempted to spit at a CNA, who then forcefully pushed the resident’s face, causing multiple facial abrasions and redness. Another CNA witnessed the incident and recognized it as abuse, and an LPN later observed the injuries after hearing the resident scream, but staff did not immediately notify the on‑duty RN supervisor or management as required by facility policy. The Administrator and DON were not informed until about five hours after the incident, at which time law enforcement was contacted, and the required 5‑day investigative report to the State Agency was not submitted until 12 days later, in violation of abuse reporting and care planning requirements.
A resident with Alzheimer’s disease and bipolar disorder exhibited escalating verbal and physical aggression over several months, including throwing hot liquid, hitting other residents, swinging at staff, and attempting to throw a glass object, culminating in striking another resident in the head with a wheelchair leg rest. Despite repeated incidents, nursing staff did not complete incident reports in all cases, did not conduct root cause analyses, and did not timely initiate or update a behavioral care plan with specific interventions to prevent recurrence. Documentation showed ongoing refusal of psychotropic medication, use of racial slurs, and aggression, while staff interviews revealed reliance on informal monitoring and redirection rather than a formalized, individualized behavior plan. The facility’s policies required comprehensive care planning and abuse prevention measures, but these were not effectively implemented for this resident until after multiple resident-to-resident altercations had already occurred.
A resident with a history of respiratory failure and OSA, on 4 L O2 via nasal cannula, developed sudden labored respirations and severely low O2 saturations in the 20–40% range, became minimally responsive, and was placed on 10 L O2 via non-rebreather without a provider order. Nursing staff notified a supervising RN and repeatedly checked saturations but did not immediately contact the physician or NP, did not promptly call 911, and did not notify the resident’s health care proxy of the change in condition or transfer. EMS was eventually called, and the resident was transported to the ED in critical respiratory distress and later pronounced deceased. Staff interviews confirmed that facility policy required immediate provider and family notification for significant changes in condition and that such low O2 saturations should have triggered emergency response, but these steps were not followed, resulting in an Immediate Jeopardy deficiency.
A resident with respiratory failure and obstructive sleep apnea had a care plan and physician order for continuous oxygen at 4 L via nasal cannula, but a respiratory therapist provided only 3 L without verifying the order, and there was no RN assessment or documented monitoring when the resident reported shortness of breath. Family reported that an oxygen concentrator was not working, staff were notified, and the resident was placed on a portable tank, yet no staff addressed the oxygen issue before the family left. Later, an LPN found the resident minimally responsive with severely low O2 saturation, contacted an RN who briefly assessed and instructed use of a face mask but did not stay, and the LPN increased oxygen to 10 L via non-rebreather without a provider order; there was no documented RN assessment or physician notification before EMS was called, and EMS arrived to find the resident unresponsive and unattended on the unit.
A cognitively intact but high-risk resident with SUD, suicidal ideation, COPD on continuous O2, visual impairment, and poor safety awareness eloped after packing belongings, using a wheelchair with O2 to reach the lobby, and walking out the front entrance without being stopped or signed out. The resident had scored high on an AMA risk assessment but was scored zero on an elopement assessment, received no elopement-related care plan interventions or wander alert device, and had no MD order to be out on pass. Staff did not locate the resident during routine checks, initiated overhead pages and a Code White search hours after the last known contact, and marked later medications as "Out of Building" despite no documented discharge. The facility’s elopement policy lacked a defined timeframe for contacting 911, and emergency services were not called until more than five hours after the Code White, while the resident’s whereabouts were unknown. Police were told the resident was free to leave even though there was no documented AMA counseling, MD notification, or discharge order, and the AMA form was signed the next day at an off-site location without documented risk counseling.
The facility failed to maintain an effective compliance and ethics program and a non-retaliatory reporting culture. Written policies, including a Code of Conduct, a Non-retaliation and Non-retribution policy with an anonymous hotline, and an abuse prevention policy, stated that staff could report concerns without fear of retribution. However, multiple staff reported they did not trust the reporting process, feared loss of vacation, overtime, or work if they reported concerns, and believed anonymous reporting was ineffective. Staff also described fears of retaliation and threats of harm from coworkers. During surveyor interactions, the administrator, assistant administrator, and DON challenged the survey process in raised voices, leaned forward with clenched fists, questioned the Immediate Jeopardy decision, and the administrator attempted to prevent surveyors from leaving, reflecting an environment inconsistent with safe, non-retaliatory reporting.
A resident with Alzheimer’s disease and bipolar disorder, with moderately impaired cognition, was involved in two separate altercations where coffee was thrown and another resident was struck on the cheek, causing redness. Although facility policy and state guidance required review and reporting of incidents involving possible abuse or mistreatment to the state agency within five days, staff did not complete or submit required incident reports to the New York State Department of Health. The DON later explained that these events were not reported because there was no significant injury, pain, or mental anguish, and the Administrator described relying on internal communication processes to learn of such incidents.
A resident with Alzheimer’s disease and bipolar disorder, moderate cognitive impairment, and a known history of agitation and racial slurs exhibited escalating behaviors including throwing coffee that struck another resident, hitting another resident during a meal dispute, refusing Depakote, using racial slurs, physical aggression toward staff, being punched by another resident while cleaning tables, attempting to throw a vase at staff, and later striking the same resident with a wheelchair leg. Despite these repeated behavioral incidents and documentation in progress notes and investigative summaries, the comprehensive care plan either lacked interventions or contained only a generic redirection intervention, with no measurable objectives, timeframes, or detailed, person-centered behavior strategies. Interviews with CNAs, LPNs, RNs, and the DON showed that staff were aware of the behaviors and expected that care plans should be updated after such events, but behavior-focused care plan revisions were not completed in a timely or adequate manner.
A resident with complex medical and psychiatric conditions, including acute respiratory failure requiring O2 and a history of suicide attempts, was care planned as an elopement risk but left the building undetected, without ordered O2, medications, or an evening meal. The resident reported informing a staff member of their intent to leave, exiting through the main lobby with packed bags, abandoning their O2 due to difficulty carrying it, and receiving no challenge or sign-out request from staff. Facility policies required reporting and investigation of incidents such as elopement and potential neglect, yet documentation showed no timely, thorough investigation: key witnesses (day-shift staff, front desk, security, the nurse who contacted EMS, the nurse who spoke with police, and the social worker who later met the resident) were not interviewed, camera review was not documented, and statements were largely limited to evening-shift staff who had not seen the resident all shift. There were also inconsistencies and incomplete documentation around whether the departure was treated as an AMA discharge, contributing to the finding that the facility failed to thoroughly investigate the alleged neglect.
A resident with respiratory failure, OSA, and a history of pulmonary embolism had an active physician order and care plan for continuous O2 at 4 L/min via nasal cannula. During a visit, the resident reported breathing difficulty; the health care proxy found the concentrator not delivering air as expected and was unable to get staff assistance, after which the resident’s granddaughter independently connected the nasal cannula to a portable O2 tank of unknown flow. When a Respiratory Therapist later assessed the resident for reported SOB, the resident was on 3 L/min from the portable tank with SpO2 of 92% and was then switched to the concentrator at 3 L/min. The RT did not verify the current O2 order and stated they were unaware the resident was ordered 4 L/min, relying instead on a prior recollection of a 3 L/min setting, resulting in O2 being provided at a lower flow than prescribed.
A resident with respiratory failure, OSA, and hypertension experienced an acute change in condition with labored respirations, decreased responsiveness, and very low O2 saturations. An LPN notified the RN supervisor, oxygen delivery was escalated from nasal cannula to mask and then to a non-rebreather, and EMS ultimately transported the now unresponsive resident to the hospital. Despite facility policies requiring RN assessment and detailed transfer documentation, there was no recorded RN assessment, no documented vital signs (HR, BP, RR, temp), and no documentation of the resident’s response to oxygen therapy, and the RN’s progress note entry remained blank, leaving the medical record incomplete and not in accordance with professional standards.
A resident with opioid dependence, anxiety, depression, and a history of smoking violations had an active physician order and care plan intervention for 1:1 safety supervision following an IDT decision to place the resident on a safety watch. Facility policy required continuous close monitoring and documentation, but CNAs described inconsistent practices and unclear expectations regarding required proximity during 1:1 supervision. After the resident was readmitted from a hospital stay, the existing 1:1 safety watch was not implemented, no discontinuation order was documented, and staff on the new unit did not provide 1:1 supervision. Within days of this readmission without 1:1 in place, the resident was found with a self-inflicted neck laceration and superficial cuts to both wrists, constituting actual harm.
Staff were observed and reported to have used foul language, ethnic slurs, and laughed at residents in hallways and common areas, causing discomfort and distress among residents. Multiple residents and some staff confirmed that inappropriate language and behavior occurred frequently, in violation of facility policies requiring dignity and respect for all residents.
Surveyors found that the facility did not ensure resident rooms and common areas were clean and in good repair, with strong urine odors, soiled toilets, broken or empty dispensers, stained bedding, dirty floors, and maintenance issues such as broken tiles and missing ceiling tiles. A resident reported unclean bathrooms and shower rooms. Facility staff acknowledged the issues during interviews.
Surveyors found that the facility did not consistently provide palatable, flavorful, or properly temperature-controlled meals. Multiple residents reported cold, unappetizing food and missing meal items, while staff confirmed ongoing issues with food temperatures and tray accuracy. Observations showed food and beverages served outside recommended temperature ranges, and the Food Service Director acknowledged equipment problems affecting meal quality.
The facility failed to document actual administration times for standing medication orders, instead using broad pass windows such as 8:00 AM to 1:00 PM and 5:00 PM to 10:00 PM. Records for several residents showed this practice for medications including Eliquis, gabapentin, doxycycline, risperidone, valproic acid, amoxicillin-clavulanate, Keppra, carvedilol, and Depakote. The Administrator and DON stated that actual times could be reviewed only for PRN meds, not standing orders, and that medication passes could extend for several hours.
Surveyors found multiple medication carts and med rooms with unlabeled or undated insulin pens, inhalers, eye drops, nasal sprays, and other meds, along with expired items, loose pills, and pre-poured medication cups left in carts. Refrigerator temps were not consistently logged, one refrigerator was out of range, and a narcotic count discrepancy was noted for Xanax. Controlled substances were also not properly reconciled or signed out, a narcotic box was not securely affixed, and a treatment cart was left unlocked and unattended.
Food service sanitation was not maintained in the main kitchen and multiple unit kitchens. The dishwashing machine final rinse was not sanitizing as observed, the manual sanitizer was too concentrated, and a broken, uncleanable scoop was in use. Multiple food contact and non-food contact surfaces, equipment, floors, and storage areas were soiled, and there was no documented evidence that resident refrigerator temperatures, including one resident’s refrigerator, were being monitored.
Improper Disposal Area Sanitation: The trash compactor and loading dock area was observed to be heavily soiled, with black drip marks below the compactor access portal, splash marks and discoloration on the walls, and cobwebs throughout the area. An EVS director stated the area would be thoroughly cleaned.
Administration failed to ensure a safe, clean, comfortable, and homelike environment and failed to ensure the infection prevention and control program was fully implemented to prevent spread of infectious diseases. The Administrator said QA reviewed prior deficiencies and that infection prevention included staff/resident education, flu vaccine encouragement, and monthly meetings, but later stated they were not aware infection control was still an issue, including unvaccinated staff not wearing masks or wearing them incorrectly.
A resident with chronic respiratory failure, hypoxia, COPD, and morbid obesity had oxygen tubing documentation that did not match observations, and an LPN stated the tubing date was entered as the due date instead of the actual change date. The facility also did not provide surveyors full access to EHRs, as the ADM and DON said exact medication administration times for standing orders could not be viewed even though an LPN demonstrated that exact times were available.
QAA Committee Failed to Correct Repeat Quality Deficiencies: The facility’s QAA committee met monthly and included leadership and department representatives, but surveyors found repeated deficiencies in resident rights, med administration, self-determination, environment, care planning, quality of care, drug storage, food service, and infection control. Leadership stated these issues were being tracked through audits, minutes, and education, yet they also acknowledged ongoing concerns, inability to access exact med administration times, and unawareness of some infection control and masking issues during influenza season.
The facility failed to maintain infection control practices when two residents had urinary drainage bags placed directly on the floor, a broken soap dispenser remained in a room used for enhanced barrier precautions, and multiple residents had influenza while several unvaccinated staff were observed in resident areas without proper facemask use. Staff interviews confirmed the drainage bags should not be on the floor and that unvaccinated employees were expected to wear masks over the nose and mouth, but this was not consistently happening.
Strong urine odors were repeatedly detected in several resident rooms and a common area across multiple units, indicating a failure to maintain a sanitary and comfortable environment. The Director of Environmental Services acknowledged the issue and planned to involve the nursing department for further investigation.
Incomplete Person-Centered Care Plans for Multiple Residents: The facility did not ensure comprehensive care plans reflected resident-specific needs for three residents. One resident with dementia had no activity care plan and only generic dementia interventions, another resident’s plan did not address insulin or anticoagulant use despite active orders and administration, and a third resident receiving oxygen therapy had no care plan for oxygen or respiratory therapy. Survey review also noted oxygen equipment observations and nursing documentation showing varying oxygen flow rates.
Failure to provide resident-preferred activities: Two residents did not receive consistent access to meaningful activities aligned with their care plans and interests. One resident with severe cognitive and communication impairments was often left in the room without stimulation and had limited documented activity participation despite a plan for regular 1:1 and music-based engagement. Another resident with intact cognition repeatedly missed preferred morning activities such as coffee hour and BINGO because staff did not get them up in time, with delays tied to breakfast routines and difficulty locating transfer equipment.
Two residents with impaired mobility and hand contractures did not consistently receive ordered hand devices. One resident with cerebral palsy and severe cognitive impairment had a physician order for a palm grip to the right hand, but staff repeatedly observed the device absent and the TAR did not document use. Another resident with left hemiplegia and moderate cognitive impairment had an order for a rolled washcloth to the left hand, but it was not documented on the MAR/TAR and was not observed in place; OT also noted long, jagged nails and a foul odor from the left palm. Staff interviews showed confusion about the orders and lack of communication about refusals.
A resident with ESRD, CHF, and a history of sepsis received hemodialysis but had missing pre- and post-dialysis documentation, including vital signs, weights, access-site checks, and signatures in both the dialysis notebook and EMR. The resident’s care plan and orders required dialysis M/W/F and every-shift monitoring of the AV fistula, yet multiple shifts had no documented access-site assessment, and staff stated they were unsure how to locate prior vital sign records while the DON confirmed the expected documentation process.
Medication pass observations found the facility’s error rate exceeded the allowed threshold, with two errors during 28 administrations. An LPN failed to verify a resident before giving meds and mixed MiraLAX without confirming the water amount, while another LPN prepared Buspirone from a blister pack that did not match the current MAR order until the discrepancy was identified during the pass.
A resident with multiple diagnoses was found with an old bandage on the forearm, with no documentation, physician order, or record of treatment in the medical or treatment administration records. Nursing staff were unaware of the origin or need for the bandage, and there was no incident report or progress note explaining its presence, resulting in a failure to provide care according to professional standards.
Failure to assess a resident for self-administration of medication: A resident with moderately impaired cognition had an unprescribed anti-fungal powder kept at bedside and stated the nurse gave it for PRN use under the breasts. The care plan had no self-medication documentation, the MAR had no order for the powder, and staff stated no residents were self-administering meds despite the resident’s bedside access to the medication.
Resident preferences for meals were not consistently honored. A cognitively intact resident with Hodgkin lymphoma, pain, and anemia was supposed to receive nutrition support and preferred sandwiches, oral nutrition supplements, and oranges, but staff and dietary records showed the resident often did not get the requested items. The resident reported buying food from an outside source and keeping it in a room refrigerator, while staff said there were times when there were not enough sandwiches or other food items and they sometimes had to call the kitchen or make a sandwich themselves.
A resident with Alzheimer’s disease, anxiety, and HTN had moderate cognitive impairment, and the RP reported missing clothing items and a new pair of sneakers. The RP said the complaint was made to the SW but no resolution was received, and the facility had no record of a missing-items grievance or documented investigation.
A resident with acute and chronic respiratory failure with hypoxia, pneumonia, and COPD was ordered oxygen at 6 L via NC with tubing changes on a set schedule. Staff observed the tubing dated incorrectly, and the resident said it had been several weeks since it was changed. An LPN admitted the tubing was not changed when due, later changed it, and dated it with a date that did not match the task; the RN supervisor stated the tubing should have been changed and that the incorrect documentation was a safety concern.
Two residents did not receive critical medications as ordered due to failures in medication procurement and administration processes. One resident missed several doses of Lithium because the medication was not available and staff did not follow up with the pharmacy after a refill error. Another resident with kidney disease did not receive cinacalcet and Sevelamer for an extended period due to confusion over medication sourcing and delays in obtaining the medications from the pharmacy. Nursing and pharmacy staff interviews confirmed lapses in following procedures for ensuring medication availability.
Two Deaf residents were not provided with their preferred method of communication, American Sign Language, and were instead limited to using whiteboards and written communication. Staff lacked training and access to technology such as tablets with video relay interpreting services, resulting in the residents' inability to communicate needs, participate in activities, or engage in care discussions, leading to actual psychosocial harm.
Multiple residents on contact and droplet precautions for infectious diseases did not have appropriate isolation signage, and staff frequently failed to use required PPE or perform hand hygiene. Contaminated laundry was not properly separated, and housekeeping and laundry staff did not consistently follow infection control protocols, leading to widespread non-compliance with facility policies.
Two continent residents were placed in incontinence briefs and instructed by staff to urinate or defecate in them instead of being assisted to use the toilet or bedpan. Staff failed to update care plans and reassess toileting needs, resulting in residents being left in soiled briefs for extended periods, causing embarrassment and psychosocial harm. Multiple staff and clinical leaders acknowledged that this practice violated resident dignity and failed to provide individualized care.
Delayed hematology follow-up and lab testing for a resident with severe anemia
Penalty
Summary
The facility failed to ensure a resident received treatment and care in accordance with orders and the comprehensive person-centered care plan when a hematology consultation ordered for iron deficiency anemia was not completed and laboratory testing was delayed for 14 days after it was ordered. The resident had diagnoses including unspecified anemia, atrial fibrillation, and anxiety disorder, and was documented as cognitively intact and able to make needs understood. The record showed the nurse practitioner discussed the resident’s anemia, planned a hematology follow-up, and later entered an order for a hematology consultation, but there was no documented evidence that an appointment was made or that the consultation occurred. The resident and family repeatedly raised concerns about the anemia and the need for bloodwork. The resident stated they had required iron supplements and B12 injections, had previously been hospitalized multiple times for anemia, and had become very sick before a later hospitalization when bloodwork had been delayed. The family member stated they had spoken with facility staff about the need for timely bloodwork for the resident’s anemia and were told it would be taken care of. The nurse practitioner documented that the resident had chronic anemia and that follow-up with hematology was still pending, while the ward clerk and staff described a process in which orders had to be entered into the laboratory system and placed in a binder for the phlebotomist. Laboratory orders for a CBC and magnesium were entered, discontinued, and replaced multiple times, but there was no documented evidence that the ordered tests were completed until the resident’s condition worsened. The resident reported shortness of breath and fatigue, and the laboratory later reported critical values, including hemoglobin of 4.5 to 4.6 g/dL and low white blood cell count. The resident was sent to the hospital for emergency transfusion, where the hospital documented acute on chronic anemia and noted the resident had reported fatigue and weakness for about two weeks and that no laboratory work had been done at the facility until just before hospital admission. The medical director stated there was a delay in diagnosis due to a lack of collecting the laboratory specimens.
Delayed Completion of Ordered Lab Tests for Resident With Anemia
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for one resident with chronic anemia. The resident had diagnoses including unspecified anemia, atrial fibrillation, and anxiety disorder, and the Minimum Data Set documented the resident was cognitively intact and able to make themselves understood. The record also showed there was no documented comprehensive care plan for the anemia diagnosis. A nurse practitioner saw the resident and ordered a complete blood count, later adding magnesium, to evaluate the resident’s anemia. The physician orders showed the laboratory request was entered, then discontinued and replaced multiple times, but there was no documented evidence that the ordered CBC and magnesium tests were completed on the earlier occasions. There were also no nursing progress notes for extended periods, and the nurse practitioner note did not document the status of the laboratory tests. The laboratory tests were not completed until the order was entered a third time, at which point the resident’s CBC showed critically low hemoglobin and hematocrit values. Nursing documented critical lab values and the resident reported fatigue and feeling generally unwell, after which the resident was sent to the hospital for emergency transfusion. The hospital record documented acute on chronic anemia and that the resident received two units of red blood cells. The discharge summary stated the resident had reported being fatigued and weak for about two weeks and that there had been no laboratory work done at the facility until just before hospital admission.
Food Storage and Dishwasher Temperature Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards when surveyors found opened, undated, and unlabeled food items in the main kitchen on 05/05/2026. In the walk-in refrigerator, surveyors observed one tub of mayonnaise, one tub of Italian dressing, and a sheet rack of bagged liquid eggs without a label. In the walk-in freezer, surveyors observed one package of meat without a label, one box of cucumbers, and one package of sausage patties that were open and undated. The three-compartment sink contained soapy water and food debris, a rag was wrapped tightly around the leftmost faucet, the floor around the sink was visibly dirty, and two chemical bottles sat on a dirty cart. A metal preparation cabinet missing its door was dirty on the shelves and had items arranged haphazardly. Surveyors also observed that the facility-designated employee handwashing sink adjacent to the automatic dishwasher did not function and had part of an eye washing station attachment attached to it, along with red grime and a spoon in the sink. On 05/12/2026, while the automatic dishwasher was in use, the final rinse temperature gauge read 178 degrees Fahrenheit. Record review showed the dishwasher final rinse temperature was documented below 180 degrees Fahrenheit on multiple meal services from 05/01/2026 through 05/11/2026, including breakfast, lunch, and dinner services. Vendor records showed the dishwasher had repeated service issues earlier in the year, including problems with the booster, final rinse gauge, pumps, drains, vacuum breakers, and debris buildup in the machine. During interviews, the interim Food Service Director acknowledged that opened items should be dated and labeled and stated that unlabeled or undated items would be discarded. The Food Service Director also stated staff should report equipment problems to maintenance or a vendor. The Administrator stated the facility had recently invested in repairing the dishwasher, and the Director of Plant and Operations stated the dishwasher used domestic hot water with a booster heater and that the lowest final rinse temperature they had seen was 177 degrees Fahrenheit. The Food Service Director who had just started in the kitchen stated they were observing operations and working with staff on proper labeling.
Unclean Resident Areas and Inadequate Room Maintenance
Penalty
Summary
The facility failed to maintain a clean and homelike environment. Survey observations on 05/05/2026 found sticky floors in multiple areas, including the hallway outside Rooms #301, #322, and #640, the 3rd floor main common/dining room (Core), Resident #118’s room and door, and the 7th floor nurses’ station. On 05/05/2026, Resident #27’s room walls were dirty, and Resident #126 had a full, odorous urinal sitting on the overbed table. A Resident Council interview on 05/06/2026 included 10 anonymous residents who stated the facility was not clean and that housekeepers often only changed garbage in resident rooms without doing other cleaning. Resident #118 was admitted with diagnoses including unspecified anemia, atrial fibrillation, and unspecified anxiety disorder, and the MDS dated 02/26/2026 documented the resident was cognitively intact and usually understood others. During interview and observation on 05/07/2026, Resident #118 stated there had been no light in a recessed fixture near the wardrobe because the bulb had been removed and placed in the roommate’s fixture, and there was also a bulb out over the bathroom sink, leaving the room dimly lit. The resident stated maintenance was aware and had not replaced the bulbs. Housekeeping and plant operations interviews described routine room cleaning tasks and a work order system for maintenance issues, including replacing light bulbs.
Failure to Develop and Implement Comprehensive Care Plans for Diagnoses, Altercation, and Oral Surgery
Penalty
Summary
Comprehensive person-centered care plans were not developed and implemented for Resident #118’s diagnosed anemia, iron deficiency, and dry eye syndrome. The resident was admitted with unspecified anemia, atrial fibrillation, and dry eye syndrome of the bilateral lacrimal glands, and the MDS dated 02/26/2026 documented the resident was cognitively intact and had an active diagnosis of anemia in the prior seven days. The record also showed the resident was receiving ferrous sulfate and artificial tears, yet there was no documented evidence of a comprehensive care plan for the anemia, iron deficiency, or dry eye diagnoses. Comprehensive person-centered care plans were also not developed and implemented for Resident #248 after a resident-to-resident physical altercation and after oral surgery. Resident #248 was admitted with diagnoses including orthopedic aftercare for a right lower leg fracture, UTI, and COPD, and was documented as cognitively intact. The resident had an existing care plan addressing cognition, psychosocial status, mood, and behavior, including anxiety, agitation, trauma history, and difficulty with roommates and staff, but there was no documented update to address the 01/20/2026 incident in which the resident was startled while sleeping, hit a roommate in the face, and stated the roommate had touched them. The record also showed Resident #248 returned from a dental procedure on 01/21/2026 with new orders reviewed with the NP, received pain medication with positive effect, had no active bleeding, and was offered soft foods, but there was no documented evidence of a comprehensive care plan for the oral surgery. Interviews with the ADON, RN, and DON indicated they were responsible for care planning and stated there should have been care plans for diagnoses and events that were treated, but the record did not show care plans were developed and implemented for these issues.
Delayed Dental Evaluation and Denture Follow-Up
Penalty
Summary
The facility failed to ensure routine and emergency dental services were provided for two residents, including assistance in obtaining dental evaluation and treatment. One resident was found by family to have a broken front tooth with exposed roots and several cracked teeth, but there was no documented dental referral or dental follow-up after the concern was raised. The resident had dementia and was documented as usually understood and usually understanding others, yet the grievance record and nursing documentation reflected conflicting findings about whether the tooth was cracked, and no additional dental consultation was documented after the initial dental exam months earlier. A second resident was reported to have missing upper dentures, and the resident remained without the dentures for an extended period. The resident was admitted with atrial fibrillation, hypo-osmolality, hyponatremia, and depression, and the MDS documented intact cognition for daily living decisions. A missing-item report documented the dentures were missing, and a dental consult later noted evaluation for lost full upper dentures with diet adjustment as needed. However, the resident’s diet was not adjusted until several days after the missing dentures were identified, and the full upper denture impressions were not completed until weeks later. During this time, the resident reported difficulty chewing the food served, including uncut roast beef, and stated they wanted ground meat until the dentures were restored. Survey observations and interviews showed the resident without upper dentures while eating a regular meal, and staff statements indicated the dentures had been missing for months. Staff also described delays and uncertainty in the denture process, including waiting for insurance approval and not completing impressions at the first dental visit for the missing dentures. For the resident with the broken tooth, family reported the tooth was chipped and painful, but staff assessments documented no visible crack or sharp edges and there was no documented dental consult after the concern was raised. The facility policy required timely identification, referral, and documentation of dental needs, but the records and interviews showed these dental needs were not promptly addressed.
Failure to Document Resident Meal Consumption
Penalty
Summary
The facility failed to provide Resident #412 with a nourishing, palatable, well-balanced diet that met daily nutritional and special dietary needs by failing to document meal consumption for breakfast, lunch, and dinner during November 2025. Resident #412 was admitted with osteomyelitis of the lumbar spine, acute and subacute infective endocarditis, and Type 2 diabetes mellitus without complications. The Minimum Data Set dated 11/04/2025 documented that the resident could make themselves understood, understood others, and was cognitively intact. Review of the facility policy titled Fine Dining Policy dated 09/2025 stated that nursing staff are required to document meal consumption. The Certified Nurse Aide Meal Documentation record for Resident #412 for November 2025 did not include documentation for multiple breakfast, lunch, and dinner meals across the month. During interviews, an LPN stated that meals and snacks are documented in the electronic health record and that each shift is expected to document its own meals and snacks, and a CNA stated that all meal intakes were to be documented in the electronic medical record system for every resident.
Failure to Provide Water and Ice to a Resident
Penalty
Summary
The facility failed to provide drinks, including water and ice, consistent with a resident’s needs and preferences and sufficient to maintain hydration for one resident. The resident was admitted with unspecified anemia, urinary tract infection, and adult failure to thrive. The MDS documented the resident was cognitively intact and able to make themselves understood. The care plan directed that the resident remain well hydrated and included thin liquids as an intervention, and the facility’s nourishment and clinical nutrition policies stated residents should have access to appropriate hydration and water should be provided multiple times each day. During observation and interview, the resident showed an empty water pitcher that had no lid and stated the lid broke and a CNA never returned with a replacement. On a later observation, the pitcher was still on the nightstand without a lid and remained empty, and the resident stated they had no water to drink and staff had not filled the pitcher the prior evening or night. The resident stated staff did not bring water unless they asked for it, that they liked water and ice, and that they had to drink bathroom water on several occasions because staff did not bring water to them. The resident later stated they finally received a lid only after telling staff the State was present, but staff still did not bring water or ice. They reported having to fill a travel cup with bathroom water and walking to the kitchenette to get their own water and ice. CNA interviews indicated staff were responsible for ensuring water and ice were available, typically during rounds every two hours or per care plan, but several aides and an LPN described different routines and were unsure of the specific hydration policy. The ADON stated CNAs should be bringing water to residents every shift and supplementally between meals.
Delayed Dinner Service and Empty Snack Pantry
Penalty
Summary
Meals were not served at regular times comparable to normal mealtimes in the community, and suitable, nourishing alternative snacks were not available for residents waiting for meals. On the 4th floor, dinner service on 05/11/2026 took more than two hours to complete. Residents were seated in the dining area between 4:20 PM and 5:03 PM, but dinner was not fully served to those residents until between 4:50 PM and 5:30 PM, and residents eating in their rooms were not served until much later, with hallway cart service continuing until after 7:00 PM. The facility’s written meal schedules identified dinner as occurring between 5:30 PM and 7:00 PM, but the observed service extended beyond that timeframe. During the dinner observation, residents at tables were left waiting while others at the same table began eating, and staff were observed standing in the dining area without assisting with meal service or expediting tray delivery. At least ten staff were present in the dining area at 4:25 PM, but no staff were observed helping with meal service. One resident was seen trying to unwrap a sandwich at 5:05 PM, and dining staff did not notice the resident needed help until an activities aide intervened and assisted at 5:06 PM. A resident later stated they were unable to go to the patio because dinner had not yet arrived and said breakfast and dinner were always served late. The snack pantry was also found to lack nourishing options, and a CNA stated it should always be stocked but had not been. Staff interviews indicated the snack restocking process was inconsistent, with one staff member responsible for checking inventory daily and restocking between meals, while another stated the new tray line system and staffing shortages were making meal service difficult. The Food Service Director and other staff described a new food system implemented on 05/05/2026, including separate preparation for residents eating in rooms and those eating in floor dining rooms, and acknowledged that dinner service on the prior day had been a major struggle for the tray line serving residents in their rooms.
Failure to Follow Up Abnormal Urine Testing and Urology Consult Leading to Urosepsis
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards, physician/NP orders, and facility policies related to lab follow-up and outside consults. The resident had chronic kidney disease, diabetes, and a history of UTIs, and was cognitively intact and normally continent. On 12/15, nursing and the NP identified acute dysuria, new/increased incontinence, urgency, and frequency, and an order was obtained for a urinalysis and urine culture. The NP documented a plan to send urine to evaluate for a possible UTI. However, the 12/17 urine specimen was reported on 12/19 as unsuitable, with instructions to resubmit using the correct transport tube. There was no documentation that nursing obtained a new specimen or that the NP or physician were aware the urinalysis was not performed. During this same period, the resident developed fever, lethargy, diaphoresis, abdominal and back pain, and decreased appetite, and the physician documented a recent fever with a “negative work up” without evidence of reviewing or addressing the unperformed urinalysis. Over the following weeks, the resident repeatedly reported not feeling well, with ongoing nausea, vomiting, poor intake, lethargy, and new urinary incontinence. Blood work on 12/26 showed elevated WBCs and other indicators of infection, and multiple viral respiratory panels and chest x‑rays were negative. Despite this, there was no documented evidence that the NP reordered a urinalysis after the initial unsuitable specimen, and when a urinalysis and culture were finally obtained on 12/30, the 01/01 report showed trace blood and protein, 2+ leukocyte esterase, 40–60 WBCs, and squamous epithelial cells suggesting an unclean specimen, with a recommendation for recollection and culture. The culture showed <10,000 CFU/mL of a single gram‑negative organism and recommended recollection using a method to minimize contamination. There is no documentation that this urinalysis and culture report was reviewed by the NP or physician on or after 01/01, despite multiple subsequent NP visits for abdominal pain, nausea, cough, congestion, and abnormal labs, and repeated nursing notes describing fever, lethargy, poor appetite, vomiting, and continued complaints of not feeling well. During this same timeframe, the resident was repeatedly treated empirically with Rocephin (a cephalosporin antibiotic) without obtaining a definitive urine culture and sensitivity to guide therapy. Orders were given for one‑time and multi‑day Rocephin courses in response to fevers and systemic symptoms, even though the 01/01 urinalysis suggested infection and recommended recollection and further culture, and no culture and sensitivity was obtained to determine organism susceptibility. On 01/20, the resident underwent a urology consult and cystoscopy for gross hematuria and urge incontinence; the urologist recommended nightly vaginal estrogen for atrophy and concerns for recurrent UTIs. Nursing documented review of the consult and the recommendation to start vaginal estrogen, but there was no documentation that a physician or NP reviewed the consult details, discussed them, or implemented the vaginal estrogen order. The attending physician’s 01/21 visit note did not reference the 01/01 urinalysis or the urology consult, and subsequent NP notes continued to omit genitourinary assessments and did not address the abnormal urinalysis or consult recommendations. The resident continued to be ill, with persistent systemic symptoms, multiple Rocephin doses, and no documented provider follow‑up on the abnormal urinalysis, lack of adequate urine culture and sensitivity, or urology recommendations, until the resident became unresponsive and was sent to the hospital, where they were diagnosed with severe sepsis due to UTI, metabolic acidosis, and acute kidney injury, and the urine culture showed resistance to cephalosporins. The survey determined this resulted in actual harm that was not Immediate Jeopardy.
Failure to Prevent Physical Abuse and Follow Care Plan Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during the provision of care. The resident had a history of traumatic brain injury, anxiety, severely impaired cognition, and exhibited verbal and physical aggression toward staff. The resident’s comprehensive care plan required two caregivers for care, specified no male caregivers, and ordered 1:1 supervision during the night shift due to falls. Despite these documented interventions, a male certified nurse aide (CNA) participated in providing incontinence care to the resident during the night shift, and the care was initiated even after the resident verbally refused to be touched. During early morning care, two CNAs, including a male CNA, attempted to change the resident’s incontinence brief. The resident, who was lying naked on the bed, stated they did not want to be touched. One CNA suggested reapproaching later, but the male CNA insisted on proceeding due to time constraints. The resident initially allowed repositioning but began swinging when the brief was being pulled up and stated they did not want the CNAs touching them. The resident then spat in the male CNA’s face, after which the male CNA placed a hand on the resident’s face and forcefully pushed it down. This action was witnessed by the assisting CNA, who observed the resident become red in the face and more agitated. Following the incident, the assisting CNA pushed the male CNA away from the resident and told him to leave the room. A nearby LPN heard the resident screaming and, upon entering the room, was told by the resident that a CNA had yelled at and disrespected them and had scratched their face twice. Assessment by the RN/Assistant DON later that day revealed multiple abrasions and areas of redness on the resident’s face, including below the right eye and cheek, the tip of the nose, the left eyebrow and below the left eye, and around the lips and chin. The resident appeared agitated and reported being scratched in the face. The incident was reported up the chain of command, but there was no documented evidence that the male CNA was immediately removed from the premises after clocking out, and facility leadership could not confirm that the CNA had actually left the building at that time.
Removal Plan
- Conduct a head-to-toe assessment and psychosocial evaluation for Resident #1 to ensure no further harm occurred.
- Revise the facility abuse policy to include that failure to follow a resident's care plan can place residents at risk for abuse and require employees alleged of abuse to be immediately escorted from the facility by security and placed on administrative leave pending completion of the investigation.
- Terminate Certified Nurse Aide #2's employment.
- Educate 100% of in-house staff on the abuse prevention policy, reporting abuse within appropriate timeframes, and the importance of following the care plan.
- Complete an immediate review to identify individuals with the specific need for no male care and evaluate current staff assignments to match residents based on care plan and needs.
- Review and verify the staff education list against the post-test and staff listing to ensure no discrepancies.
- Verify staff education on site by interviewing certified nurse aides, licensed nursing staff, security, and housekeeping regarding abuse and reporting abuse.
Failure to Follow No-Male-Caregiver Care Plan Resulting in Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan consistent with resident rights for a resident with a documented restriction against male caregivers. The resident had diagnoses including traumatic brain injury and anxiety, with a Minimum Data Set dated 01/22/2026 indicating severely impaired cognition, verbal and behavioral symptoms directed toward others, and a need for moderate assistance or dependence for most ADLs. The comprehensive care plan dated 01/23/2026 documented behaviors related to traumatic brain injury, including verbal and physical aggression toward staff, and included specific interventions: two caregivers for care, no male caregivers, and 1:1 supervision during the night shift due to falls. Undated care instructions also documented two staff for all care and no male caregivers. Despite these documented interventions, multiple CNA assignment sheets showed male CNAs being assigned to the resident. Assignment sheets dated 02/01/2026, 02/09/2026, and 02/12/2026 listed a male CNA assigned to the resident on the 7:00 AM–3:00 PM shifts. The 02/03/2026 CNA assignment sheet documented a male CNA assigned as the resident’s 1:1 during the 11:00 PM–7:00 AM night shift, contrary to the care plan specifying no male caregivers. Interviews with the Assistant DON and other staff confirmed that the resident was more agitated and aggressive toward males, that the spouse agreed with this, and that the care plan had been updated to include no male caregivers, with this information also placed on the care card accessible to CNAs. On the night shift when a male CNA was assigned 1:1, an incident of abuse occurred. According to the 02/04/2026 incident report and witness statements, during morning care at the end of the night shift, the resident became combative while being assisted by the male CNA assigned as 1:1 and another CNA. One CNA interlocked hands with the resident to de-escalate, and the resident spat at the male CNA. The male CNA was then witnessed forcefully pushing the resident’s face down into a pillow, causing scratches over the resident’s face and neck. Multiple staff interviews, including with an LPN, a unit manager, the RN supervisor, the NP, and the Medical Director, confirmed that the resident was care planned to have no male caregivers, that male caregivers triggered the resident, and that the care plan should have been followed. The DON acknowledged that the care card directed care and that CNAs, LPNs, and the RN supervisor were supposed to review it at the beginning of their shift, but the male CNA was nonetheless assigned and involved in the resident’s care, in violation of the care plan.
Removal Plan
- Review Resident #1's care plan to ensure all interventions, including the no-male caregivers requirement, are clearly documented and communicated to all staff.
- Educate all in-house staff on adhering to care plans, identifying residents who require no male care and where it is documented, and reviewing care cards for their assignment prior to starting care with care card acknowledgement sign-off.
- Complete an immediate review to identify individuals with the specific need for no male care.
- Verify unit assignment sheets clearly identify residents requiring no male caregivers by comparing against the facility master list.
- Review and verify the staff education list against the post-test and staff listing to ensure accuracy.
- Verify staff assignments against the no male caregiver list to ensure residents who are care planned to not have male care are not assigned male staff.
- Verify care card acknowledgement sign-off sheets against staff assignment sheets to ensure they are being completed.
- Review care plans and care cards for residents identified as not wanting male care to ensure the information is clearly documented.
- Re-educate staff on reviewing the care card prior to their shift, ensuring the no-male designation is clearly identified on the care plan, and completing the care card acknowledgement sheet process.
Failure to Timely Report Witnessed Staff-to-Resident Abuse and Submit Required Investigation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report a witnessed incident of staff-to-resident abuse to the State Agency, law enforcement, and the Administrator, and to timely submit the required 5‑day investigative report. A resident with traumatic brain injury, anxiety, restlessness, agitation, and severe cognitive impairment had documented verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. On the morning in question, the resident became agitated during incontinence care, attempted to spit at a CNA, and the CNA responded by forcefully pushing the resident’s face with their hands, which was witnessed by another CNA who recognized this as abuse and told the staff member to leave the room. Following the incident, the resident reported that staff had yelled at and disrespected them and had scratched their face twice. An LPN, who entered the room after hearing the resident scream, observed redness and scratches on the resident’s face. The resident was later physically assessed by the Assistant Director of Nursing, who documented multiple abrasions and redness on various areas of the resident’s face, including below both eyes, the right cheek, the tip of the nose, the left eyebrow, above the upper lip, and a scratch extending from the bottom right lip to the chin. Based on interviews, record review, witness statements, and the internal investigation, the facility determined that the resident sustained multiple facial skin alterations related to physical contact made by the CNA. Despite facility policy requiring all allegations of abuse to be reported immediately, but no later than two hours after the allegation, staff did not promptly notify facility leadership or external authorities. The CNA who witnessed the abuse stated they reported the incident to the Assistant Director of Nursing when that person arrived around 8:00 a.m., but the Assistant Director of Nursing reported not being notified until between 11:30 a.m. and 12:00 p.m. The night-shift RN Supervisor was never notified. The Administrator and DON were first made aware around 12:30 p.m., approximately five hours after the 7:00 a.m. incident, and law enforcement was called at about 1:10 p.m. The required 5‑day Nursing Home Investigative Report was not submitted to the State Agency until 12 days after the incident, well beyond the required timeframe, resulting in noncompliance with reporting requirements under F600 and F656.
Failure to Implement and Update Behavioral Care Plan to Prevent Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing effective or timely interventions and care plan revisions for a resident with escalating verbal and physical behaviors. The resident had Alzheimer’s disease and bipolar disorder with psychotic features, and a 10/02/2025 MDS documented moderately impaired cognition and no behavioral symptoms during the assessment period. Despite this, the resident exhibited multiple aggressive incidents over several months, including throwing coffee that struck another resident on 09/10/2025, hitting another resident in the face on 09/30/2025, swinging at staff on 11/10/2025, attempting to throw a glass vase at staff on 12/24/2025, and hitting another resident in the head with a wheelchair leg rest on 12/25/2025. There was no documented behavioral care plan in place for this resident prior to 12/25/2025, contrary to facility policy requiring care plans to be initiated and updated with changes in status, needs, or behaviors. After the 09/10/2025 incident in which the resident threw coffee at staff and hit another resident, the RN Supervisor documented the event and notified medical staff, resulting in lab orders and a Depakote level, which later returned low. However, there was no incident report, no root cause analysis, and no evidence that the care plan was reviewed or updated to address behavioral symptoms. Following the 09/30/2025 incident where the resident hit another resident’s cheek after an attempt to remove food from their plate, an incident report and investigative summary were completed, and the corrective action focused on encouraging the other resident to remain seated during meals. There was still no documented evidence that the aggressive resident’s care plan was reviewed or updated with interventions to prevent recurrence. Nursing notes from 11/05/2025 to 11/10/2025 documented ongoing refusal of medications, use of racial slurs, and physical aggression toward staff, yet no behavioral care plan was initiated during this period. On 12/23/2025, the aggressive resident was punched in the mouth by another resident while attempting to clean up the table, resulting in a loose lower front tooth. Interventions and medication changes, including Depakote and a psychiatric consult, were implemented for the resident who punched, and the aggressive resident’s care plan was updated only with the potential to be abused. On 12/24/2025, documentation showed the aggressive resident attempted to throw a glass vase at staff and used racial slurs; the resident was redirected to their room, and a provider documented a plan to increase Depakote, but there was no corresponding order at that time. On 12/25/2025, the resident hit the same other resident in the forehead with a wheelchair leg rest, stating they wanted the other resident to pay for their dental bill and threatening further harm. Only then was the comprehensive care plan updated with potential to abuse others, and the sole intervention added was to redirect the resident. Interviews with CNAs, LPNs, RNs, and the Medical Director confirmed that staff were aware of the resident’s behaviors, expected care plans to be updated after incidents, and acknowledged that behavior care planning and timely updates had not been done. The facility’s failure to implement and document effective, individualized behavioral interventions and care plan revisions after each incident resulted in a determination of Immediate Jeopardy and Substandard Quality of Care. Interviews further highlighted gaps in care planning responsibility and follow-through. A CNA reported that the resident could be violent, had issues with certain staff characteristics, and had recently thrown a vase, and that staff knew to monitor and keep the resident away from certain residents but could not recall a specific behavior plan. An LPN Assistant Manager confirmed the resident had no behavior care plan prior to 01/09/2026 and stated that RNs were responsible for implementing such plans. Another LPN described the resident as holding resentment after being punched and stated that no changes were made to the care plan after the 12/25/2025 assault, with staff simply continuing to monitor the resident. RNs involved in earlier incidents acknowledged that care plans should have been updated after behavioral events and resident-to-resident altercations but could not explain why this was not done. The Quality Assurance RN stated that any resident-to-resident altercation required a care plan update and that the supervisor should have updated the plan after the 12/25/2025 incident. The Medical Director expected all residents with behaviors to have a care plan and noted that providers were notified of incidents, while a nurse practitioner viewed the events as isolated and deferred care planning decisions to nursing. The Administrator acknowledged that care plan updates were a nursing responsibility and that long-term staff relied on verbal reporting and the general direction to “redirect” the resident, without documented, specific behavioral interventions. The facility’s own policies required comprehensive care plans to describe residents’ mental and psychosocial needs and to be updated with any change in status, needs, goals, or interventions, and required staff to be familiar with prevention of abuse and to prevent further abuse while investigations were in progress. Despite multiple documented aggressive behaviors and resident-to-resident altercations over several months, there was no timely initiation of a behavioral care plan, no documented root cause analyses, and no evidence of effective, individualized interventions to protect other residents from potential abuse by this resident until after the final documented assault. This pattern of inaction and incomplete care planning in the face of repeated behavioral incidents formed the basis of the cited deficiency.
Removal Plan
- Resident #1 was assessed by social work, medical, and nursing, and a psych referral was ordered.
- Pharmacy reviewed the resident's medications.
- Resident #1's care plan was revised to include 1:1 monitoring.
- The plan will be reviewed and revised as needed.
- A complete hazard sweep was completed to ensure no objects could be used as weapons.
- Staff communication included a shift report indicating the resident's supervision level.
- All residents with a resident-resident encounter within the last 90 days had their care plans reviewed and revised as necessary with appropriate interventions in place.
- Facility staff received education.
- Understanding and retention of education for staff was verified by interviews.
Failure to Notify Physician and Family During Resident’s Acute Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative when there was a significant change in the resident’s condition. Facility policy required the nurse supervisor or charge nurse to notify the attending or on-call physician for any significant change in a resident’s physical, emotional, or mental condition, or when a transfer to a hospital was needed, and to inform the resident’s family or designated representative of such changes. Resident #11 had diagnoses including respiratory failure, obstructive sleep apnea, and hypertension, and had an order for 4 liters of oxygen via nasal cannula every shift. The resident was documented as cognitively intact and able to make themselves understood. On the night of the incident, progress notes documented that around 1:00 AM the resident was resting comfortably with no signs of acute distress and remained stable and responsive through the night until approximately 5:00 AM. At that time, the resident was found with labored respirations and minimally responsive to verbal stimuli, with an oxygen saturation of 40% on 4 liters via nasal cannula. The supervisor was notified and changed the nasal cannula to an oxygen mask. Multiple pulse oximeters were used, showing readings of 42%, 43%, and 26%, and the resident’s labored breathing continued. Oxygen therapy was escalated to 10 liters via non-rebreather mask using a portable oxygen tank without a physician order. Despite these significant changes in respiratory status and very low oxygen saturation levels, there was no documented evidence that the medical provider was notified at the time of the change. Emergency Medical Services were not called until approximately 6:00 AM, after the resident’s condition had further deteriorated. Upon EMS arrival, the resident became unresponsive and was transported to the hospital, where emergency department documentation described the resident as responding only to pain, in respiratory distress with agonal breathing, and on high-flow oxygen. The resident was later pronounced deceased due to respiratory arrest. Interviews with staff revealed that the nursing supervisor on duty acknowledged not calling the nurse practitioner, delaying calling 911 while attempting to manage the resident’s oxygen levels, and forgetting to call the family. Other nursing staff described a protocol in which significant changes in condition, especially oxygen saturations in the 40% range or respiratory distress, should prompt immediate notification of a supervisor, provider, and/or 911. The resident’s health care proxy stated they did not receive any calls from the facility about the change in condition or the transfer to the hospital. The Director of Nursing and Medical Director both stated that the provider should have been called and that failure to call the provider or 911 immediately constituted a delay in treatment. The surveyors determined that the facility failed to follow its own Change in Resident Condition policy by not immediately consulting the physician when Resident #11 experienced a significant change in respiratory status, and by not notifying the resident’s family or representative. This failure occurred despite multiple extremely low oxygen saturation readings, labored breathing, and decreased responsiveness, and despite staff recognition in interviews that such findings represented an urgent or emergent situation requiring provider notification and/or calling 911. The lack of timely physician consultation and family notification, combined with delayed activation of EMS, formed the basis of the cited deficiency and was determined to have resulted in Immediate Jeopardy to the resident and placed other residents with potential significant respiratory changes at risk for serious harm, serious impairment, serious injury, or death.
Removal Plan
- All residents on oxygen had a pulse oximetry reading completed and any results deviating from the resident's baseline had a registered nurse assessment and physician notification via telephone.
- Education for licensed nursing staff was implemented on the Change in Resident Condition Policy requiring documented physician notification via telephone for all significant changes in resident condition.
- All oncoming licensed nursing staff would be educated on the Change in Condition Policy.
- Licensed nursing staff were educated on the Change in Condition Policy.
Failure to Follow Respiratory Orders and Monitor Resident in Respiratory Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory treatment and care according to physician orders, professional standards of practice, and the resident’s comprehensive care plan for a resident with significant respiratory diagnoses. The resident had respiratory failure, obstructive sleep apnea, and hypertension, and the care plan identified risk for compromised respiratory status with interventions including monitoring respiratory status, breath sounds, vital signs, and providing oxygen per physician order. A physician order dated 11/18/2024 required four liters of oxygen via nasal cannula every day, every shift. On 11/25/2025, the resident complained of intermittent shortness of breath, and a respiratory therapist assessed the resident, documented oxygen saturation of 92% on three liters of oxygen, and switched the resident to an oxygen concentrator at three liters without checking the current physician order for four liters. There was no documented evidence that a registered nurse assessed the resident when they were experiencing shortness of breath on 11/25/2025, nor that the resident’s respiratory status was monitored as outlined in the care plan. The resident’s health care proxy reported that on the same day, family members found the oxygen concentrator not working, notified staff, and another family member placed the resident on a portable oxygen tank; when they left at 5:00 PM, no staff had come to address the oxygen issue. These events indicate that the resident’s respiratory complaints and equipment concerns were not appropriately addressed, and physician orders for oxygen therapy were not followed. On 11/26/2025, between approximately 4:30 AM and 5:00 AM, a CNA notified an LPN that the resident was not breathing right. The LPN found the resident minimally responsive with labored breathing and an oxygen saturation of 40% on four liters via nasal cannula, and contacted an RN, who instructed the LPN to place the resident on a face mask but did not remain in the room. The LPN later rechecked the oxygen saturation, which remained in the 40s with increased labored breathing, and escalated the portable oxygen to ten liters via non-rebreather mask without a provider order. There was no documented RN assessment of the resident’s declining condition and no documentation that a physician was notified. Emergency Medical Services records show 911 was called at 6:04 AM, and upon arrival the resident was unresponsive with agonal respirations and no staff present on the unit, requiring EMS to call the fire department for assistance. These actions and omissions demonstrate failure to monitor and respond to a significant change in condition, failure to follow physician orders, and failure to provide supervision while awaiting EMS, resulting in Immediate Jeopardy and substandard quality of care for the resident.
Removal Plan
- Complete a pulse oximetry reading for all residents on oxygen and ensure any results deviating from the resident's baseline receive a registered nurse assessment and physician notification via telephone.
- Ensure any resident demonstrating respiratory distress is not left unattended while awaiting Emergency Medical Services.
- Review all resident accident and incident reports for the last 30 days.
- Review any significant change in status and abnormal laboratory results requiring action to ensure they were addressed and determine whether treatment needed to be significantly altered or the resident needed to be transferred.
- Re-educate Registered Nurse #8 on assessments and supervision.
- Educate licensed nursing staff on the Change in Condition Policy for significant change in respiratory status.
- Educate licensed nursing staff on communication with the registered nurse and proper assessment of respiratory complaints.
- Educate certified nursing assistants on communicating respiratory changes in condition and other changes in condition to licensed nursing staff.
- Educate licensed nursing staff on following physician orders and performing within scope of practice.
- Educate licensed nursing staff on obtaining vital signs with a change in condition.
Failure to Supervise High-Risk Resident Resulting in Elopement and Delayed Emergency Response
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for one cognitively intact resident with significant mental health and substance use history. The resident had diagnoses including cocaine and opioid dependence, other psychoactive substance abuse with mood disorder, suicidal ideations and past suicidal behavior, depression with psychotic features, PTSD, cluster B personality traits, chronic pain, COPD requiring 3L O2 via nasal cannula at all times, right eye blindness with depth perception issues, and poor safety awareness as reported by therapy and the physician. An elopement risk assessment completed on admission scored the resident as zero because they were documented as not independently mobile, and no elopement-related care plan interventions or wander alert device were implemented, despite the resident scoring above five on the Against Medical Advice (AMA) risk assessment and having suicidal ideations and substance use disorder. The basic care plan initiated for discharge did not include supervision or elopement prevention interventions related to the resident’s medical and behavioral history. On the day of the elopement, the resident’s last documented meal was breakfast, and a nurse administered a scheduled medication at 2:00 PM. The resident later reported packing their bags, using a wheelchair with oxygen to reach the lobby, and then walking out the front entrance carrying their bags, leaving the oxygen behind because it was too heavy. The resident stated that no staff attempted to stop them, ask where they were going, or request that they sign out. A stranger in a car picked the resident up off the property, and the resident went to a friend’s house rather than their last known address. Facility documentation and staff interviews showed that the LPN assigned to the resident’s floor did not see the resident in the room at 2:45 PM, was told by the roommate that the resident visited friends on other floors, and continued to check back, finally initiating overhead pages and a Code White search around 5:45 PM when the resident still had not returned. Medication administration records for later that day were marked “Out of Building,” although there were no physician orders for the resident to be out on pass or to leave the building. The facility’s Code White/Elopement policy required internal searches and announcements but did not specify a timeframe for calling 911 or define which outside agencies should be contacted. After the Code White failed to locate the resident, the facility delayed calling emergency services; 911 was not contacted until 11:16 PM, more than five hours after the Code White was initiated, during which time the facility did not know the resident’s whereabouts. Law enforcement records and interviews documented that staff told police the resident was free to leave, despite no documented discharge, no evidence of required AMA counseling, and no physician notification or discharge order. The AMA form was dated with the day of departure but was actually signed by the resident the following day at a friend’s home, with no documentation that the resident was counseled on risks or that the physician was notified. The facility’s own staff, including the NP and social work, reported they were not notified of the resident’s departure or elopement and that there was no clear documentation of when or with whom the resident left. Surveyors determined this failure to supervise and to promptly recognize and respond to the resident’s unaccounted absence constituted Immediate Jeopardy and substandard quality of care for the resident and others at risk of elopement or leaving AMA.
Removal Plan
- All residents in the facility had their elopement risk assessment completed in accordance with the Minimum Data Set and had interventions in place in accordance with the assessed risk.
- All residents assessed as an elopement risk that triggered the requirement for use of a Wanderguard bracelets had their bracelet in place.
- Residents with Wanderguard bracelets were placed on the Adventure Club list, which contains their picture indicating their elopement risk.
- The Adventure Club list was within the electronic medical records and available to staff.
- If the resident required 1:1 supervision, that supervision was provided.
- Exit doors were inspected, locked, and alarmed.
- Exit door functionality was confirmed.
Failure to Maintain Effective Compliance Program and Non-Retaliatory Reporting Culture
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective compliance and ethics program that promotes quality of care and prevents and detects violations. Facility policies such as the Code of Conduct and the Non-retaliation and Non-retribution policy state that all affected individuals must act ethically, report concerns in good faith, and are protected from retaliation when reporting suspected violations, fraud, waste, abuse, or unethical behavior. The Non-retaliation policy describes prohibited retaliatory actions and lists various reporting channels, including an anonymous hotline, and the abuse prevention policy states that all employees shall receive information on how and to whom they report concerns without fear of retribution. Despite these written policies, staff interviews revealed that employees did not believe they could report compliance concerns without retaliation and did not trust the facility’s reporting mechanisms. One staff member stated that reporting violations to the DON was a “long shot” and that a unit manager conveyed that their title was more important than the staff reporting to them. Another staff member reported fear of losing vacation, overtime, or future work if they reported issues, and described being contacted by the DON after a prior State Surveyor interview to ask what was discussed. Additional staff reported that anonymous reporting was “a joke,” that someone would always find out who reported, and that they did not feel confident reporting beyond their immediate manager. Another staff member reported fear of retaliation from coworkers, including threats of tire slashing and physical harm, and hearing a threat in the breakroom about having a grown son beat someone up. Surveyor observations of facility administration during the survey further demonstrated an environment inconsistent with an effective compliance and ethics program. The DON told surveyors that their presence stressed staff and that they would “hate for the facility staff to get punchy” with them. During a meeting with the administrator, assistant administrator, and DON, all three spoke in elevated voices, leaned forward, clenched their fists on the table, and repeatedly challenged the survey process, the basis for the Immediate Jeopardy determination, and the questions asked of staff. They demanded to know who decided on the Immediate Jeopardy and what data were provided to supervisors. Later, when surveyors attempted to leave the building, the administrator followed them, stated they could not leave after issuing an Immediate Jeopardy, and questioned how they could depart, despite the surveyors explaining the next steps. These actions and staff reports showed that the facility did not create and promote a credible, safe program contact and anonymous reporting method free from fear of retribution, as required by its own policies and regulatory standards.
Failure to Report Resident-to-Resident Altercations to State Agency
Penalty
Summary
The facility failed to report resident-to-resident altercations to the New York State Department of Health (NYSDOH) as required by state regulations and its own policies. Facility policy on Reporting and Monitoring Accidents and Incidents, revised in 09/2024 and again in 05/2025, required the DON, ADON, Director of Investigations or designee to review all incidents for alleged abuse, mistreatment, neglect, injury of unknown origin, or elopement, and to report such incidents immediately to Administration. State guidance in DAL NH 22-20 and CMS memo QSO-22-19-NH required nursing homes to submit an initial incident report and a final Investigation Summary Report to NYSDOH within five days of an incident involving reportable events such as abuse, neglect, mistreatment, exploitation, misappropriation, injury of unknown origin, elopement, and certain deaths. Despite these requirements, the facility did not submit required reports for two separate resident-to-resident altercations involving one resident. Resident #1, who had Alzheimer’s disease and bipolar disorder with psychotic features and was documented as having moderately impaired cognition and no behavioral symptoms during the 10/02/2025 MDS assessment period, was involved in two incidents. On 09/10/2025, a RN Supervisor’s progress note documented that Resident #1 threw coffee on staff, striking another resident seated at the table, then refused to discuss the behavior and used excessive profanity toward staff and residents; there was no incident report or evidence this event was reported to NYSDOH. On 09/30/2025, an incident report and attached investigative summary documented that Resident #1 hit another resident on the cheek, causing light redness, after the other resident attempted to remove food from Resident #1’s plate; there was no documented evidence this altercation was reported to NYSDOH. In interviews, the DON stated the 09/10/2025 coffee incident was considered incidental and not reported because the coffee was cold and the other resident was not injured, and the 09/30/2025 altercation was not reported because there was no injury, pain, or mental anguish noted. The Administrator stated they became aware of incidents through internal processes and were involved when there was an incident report for resident-to-resident abuse, but there was no indication that these two incidents were reported externally as required.
Failure to Develop and Update Comprehensive Behavior Care Plan for Resident With Recurrent Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s behavioral symptoms and psychosocial needs. The resident had diagnoses of Alzheimer’s disease and bipolar disorder with psychotic features, and the MDS documented moderately impaired cognition. An initial comprehensive care plan noted the resident was pleasant and cooperative but could become agitated and had a history of using racial slurs toward peers and staff; however, no specific interventions were documented. Despite multiple subsequent behavioral incidents, there was no documented evidence that the care plan was updated to address the resident’s behaviors, potential to abuse others, or potential to be a victim of abuse until late in the sequence of events. On one occasion, staff reported the resident threw coffee at staff, which also hit another resident, and the resident used excessive profanity toward staff and residents. On another date, an incident report and investigative summary documented that the resident struck another resident on the cheek after that resident attempted to remove food from the resident’s plate, causing light redness. Nursing progress notes over several days later in the year documented that the resident was refusing medications, including Depakote, using racial slurs, and being physically aggressive toward staff. There was no documented evidence that the care plan was revised to include behavior-specific, person-centered interventions or measurable goals in response to these events. Further incidents included the resident being punched in the mouth by another resident while attempting to clean up a dining table, resulting in a loose lower front tooth, and later attempting to throw a glass vase at staff while using racial slurs before being redirected to their room. Another incident documented that the resident hit the same other resident in the head with a wheelchair leg as that resident ambulated down the hallway, and multiple wheelchair legs were found in the resident’s room. The comprehensive care plan was eventually updated to note a history of altercations and abusing others, but the only intervention listed was redirection, with no additional resident-centered interventions or measurable objectives. Interviews with CNAs, LPNs, RNs, and the DON confirmed that staff recognized the resident’s behavioral issues and history of altercations, but there was no timely or adequate behavior care plan in place, and expected care plan updates after each incident were not completed.
Failure to Thoroughly Investigate Resident Elopement and Alleged Neglect
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of neglect related to a resident elopement. The resident had multiple significant diagnoses, including diabetes, pneumonia, protein-calorie malnutrition, cocaine and opioid dependence, other psychoactive substance abuse with mood disorder, suicidal ideations and history of suicidal behavior, noncompliance with medical treatment, anxiety disorder, and acute respiratory failure. On admission, the resident was assessed as alert and oriented, on 2L oxygen with diminished lung sounds, requiring supervision with meals and limited assistance with toileting, and having a history of falls. The comprehensive care plan documented that the resident had compromised respiratory status with oxygen therapy in place, was an elopement/wandering risk with a goal to remain safely in the facility, and had a history of suicide attempts. On the date of the incident, the resident left the facility undetected and was last seen by staff at 2:00 PM, with their absence not discovered until 5:45 PM. The resident left the building without their required oxygen, did not receive ordered medications, and did not receive their evening meal. A 911 audio file later documented that the resident had walked or “snuck” out of the building on foot, and the caller, an RN starting the night shift, did not know when the resident left. In a later interview, the resident stated they told a staff member on the seventh floor they were leaving and the staff member responded dismissively. The resident reported packing their bags, using a wheelchair with oxygen to reach the lobby, then walking out the front door with their bags, leaving the oxygen behind because they could not carry it, and experiencing difficulty breathing when picked up by a stranger off the property. The resident stated no one attempted to stop them, ask where they were going, or request that they sign out. The facility’s own policies required that all accidents/incidents, including potential abuse, neglect, and elopements, be reported and investigated, with the DON, ADON, Director of Investigations, or designee responsible. However, there was no documented evidence of a thorough investigation of this elopement. The facility initially reported there were no investigations for this resident, and when an investigation dated 03/04/2025 was later produced, it contained limited and incomplete information. Statements were obtained primarily from evening-shift staff who reported not seeing the resident for the entire shift and described overhead pages, a Code White, and searches after the resident was found missing. A recreation therapy director reported finding a wheelchair with an oxygen tank and name tag in an elevator and leaving it with security, but there was no documentation that information was obtained from reception, security, or day-shift staff about the elopement. The DON acknowledged that there were no statements from front desk staff, the nurse who called emergency services, the nurse who spoke with police, or the social worker who later met with the resident, and that the review of camera footage was not documented. The DON could not confidently state that all unknowns related to the incident were investigated. This lack of comprehensive documentation and follow-through on all relevant leads and witnesses constituted the failure to ensure that the allegation of neglect was thoroughly investigated. Additionally, there were inconsistencies and gaps in the facility’s documentation regarding whether the resident left against medical advice (AMA). The DON stated the resident departed against medical advice and that emergency services were contacted for a wellness check for residents who left AMA, but there was no documented evidence that the resident left AMA on the date of elopement. A Nursing Discharge Against Medical Advice form was dated with the elopement date but signed and witnessed the following day, with the reason for leaving documented as not wanting to stay at the facility. The resident later reported being contacted by the facility and meeting a staff member at a friend’s house to sign papers that were not explained and that they did not know were AMA papers. These inconsistencies, combined with the absence of a complete investigative record, demonstrate that the facility did not conduct and document a thorough investigation into the circumstances of the resident’s elopement and the associated allegation of neglect.
Failure to Administer Ordered Oxygen Flow Rate and Verify Respiratory Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards of practice and the resident’s person-centered care plan. A cognitively intact resident with diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, pulmonary embolism without acute cor pulmonale, and hypertension had a physician’s order, in place since 11/18/2024, for oxygen therapy at four liters per minute via nasal cannula every day, every shift. The resident’s care plan for risk of compromised respiratory status directed staff to monitor respiratory status, breath sounds, activity tolerance, vital signs, and to provide oxygen per physician order and consult Respiratory Therapy as needed. The facility’s oxygen administration policy required verification of the physician’s order and setting the oxygen flow as prescribed. On the date in question, the resident’s health care proxy reported that during a visit, the resident complained of trouble breathing. The proxy removed the nasal cannula and perceived that no air was coming out. They checked the oxygen concentrator, which they believed was set at three or four liters, and observed it was not working; when they attempted to increase the flow, the floating ball did not move. The proxy sought assistance from a nurse, who reportedly stated they could not help and that an order was placed for a Respiratory Therapy consult. According to the proxy, no staff entered the room before they left temporarily, and during that time the resident’s granddaughter noticed a portable oxygen tank in the room, asked staff for help and was told they could not assist, and then independently connected the nasal cannula to the portable tank without knowing the oxygen flow setting. Later that day, a Respiratory Therapist assessed the resident after being called by an LPN for reported shortness of breath. The Respiratory Therapist found the resident in their room during dinner, eating pizza and in no apparent distress, with even, unlabored respirations and clear bilateral lung sounds. At that time, the resident was on a portable oxygen tank set at three liters per minute, with an oxygen saturation of 92%. The Respiratory Therapist switched the resident from the portable tank to the oxygen concentrator, maintaining the flow at three liters per minute, and documented the assessment and oxygen saturation. The Respiratory Therapist later stated they were not aware the resident was ordered four liters of oxygen and did not verify the current physician order, relying instead on a recollection that the resident had previously been on three liters during their stay. Subsequent review by the DON confirmed that the physician’s order in effect required four liters of oxygen.
Failure to Document RN Assessment and Vital Signs During Acute Respiratory Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and professionally acceptable medical records for a resident who experienced an acute change in respiratory and mental status. The resident had diagnoses including respiratory failure (unspecified hypoxia/hypercapnia), obstructive sleep apnea, and hypertension, and was care planned for risk of compromised respiratory status with interventions such as monitoring respiratory status, vital signs, and providing oxygen per physician order. Facility policies on Change in Resident Condition and Resident Hospital Transfer required the RN to complete and document an assessment, use an SBAR tool, and write a nursing progress note including all steps taken, the time of transfer, transport details, and report to the emergency department. On the night in question, an LPN documented that around 1:00 AM the resident was resting comfortably and remained stable and responsive through the night until approximately 5:00 AM, when the resident was found with labored respirations and minimally responsive to verbal stimuli. The LPN documented that the resident’s oxygen saturation was 40% on 4L nasal cannula, that the RN supervisor was immediately notified and came to the bedside, changed the nasal cannula to an oxygen mask, and that oxygen saturation levels were rechecked with three separate oximeters, yielding readings of 42%, 43%, and 26% with increased labored breathing. The LPN further documented that the RN supervisor was again updated with a recommendation to send the resident to the emergency department, oxygen therapy was escalated to 10L via non-rebreather mask, and that upon EMS arrival the resident became unresponsive and was transported to the hospital. Despite these events, there was no documentation in the medical record of the resident’s vital signs (heart rate, blood pressure, respiratory rate, and temperature) on that date, no documented assessment by the RN supervisor when the resident had respiratory and mental status changes, and no documented evidence of the resident’s response to the oxygen treatment provided. The nursing progress note entry for the RN supervisor at 5:57 AM was blank, and another RN later documented only that they received report from the LPN, that the resident’s oxygen saturation was in the low 40s, that the resident was unresponsive and vital signs were unable to be taken, that the RN supervisor had assessed the resident per the LPN, and that the resident was sent to the hospital and the NP was notified. In interviews, the LPN stated they had taken and written vital signs on a “cheat sheet,” and the RN supervisor stated they forgot to write a note; the DON stated they would expect RNs to write assessment notes and that the RN supervisor attempted but did not save a note in the computer system. These omissions resulted in an incomplete and non-compliant medical record for this resident’s acute change in condition and transfer.
Failure to Implement Ordered 1:1 Safety Supervision Resulting in Self-Inflicted Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of a physician-ordered 1:1 safety watch for a resident with behavioral issues and prior smoking violations. The resident had diagnoses including opioid dependence, anxiety disorder, depression, and diabetes, and a psychological evaluation documented moderate depression symptoms, though at that time the resident was assessed as not being a danger to self or others. Following multiple smoking violations, the Interdisciplinary Team met on 12/28/2024 and agreed the resident was to be placed on 1:1 supervision for safety, and a telephone order for a 1:1 safety watch was obtained from a nurse practitioner. A subsequent physician order dated 12/30/2024 documented 1:1 for safety with an ongoing end date, and the comprehensive care plan, reviewed on 01/15/2025, included 1:1 supervision for safety as an intervention for behaviors and multiple smoking violations. Despite the active 1:1 order and care plan intervention, documentation showed that the 1:1 safety watch was not consistently reflected on CNA assignment sheets prior to the resident’s hospitalization, and there was confusion among staff about the required distance and expectations for 1:1 supervision. Multiple CNAs reported having previously performed 1:1 safety watches for this resident due to smoking, generally staying within reach or at least within eyesight, often sitting outside the bathroom door or at the nurse’s station. Staff interviews revealed variability and lack of clarity in how “required distance” was interpreted, with some CNAs stating there was no clear definition and that the level of proximity depended on the resident and situation. The facility’s 1:1 Supervision policy required staff to stay within the required distance at all times, remain with the resident unless relieved, and complete necessary documentation, but practice as described by CNAs did not consistently align with these expectations. When the resident was readmitted from the hospital on 01/15/2025, the facility failed to implement the existing 1:1 safety supervision order. The admission nurse was responsible for assessing the resident, entering orders into the computer, and contacting the medical provider to review orders, and the DON later stated that 1:1 safety watches required a physician order and would appear on the care plan and Kardex so staff would know via the care card. However, upon readmission, the resident was not placed on a 1:1 safety watch, there was no documented physician order discontinuing the prior 1:1, and the DON acknowledged uncertainty about why 1:1 was still listed on the care plan. The resident was cared for on a different floor after readmission, and a CNA who cared for the resident at that time confirmed the resident was not on a 1:1 safety watch. On 01/17/2025, two days after readmission without 1:1 supervision in place, the resident was found with a self-inflicted laceration to the neck and superficial vertical cuts to both wrists, resulting in actual harm that was not Immediate Jeopardy.
Failure to Ensure Resident Dignity Due to Staff Use of Foul Language and Ethnic Slurs
Penalty
Summary
Surveyors found that the facility failed to ensure residents were treated with respect and dignity, as required by facility policy and state regulations. Seven residents reported that staff used foul language, ethnic slurs, and laughed at or made jokes about residents in hallways and common areas, making them feel uncomfortable. Observations confirmed that a certified nurse aide used an ethnic slur in a hallway with staff and residents present, and another aide laughed at a confused and distressed resident in the dining area in front of other residents. Multiple residents stated that staff frequently used foul language, ethnic slurs, and made inappropriate jokes, including about drug use, in the presence of residents. Interviews with staff revealed that some were aware of the inappropriate language and behavior, acknowledging that swearing and ethnic slurs were used in the facility and that such actions were not appropriate. Staff also recognized that laughing at or talking about residents in public areas was undignified and could make residents feel humiliated or belittled. Facility policies required all individuals to be treated with dignity and respect, prohibiting harassment, offensive language, and slurs, but these standards were not upheld in practice, as evidenced by the observations and resident reports.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment across all five resident units. Multiple resident rooms and common areas were found with strong urine odors, soiled toilets with black or brown stains, broken or empty soap and paper towel dispensers, stained bedding, and dirty bedside tables. Shower rooms contained toilet paper stuck to the floor, used personal items left behind, and empty dispensers. Soiled linens were found on the floors of several rooms and the shower area. Trash, dirt, sticky substances, used surgical gloves, and food debris were present on the floors of numerous rooms. Additional maintenance issues included broken floor tiles, missing ceiling tiles, malfunctioning thermostats, soiled windows, old tape on walls, chipped or cracked nurse station enclosures, scrape marks on walls, curtains off hooks, and doors with various marks and stains. Handrails and brass door guards were also found to be soiled, and floors in corridors and rooms were dirty, with scuff marks and unswept areas. During interviews, a resident reported that bathrooms were not cleaned and that shower rooms often had feces present. Facility staff acknowledged the cleanliness and maintenance issues, noting that cleaning, repairs, and restocking of supplies would be addressed. The observations and interviews confirm that the facility did not provide effective housekeeping and maintenance services, resulting in an environment that did not meet regulatory standards for cleanliness and repair.
Failure to Serve Palatable and Safe-Temperature Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, flavorful, and served at appetizing and safe temperatures during two observed meals. Multiple residents reported that their food was cold, overcooked, or did not taste good, and several did not receive all items listed on their tray tickets. Observations during meal service confirmed that food and beverages were often served outside of recommended temperature ranges, with hot foods below 140°F and cold foods above 40°F. Specific examples included milk and juices served above safe cold temperatures, hot foods such as pancakes and eggs served below recommended hot temperatures, and missing or incorrect meal items on trays. Staff interviews corroborated resident complaints, with CNAs and LPNs stating that food was frequently served cold and that complaints were forwarded to dietary staff and food service managers. The Food Service Director acknowledged that hallway carts used to transport food did not maintain proper temperatures due to damaged doors, and that this was a known and ongoing issue. The facility's own policies and USDA guidelines for food safety were not consistently followed, resulting in repeated instances of unpalatable and improperly served meals.
Broad Medication Pass Times and Missing Actual Administration Times
Penalty
Summary
The facility failed to ensure that medication services met professional standards of quality because standing medication orders were documented with broad administration windows rather than actual administration times. The facility policy stated scheduled medications requiring specific time increments were to be administered no more than one hour before or one hour after the ordered time, but the Medication Administration Records for reviewed residents documented only broad ranges such as 8:00 AM to 1:00 PM and 5:00 PM to 10:00 PM. The records did not show the actual time the medications were given for standing orders. For Resident #1, the records for November and December 2025 documented Eliquis 5 mg twice daily and gabapentin 100 mg twice daily with the broad administration windows. For Resident #7, the records for September, October, November, and December 2025 documented apixaban, doxycycline, risperidone, and valproic acid with the same broad time ranges, including route changes between gastrostomy tube and oral administration. For Resident #11, the records documented amoxicillin-clavulanate, Eliquis, and risperidone with the same broad windows, and for Resident #98, Keppra 500 mg twice daily was documented with the same broad ranges across multiple months. For Resident #527, the records for July and August 2025 documented carvedilol, Depakote, Eliquis, and gabapentin with the same broad administration windows. The surveyor noted that the facility used extended medication pass times that could be four or six hours per medication pass, and the Administrator stated the actual time of administration could not be seen in the electronic medical record for standing orders. The Administrator and DON further stated that specific administration times could be reviewed only for PRN medications, not standing orders.
Medication Labeling, Storage, and Narcotic Control Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted professional standards across multiple medication carts and medication rooms. Surveyors found unlabeled and undated insulin pens, including a Lantus Solostar pen in a medication cart and additional Lantus pens without resident names, opened dates, or expiration dates. They also found medication room refrigerator temperatures that were not recorded on several dates, and one refrigerator temperature was observed at 48 degrees Fahrenheit. In addition, several inhalers, eye drops, nasal sprays, and other medications had no resident name, no opened date, or no expiration date, and one insulin pen and two inhalers were expired. Surveyors also observed medication handling and storage problems in the carts. Loose pills were found in a medication cart drawer, two cups of pre-poured medications were left in a cart, and stock medication was mixed with resident medications. A bottle of Meclizine had two different open dates, and multiple multi-use medications, including eye drops and nasal sprays, lacked required labeling information. On one medication cart, two Suboxone packets were found loose in the top drawer, and on another cart, a narcotic count for Xanax did not match the blister pack count. Controlled substance procedures were not followed consistently. The narcotic book was not reconciled each shift because required signatures were missing at shift change, and one nurse stated they had administered Xanax without signing it out. A narcotic box in a medication room refrigerator was not affixed and had to be removed for access, and the refrigerator itself did not have a lock. In addition, a treatment cart on the sixth floor was observed unlocked and unattended while residents were walking by it.
Food Service Sanitation and Equipment Cleanliness Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen and five resident unit kitchens. In the main kitchen, the automatic dishwashing machine final rinse measured 0 parts per million of chlorine, while the machine’s data plate stated the final sanitizing rinse was to be 180 degrees Fahrenheit and did not provide instructions for chemical sanitizing. The quaternary ammonium sanitizer used for manual sanitizing of food contact equipment measured 500 parts per million at 68 degrees Fahrenheit, although the product label directed a concentration between 200 and 400 parts per million. The bulk thickener plastic scoop was broken and uncleanable, and multiple kitchen surfaces and equipment were observed soiled with food particles, dirt, and grime, including mixers, sheet pan carts, shelving, utensil drawers, the outside of the ice machine, hot food holding carts, stovetop, handwashing sinks, ceiling, dry storage door, floors, floor drains, elevator floors and tracks, waste receptacles, and mop bucket and wringer. In the third through seventh floor unit kitchens, pantries, and dining areas, the underside of dining tables, beverage dispensers, cabinet drawers, a microwave, an ice dispensing machine, a freezer interior, floors next to walls and under equipment, and the interior of refrigerators were also soiled. There was no documented evidence that resident refrigerator temperatures, including Resident #211's refrigerator, were being monitored by facility staff.
Improper Disposal Area Sanitation
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly. During observation, the trash compactor and loading dock area, which is part of the refuse disposal area, was heavily soiled with black drip marks below the compactor access portal, splash marks and discoloration on the walls, and cobwebs throughout the area. During interview, the Director of Environmental Services stated that the trash compactor and loading dock area would be thoroughly cleaned.
Administration Failed to Maintain Environment and Infection Control Oversight
Penalty
Summary
Administration failed to ensure residents' rights to a safe, clean, comfortable, and homelike environment, and failed to ensure the infection prevention and control program was developed and implemented to prevent the spread of infectious diseases for all residents, staff, volunteers, and visitors. The report cites deficiencies related to the safe/clean/comfortable/homelike environment, infection control prevention, food nutritive value/appearance/palatability/preferred temperatures, and food procurement/storage/prepare/serve in sanitary conditions. The facility's Administrator job description states the Administrator directs all aspects of facility operation and oversees operations to ensure safety and comfort of all residents, while the QAPI plan states the program is intended to support safety and high quality through monitoring systems, data collection, and corrective action. During interview, the Administrator stated the Quality Assurance team met monthly and reviewed areas of focus based on prior deficiencies, resident council, employee feedback, family input, and quality assurance reports. The Administrator said that after the prior recertification survey deficiency related to the safe/clean/comfortable/homelike environment, the facility continued to audit the environment, and that infection prevention efforts included education for staff and residents, encouragement of influenza vaccination, and monthly meetings of the infection prevention team with unit managers. In a later interview, the Administrator stated they were not aware infection control was still an issue after the last survey, including that unvaccinated staff were still not wearing masks or were wearing them incorrectly, and acknowledged the facility was a special focus facility and needed a higher concentration of compliance and staff education on regulations for resident safety.
Inaccurate oxygen tubing documentation and incomplete electronic record access
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with professional standards. For Resident #143, who was admitted with chronic respiratory failure with hypoxia, COPD, and morbid obesity, the record showed oxygen tubing changes were documented on the Treatment Administration Record for 10/01/2025, 10/15/2025, 11/01/2025, 11/15/2025, and 12/01/2025. However, during observations on 12/03/2025 and 12/04/2025, the oxygen tubing was noted to be dated 10/01/2025 and then 12/01/2025, and the resident stated it had been a while since the tubing had been changed. An LPN later stated they had changed the tubing on 12/03/2025, but also stated they had put the date the tubing was supposed to be changed on the tubing instead of the date it was actually changed and knew they should not have done it. The facility also did not provide surveyors full access to medical records as required. Although the facility was notified in the entrance conference letter that surveyors were obligated to have access to all resident electronic health records and no information should be excluded, the Administrator and DON later stated they could not access exact times of medication administrations for standing orders in the residents' records, only whether medications were given within scheduled time frames or late. In contrast, during observation, exact times of administration were visible on an LPN's computer for both PRN and standing orders, and the LPN confirmed that exact times could be seen for both types of orders.
QAA Committee Failed to Correct Repeat Quality Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assessment and Assurance (QAA) committee developed and implemented effective plans of action to correct repeated quality deficiencies. Survey findings identified repeat deficiencies in Resident Rights (F550), Self-Administration of Medications (F554), Self-determination (F561), Safe/Clean/Comfortable/Homelike Environment (F584), Develop/Implement Comprehensive Care Plans (F656), Quality of Care (F684), Label/Storage of Drugs and Biologicals (F761), Food Nutritive Value/Appearance, Palatability/Prefer Temperatures (F804), Food Procurement Storage/Prepare/Serve in Sanitary Conditions (F812), and Infection Prevention and Control (F880). During record review, the last six months of QAA meeting sign-in sheets showed committee members and the Medical Director attended each monthly meeting. During interviews, the Administrator, Assistant Administrator, and DON stated the QAA committee met monthly and included multiple department leaders and consultants. They said topics were selected based on prior deficiencies, resident council concerns, staff feedback, surveys, grievances, rounds, and Ombudsman feedback, and that the cited issues were being tracked through minutes, performance improvement projects, audits, and education. They also stated the facility had continuing concerns involving resident rights, environment issues, misappropriation, care plans, food palatability and temperatures, snacks, food storage, infection prevention and control, and pest control. The Administrator later stated good faith efforts had been made to correct prior deficiencies, but it would take time to reach the facility’s goals. In a later interview, the Administrator and DON stated the facility could not access exact medication administration times, only whether medications were given within scheduled time frames or late, and they were unaware of infection control issues, including that some unvaccinated staff were not correctly wearing surgical masks during influenza season as required by New York State Department of Health regulations.
Infection Control Failures With Drainage Bag Placement, Hand Hygiene Access, and Influenza Mask Compliance
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the survey, Resident #11 and Resident #336 were observed with urinary drainage bags on the floor without a barrier separating the bag from the floor. The facility policy stated drainage bags were to be placed below the level of the bladder, dated, and covered, and staff interviews confirmed the bag should not be lying directly on the floor because the floor was not a clean surface and bacteria could potentially enter the bladder. The survey also identified a broken soap dispenser in room [ROOM NUMBER] that was observed unable to dispense soap on more than one occasion. The resident in that room was on enhanced barrier precautions, and staff interviews indicated handwashing was required before entering and when leaving the room. The broken dispenser remained in place during the survey observations, and staff stated they were not sure how long it had been broken. In addition, multiple residents were diagnosed with influenza, including residents with diagnoses such as pneumonia, sepsis, dementia, encephalopathy, and other chronic conditions. The facility had declared influenza prevalent and posted a sign stating employees without a flu vaccine must wear a facemask. However, multiple unvaccinated staff were observed in resident care areas without a facemask or wearing it improperly, including masks below the chin, covering only the mouth, or not worn at all while providing care, serving meals, or working in resident areas. Staff interviews confirmed some were unvaccinated, knew they should be wearing facemasks over the nose and mouth, and stated they had not been consistently doing so.
Failure to Maintain Sanitary and Comfortable Environment Due to Persistent Urine Odors
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment on three out of five resident units. During multiple observations conducted over several days, strong urine odors were detected in specific resident rooms and in the north elevator lobby area on the third floor. These odors were noted in rooms #555, 566 (on two occasions), and 671, as well as in a common area, indicating a persistent issue with cleanliness and sanitation in these locations. During an interview, the Director of Environmental Services acknowledged awareness of the odors and indicated intent to involve the nursing department for further investigation.
Incomplete Person-Centered Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were implemented for three residents whose nursing needs were not fully addressed in their records. The facility policy stated that comprehensive person-centered care plans should include measurable objectives and timetables and reflect resident-specific interventions, with review and revision as appropriate. Survey review found that the care plans for Residents #1, #7, and #98 did not include required resident-specific information related to their conditions and treatments. Resident #1 was admitted with Parkinson's disease, dysphagia, and dementia. The MDS dated 10/10/2025 documented the resident was understood, could understand others, and was cognitively intact. Survey review found no documented comprehensive care plan addressing activities for the resident. The cognitive loss/dementia care plan dated 09/15/2025 included general interventions such as assess level of involvement, address in a slow quiet manner, maintain calm environment, and monitor for changes, but these interventions were not resident specific. The Director of Recreation stated every resident should have a care plan that addresses recreation needs and preferences. Resident #7 was admitted with depression, diabetes, and end-stage chronic kidney disease. The MDS documented the resident was cognitively intact, required substantial to maximum assistance with most ADLs, and received antidepressants, anticoagulants, and insulin injections on 7 of 7 days, along with dialysis. The record showed orders for Tresiba insulin and Apixaban, and the MAR documented both medications were being administered. However, the comprehensive care plan updated on 11/19/2025 addressed diabetes only in general terms and did not document insulin use, and the cardiac care area did not document anticoagulant use. Resident #98 was admitted with chronic congestive heart failure, dyspnea, and spastic hemiplegia affecting the left dominant side. The MAR documented oxygen therapy at 2 liters per minute for acute respiratory failure with hypoxia, nursing notes documented oxygen use at 2 and 3 liters per minute, and observations found the oxygen concentrator set at 3 liters per minute and later 2.5 liters per minute with the nasal cannula partially in the nostrils and tubing extended across the forehead. The comprehensive care plan dated 10/01/2025 did not include a care plan for oxygen or respiratory therapy.
Failure to Provide Resident-Preferred Activities
Penalty
Summary
The facility failed to provide ongoing programs to support each resident in their choice of activities for two residents. The deficiency was identified during observations, record review, and interviews, and involved Resident #15 and Resident #163. The facility policy stated that each resident should have a structured and individualized activities and therapeutic recreation program that met interests and enhanced quality of life in accordance with the comprehensive care plan, preferences, and abilities. Resident #15 had diagnoses including cerebral palsy, cortical blindness, and aphasia. The resident’s MDS documented severe cognitive impairment, dependence on staff for all ADLs, and that the resident was sometimes understood and sometimes understood others. The care plan called for at least 12 leisure activities per month, with interventions including 1:1 activities and seating near the front so the resident could see and hear better. Records showed limited documented activity participation in October and December, with no documented activities after 10/16/2025 in October and only one 1:1 entry on 12/01/2025 in December. The resident was observed multiple times sitting in their room without music or television stimulation, including while a musician was performing down the hall, and staff stated the resident enjoyed cartoons and should have the television on for stimulation. Staff also stated the resident was unable to refuse activities and should have been brought to music activities, but the recreation therapist could not recall the activity or day of the one 1:1 visit and was not sure why the resident was not brought to live music. Resident #163 had diagnoses including chronic pain syndrome, difficulty walking, and schizoaffective disorder. The resident’s MDS documented intact cognition and substantial to maximum assistance with some care needs. The care plan called for at least 12 leisure activities per month and noted interests including cooking, cards, bingo, music, reading, spiritual circle, television, socials, trivia, word search, puzzles, and pets. The resident reported being upset because staff did not get them up in time for morning activities, especially coffee hour and BINGO, and stated they missed activities on multiple occasions because they remained in bed. The resident said CNA #20 told them they had to wait until breakfast trays were served and picked up before getting up, and staff also reported delays when a transfer sling could not be found. The activity calendar listed coffee brew on several mornings, but the resident did not attend those listed activities and repeatedly stated they wanted to participate but were not brought up in time.
Failure to Provide Ordered Hand Devices for Residents With Contractures
Penalty
Summary
The facility failed to ensure that two residents with limited mobility received the ordered services and devices needed to maintain hand range of motion and prevent complications. Resident #15, who had cerebral palsy, cortical blindness, severe cognitive impairment, and contractures, had a physician order for a palm grip to the right hand after morning care and removal at night, but the treatment record did not document its use and staff repeatedly observed the resident without the palm guard in place. The resident was seen in a chair with both hands contracted, right greater than left, and staff interviews showed confusion about whether the palm guard was currently ordered or being used. Resident #301, who had left hemiplegia, epilepsy, anxiety, and moderate cognitive impairment, had an active physician order for a rolled washcloth to the left hand off for hygiene. The December 2025 MAR and TAR did not document the order, and multiple observations showed no rolled washcloth in the resident’s left hand. Staff members stated they were unfamiliar with the recommendation or did not see it on the care plan, while OT stated the rolled washcloth was recommended to protect skin integrity and that nursing had not communicated any refusals. The record also showed that OT had assessed Resident #301’s left hand and noted long, jagged nails and a foul odor from the left palm during observation. OT stated the hand needed cleansing and nail filing, and that nursing should be cleaning the hand daily, monitoring skin integrity, and documenting application or refusals. The DON stated therapy recommendations were to be care planned and reassessed as needed, and if a resident refused adaptive equipment, education and documentation of noncompliance would occur; however, the report documents that the ordered hand device for each resident was not consistently provided or documented.
Missing Dialysis Assessments and Access Monitoring
Penalty
Summary
The facility failed to ensure safe, appropriate dialysis care for a resident with end stage renal disease, status post sepsis, and congestive heart failure who received hemodialysis at a community dialysis center. The resident’s care plan and physician orders required dialysis on Monday, Wednesday, and Friday, along with monitoring of the left arm arteriovenous fistula/access site every shift. However, the record did not show documented access-site monitoring on multiple shifts in December 2025, including day, evening, and night shifts on several dates. The dialysis communication notebook and nursing progress notes also lacked documented pre- and post-dialysis assessments for multiple treatments. Missing documentation included post-dialysis vital signs, weights, evaluation of the dialysis access site, and signatures for several dialysis visits, as well as no documented pre- or post-dialysis entries for multiple other treatments. During interviews, LPNs stated they were unsure how to locate prior vital sign documentation, while the DON stated the expectation was that vital signs be documented in the EMR before residents left for dialysis and after they returned, and that the dialysis notebook should contain a report upon return from the dialysis center.
Medication Pass Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent during a medication pass observation involving five residents and 28 medication administrations. Surveyors identified two medication errors involving Resident #352 and Resident #303, resulting in a calculated medication error rate of 10.71 percent. The facility policy required staff to verify the right resident, right drug, right dose, right time, right route, and to check orders carefully before administering medications, but these steps were not consistently followed during the observed medication pass. For Resident #352, an LPN reviewed the MAR and prepared MiraLAX 17 grams mixed with water, although there was no ordered amount of water documented and the nurse did not check the bottle for mixing instructions. The medication was mixed in an undetermined amount of water in a stock cart cup, and the nurse entered the room without verifying the resident, explaining the medications, or introducing herself before administering tablets and leaving the resident unattended with a full cup of MiraLAX. For Resident #303, an LPN reviewed the MAR showing Buspirone 5 mg three times daily, but the blister pack in use was labeled for twice daily dosing. The nurse placed a tablet in a medication cup and stated she had been giving the medication daily; after the surveyor intervened, she called another LPN for clarification, who confirmed the order had been changed on 11/25/2025 and that the correct blister pack was in the overflow drawer while the old pack was in the discontinued pile.
Failure to Document and Obtain Orders for Resident Wound Care
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Parkinson's disease, dysphagia, and dementia was observed with an old bandage on their left forearm, dated several days prior, without any corresponding documentation or physician order. The resident was cognitively intact and able to communicate, but was unaware of the reason for the bandage. Multiple observations confirmed the bandage remained in place for several days, and there was no evidence in the medical record, Medication Administration Record, or Treatment Administration Record of any treatment orders or documentation regarding the bandage or a skin issue on the left forearm. Additionally, there were no progress notes or Incident and Accident forms explaining the presence of the bandage or any related skin condition. Interviews with nursing staff revealed a lack of awareness regarding the origin of the bandage and whether an order existed for its application or change. One LPN recalled changing the bandage but did not remember the underlying issue and assumed it had been reported. Both RNs and the Director of Nursing confirmed that any dressing should have an accompanying order and be documented, and that skin issues should be reported and tracked. The absence of documentation, orders, and reporting for the bandage and any associated skin issue constituted a failure to provide treatment and care in accordance with professional standards and regulatory requirements.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that Resident #314 was assessed by the interdisciplinary team to determine whether the resident could safely self-administer medication when clinically appropriate. During observations on 12/03/2025 and 12/05/2025, a bottle of unprescribed Clinical Treat Anti-Fungal Powder was seen sitting on the resident’s bedside table in the room. The resident stated that the nurse gave the powder to apply as needed underneath the breasts, and on 12/09/2025 the resident again stated they applied powder to a rash as needed underneath the breasts. Resident #314 was admitted with diagnoses including need for assistance with personal care, spinal stenosis, and depression. The MDS dated 11/06/2025 documented moderately impaired cognition, though the resident was able to be understood and understand others. The comprehensive care plan dated 10/01/2025 did not include documentation for self-medication administration, and the MARs for October, November, and December 2025 had no documented order for Clinical Treat Anti-Fungal Powder. The weekly skin tracker documented redness to the left chest on 10/28/2025 and 10/29/2025, with no corresponding nurse progress notes. Staff interviews indicated the facility had no residents self-administering medications, and the DON stated that if a resident wished to self-medicate, the interdisciplinary team would assess the resident, followed by a physician order and care plan update.
Resident Preferences for Meals Not Consistently Honored
Penalty
Summary
The facility failed to ensure Resident #211’s right to make choices about significant aspects of life in the facility by not consistently providing the resident’s preferred and nutritionist-recommended food items. Resident #211 was admitted with Hodgkin lymphoma, pain, and anemia, and the MDS documented the resident was cognitively intact and able to understand and be understood. The care plan addressed nutrition related to the resident’s condition and included interventions for diet and fluids per provider order, oral nutrition supplements, fortified foods, and honoring preferences. The nutrition assessment documented that the resident received Ensure Plus and coffee for breakfast, Ensure Plus, orange wedges, and two sandwiches for lunch, and Ensure Plus, orange wedges, and two sandwiches for dinner, while the resident preferred only sandwiches, oral nutrition supplements, and oranges with meals. Interviews and observations showed the resident often did not receive the preferred food items from the facility, had to buy food from an outside source, and kept wrapped sandwiches, bottled water, and Ensure in a refrigerator in the room. Staff stated there were times when there were not enough sandwiches or other food items, and when meals were missing the resident’s preference, staff sometimes called the kitchen or made a sandwich themselves because the kitchenettes had no food.
Missing-items grievance not documented or resolved
Penalty
Summary
The facility failed to ensure that a resident’s right to file a grievance was honored and that prompt efforts were made to resolve a missing-items complaint. Resident #380, who was admitted with diagnoses including Alzheimer’s disease, anxiety, and hypertension, had moderate cognitive impairment on the Minimum Data Set dated 06/19/2025. The resident’s responsible party reported to staff that the resident was missing 3 bags of clothing, 2 coats, and a new pair of sneakers, but there was no documented evidence that a grievance was filed, investigated, or resolved. During interview, the responsible party stated the missing items had been reported to Social Worker #3 a couple of months earlier and that no resolution had been received from the facility. Social Worker #3 stated they completed a missing item report and forwarded it to the Director of Social Work or Chief Experience Officer, while the Chief Experience Officer stated the missing-item process requires completion of the form and an investigation by the Chief Experience Officer and/or Administrator. The Chief Experience Officer also stated there was no record of a missing items report for Resident #380.
Oxygen tubing was not changed and was incorrectly dated
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who required oxygen therapy. Resident #143 had diagnoses including acute and chronic respiratory failure with hypoxia, pneumonia, and chronic obstructive pulmonary disease, and the care plan documented compromised respiratory status with interventions for oxygen use, oxygen saturation monitoring, and activity tolerance monitoring. The physician order directed oxygen at 6 liters via nasal cannula, daily checks each shift, and cleaning equipment with tubing changes on the 1st and 15th during the day shift. During observations, Resident #143 was seen wearing oxygen at 6 liters via nasal cannula with tubing dated [DATE] and initialed by LEC. The resident stated it had been several weeks since the tubing was changed and that it did not get changed often. Later the same day, the resident was again observed with tubing dated [DATE], and stated the nurse had changed the tubing earlier and discarded the old tubing in the garbage. The treatment administration record for December showed the oxygen tubing change time had expired on [DATE], and LPN #7 documented changing the tubing on [DATE] and [DATE]. Interviews showed staff understood that nurses were responsible for managing oxygen therapy, changing tubing according to physician orders, and documenting completion after the task was done. LPN #7 stated they did not change the tubing on [DATE] because they were busy, forgot to complete it later, and then changed it on [DATE]. They also stated they dated the tubing [DATE] and were not sure why the date did not match the task, acknowledging that the date should correlate with when the tubing was actually changed and that the incorrect dating was falsifying records. The RN supervisor stated the resident should not have had tubing dated [DATE], that the tubing should have been changed, and that incorrect signing was a safety concern.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to ensure the timely provision and administration of routine and emergency medications for two residents, resulting in missed doses of critical medications. For one resident with schizophrenia and a physician order for Lithium Carbonate, the medication was not administered on multiple occasions because it was not available in the automated medication dispensing machine. The pharmacy had rejected refill requests due to a computer error, and facility staff did not follow up with the pharmacy to resolve the issue. As a result, the resident's Lithium blood level was found to be low, and the resident was subsequently transported to the hospital at the family's request after concerns about symptoms were raised. Another resident with end stage renal disease, diabetes, and malnutrition did not receive prescribed medications, including cinacalcet and Sevelamer, for an extended period after admission. The medications were not available in the facility, and there was confusion regarding whether they would be provided by the dialysis center or needed to be obtained from the facility's pharmacy. Multiple nurses documented that the medications were not available and reported the issue to supervisors, but the medications were not obtained in a timely manner. The pharmacy did not fill the medications until several days after the resident's admission, and the resident missed numerous doses as documented in the Medication Administration Record. Interviews with nursing staff and pharmacy personnel confirmed that the facility's process for ordering, tracking, and ensuring the availability of medications was not followed as required by policy. Staff did not consistently notify the pharmacy or medical provider when medications were unavailable, and there was a lack of timely follow-up to resolve issues with medication procurement. These failures resulted in residents not receiving essential medications as ordered by their physicians.
Failure to Provide Preferred Communication Methods for Deaf Residents
Penalty
Summary
The facility failed to ensure the rights of two residents who were Deaf to choose activities and health care services consistent with their interests, assessments, and care plans, and to participate in social and community activities. Both residents were not provided with their preferred method of communication, which was American Sign Language (ASL), and instead were limited to using whiteboards and written communication. Staff interviews revealed a lack of knowledge and training on how to use available technology, such as tablets with video relay interpreting services, and there was no consistent provision of in-person or video ASL interpretation for daily communication, medical care, or participation in activities. One resident, who was cognitively intact but non-speaking and Deaf, reported feeling isolated and unable to communicate needs, socialize, or participate in meaningful activities. The resident's care plan and speech therapy recommendations specified the use of live ASL interpreting services via tablet, but this was not implemented. Staff relied on whiteboards, which the resident was not comfortable using due to limited English proficiency, and staff were unaware of or unable to use the tablet for interpretation. The resident experienced psychosocial harm, including feelings of isolation, inability to communicate about medication changes, and lack of participation in activities due to the absence of interpreters. The second resident, who was also Deaf with highly impaired vision and moderate cognitive impairment, was similarly not provided with their preferred communication method. Although care plans and therapy notes recommended live ASL interpretation and the use of tablets, these were not made available to the resident on a regular basis. Staff and family interviews confirmed that the resident could not effectively communicate needs or participate in care discussions, and staff often resorted to writing, which was ineffective due to the resident's vision and handwriting difficulties. The lack of appropriate communication support resulted in the residents' inability to express preferences, participate in activities, and communicate with staff and peers.
Removal Plan
- Facility provided Residents #50 and #162 tablets programmed with the video relay interpreting service that were always accessible to the resident.
- Education was provided to the staff and residents on the use of the tablets.
- Tablets were to be kept in the resident's rooms.
- Facility provided in-service education to staff with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in multiple lapses in infection control practices for six of eight residents reviewed. Several residents who were on contact or droplet precautions for communicable diseases such as Clostridium difficile, COVID-19, and metapneumovirus did not have the appropriate isolation precaution signage posted on their doors. In some cases, precaution signs were missing, posted late, or incorrectly identified the resident on precautions. Staff frequently entered and exited rooms of residents on isolation precautions without donning the required personal protective equipment (PPE) or performing proper hand hygiene. For example, staff were observed entering rooms without PPE, removing PPE outside of rooms, and failing to wash hands after glove removal. In one instance, a physical therapist wore PPE but left the resident's room to take phone calls without changing PPE, and a nurse entered a room with only a surgical mask when an N95 was required but unavailable in the PPE caddy. Laundry and housekeeping practices also failed to meet infection control standards. Contaminated laundry from residents on contact precautions was not consistently separated from general population laundry, and laundry staff were not always informed when items required special handling. Housekeeping staff did not consistently use PPE when handling refuse from isolation rooms and did not follow enhanced cleaning protocols, such as using bleach for rooms of residents with Clostridium difficile. Some staff reported cleaning all rooms the same way, regardless of isolation status, and using plain water for mopping instead of disinfectant. Additionally, staff responsible for laundry and housekeeping were not always aware of which residents were on precautions and did not consistently wear appropriate PPE due to discomfort or lack of communication. The facility's own policies required the use of color-coded precaution signs, proper PPE usage, and specific cleaning and laundry protocols for residents on isolation precautions. However, observations and staff interviews revealed widespread non-compliance with these policies. Staff were often unaware of the correct precautions, did not follow signage, and failed to implement required infection control measures, increasing the likelihood of transmission of communicable diseases among residents and staff.
Removal Plan
- The facility ensured all residents on precautions were reviewed and had the appropriate isolation precaution signage in place.
- All in-house staff were educated on infection control with competency-based training.
- All oncoming staff would be educated prior to the start of their shift.
- The facility provided in-service education to staff, with plans for ongoing education of staff not currently on the schedule, prior to the start of their next shift.
Failure to Honor Resident Dignity and Provide Individualized Toileting Assistance
Penalty
Summary
Surveyors found that two residents who were continent of bladder and/or bowel were routinely placed in incontinence briefs and instructed by staff to urinate or defecate in the briefs rather than being assisted to use the toilet or bedpan. One resident, who had moderate cognitive impairment and required assistance for transfers, was not reassessed for toileting after their transfer status improved. Despite being able to verbalize the need to use the bathroom and having the physical ability to transfer with assistance, this resident was denied toileting assistance and told to use the incontinence brief, including during their menstrual cycle. Staff interviews confirmed that the resident was not provided with regular toileting opportunities and that care plans were not updated to reflect the resident's improved abilities. Another resident, with intact cognition and a history of anxiety disorder and morbid obesity, was also continent but was made to wear incontinence briefs for staff convenience. This resident preferred to use a bedpan but was told that if they returned to bed for toileting, they would have to remain there for the rest of the day, limiting their participation in activities. The resident was left in soiled briefs and on urine-soaked lift pads for extended periods, leading to embarrassment and distress. Staff acknowledged that the resident was continent and that the use of incontinence briefs was not appropriate, but cited lack of underwear and staff availability as reasons for this practice. Observations and interviews revealed that both residents experienced psychosocial harm as a result of being denied appropriate toileting assistance and being left in soiled briefs. Staff and clinical leadership, including the Director of Rehabilitation, LPNs, and the Medical Director, confirmed that the residents should not have been told to use incontinence briefs and that this practice was a violation of their dignity and quality of life. The facility failed to update care plans, reassess residents' needs, and provide individualized care, resulting in a lack of respect for resident rights and dignity.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Syracuse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Upstate University Hosp At Community General T C U | 0.2 mi | ★★★★★ | 0 | 0 |
| Loretto Health And Rehabilitation Center | 1.8 mi | ★★★★★ | 20 | 0 |
| Central Park Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Iroquois Nursing Home Inc | 2.5 mi | ★★★★★ | 1 | 0 |
| St Camillus Residential Health Care Facility | 2.9 mi | ★★★★★ | 20 | 0 |
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