Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors identified that multiple residents were not treated with dignity and respect. A resident in the active dying phase was left in a dark room with no stimuli, lying partially off the bed, while staff walked past without entering to assess or provide comfort despite PRN orders for pain and anxiety medications. Another resident with cognitive impairment was observed self-toileting on a bedside commode in an open area without curtains drawn, surrounded by feces-stained landing strips and soiled tissues on the floor. A third resident reported that when they requested toileting, a CNA stated they were responsible for 20 residents, refused to toilet them, instructed them to relieve themselves in bed, and did not return until the next day shift.
The facility failed to protect several residents from abuse, neglect, and misappropriation of property, and did not ensure care consistent with assessed needs. One resident with dementia and anxiety was inappropriately touched on the breast by another cognitively intact resident with a documented history of sexually inappropriate behaviors, who was not under active 1:1 supervision at the time. Another resident with morbid obesity and lymphedema, care planned for two-person assistance with bed mobility, was provided incontinence care by a single CNA and slipped from the bed to the floor, with no further investigation or statements collected despite the care plan violation. A third resident with head and neck cancer, cirrhosis, and an artificial larynx was accused by an RN of consuming a crushed oxycodone dose left unattended in the room; the resident denied taking it, became distressed, contacted law enforcement, and the RN still documented the narcotic as given without recording an incident or triggering an investigation. For this same resident, the comprehensive care plan called for airway management and emergency preparedness related to an artificial larynx, but physician orders lacked any trach/laryngectomy care, suctioning, humidification, respiratory therapy involvement, or required bedside emergency airway supplies.
Surveyors found that the facility did not keep resident environments free from accident hazards when medications and supplements were left unsecured in resident rooms and fall-prevention equipment was used improperly. One resident had a cup with cream and crushed medication left at the bedside, while another had collagen peptides, alpha lipoic acid, and topical cream accessible in the room, even though the DON stated no residents self-administered medications and the Administrator indicated such items should be locked. A third resident, admitted with a femur fracture, acute respiratory failure, and HTN and care-planned for fall risk, had two thick floor mats stacked on one side of the bed, contrary to the care plan and staff expectations for mat placement, and staff acknowledged that this configuration could increase fall and tripping risk as the resident ambulated more independently.
The facility failed to ensure that nurses and nurse aides had validated competencies for specialized respiratory care and safe narcotic management. One resident with throat cancer, a tracheostomy, and HIV had physician orders for trach care every shift, yet surveyors observed an uncovered suction catheter on a canister with cloudy fluid, undated tubing and water, no Ambu bag at bedside despite the care plan, and the resident reported that trach care and suctioning were not being performed. An LPN who claimed to have provided trach care could not locate needed supplies, could not describe full trach care, and had no documented competency for tracheostomy or respiratory equipment management, while treatment records showed inconsistent documentation and directions inconsistent with the resident’s skilled care needs. Another resident with head and neck cancer, an artificial airway, and cirrhosis had a narcotic pain dose left crushed and unattended in the room by an RN; when the medication was found missing, the RN assumed ingestion despite the resident’s denial, yet still documented the narcotic as given on the MAR. The DON did not ensure required investigation, did not notify the physician or Medical Director of the narcotic discrepancy, and there was no evidence of staff interviews, root-cause determination, disciplinary action, or competency-based retraining, despite facility policies requiring incident investigation, narcotic discrepancy reporting, and staff competency validation.
The facility failed to honor resident self-determination when a cognitively intact resident was denied a requested return to bed and was not given meaningful meal choices, and another cognitively intact resident was told to move rooms without consent. Staff stated the room move was needed to open a bed for an admission, while corporate staff confirmed residents retain the right to refuse a room change and should not be forced to move. The DON acknowledged the move was to accommodate an outside admission and that residents had been moved despite documented refusal to sign consent.
An LPN left multiple meds improperly labeled and stored on a South Unit med cart, including unopened insulin pens that were not refrigerated, opened insulin pens and inhalers without open or expiration dates, and a box of hard candy in the cart. In the med room, narcotic lock box #2 was found with the inside lock unlocked, and the LPN said the lock was broken and had not yet been reported. The DON stated opened insulins must be labeled with date and time opened and narcotics must be double locked.
A resident with morbid obesity, lymphedema, and GAD, who was care planned to require two staff for bed mobility, slipped from the bed to the floor when a CNA provided incontinence care alone and turned the resident onto their side. The facility’s incident report documented no injury and full ROM, but the event, an alleged neglect incident involving failure to follow the two-person assistance requirement, was not reported to the state health department within the required timeframe, and the DON later stated it was deemed non-reportable despite facility policy assigning responsibility to leadership to determine and complete required external reporting.
A resident with COPD, pulmonary HTN, CHF, CKD, and hypoxic respiratory failure was discharged home after completing rehab, with documentation stating their health had improved sufficiently to no longer need facility services. In the days before discharge, a provider ordered PRN guaifenesin for cough and a COVID/flu respiratory panel, and the resident received cough medication twice, with one dose documented as ineffective. The swab was collected, but there was no documentation of the rationale for the orders, no evidence that test results were obtained or reviewed, and no provider evaluation of the resident’s clinical status after these orders and before discharge. Staff reported the resident had cough and congestion and that family requested testing, while leadership stated the resident had no respiratory symptoms at discharge and that results would not have been available due to outside lab processing. The complainant reported the resident was very ill at discharge and that attempts to delay discharge were unsuccessful. The resident was hospitalized shortly after discharge with shortness of breath, weakness, a one-week history of respiratory symptoms, and was found to have influenza and acute on chronic heart failure exacerbation, leading surveyors to cite a failure to ensure an appropriate and safe discharge.
A resident with end stage renal disease, type 2 DM, and chronic respiratory failure, who was cognitively intact, slipped from the side of the bed to the floor during incontinence care provided by a CNA. An Initial Event assessment documented the fall and initiation of interventions such as OT/PT evaluation as indicated, non-skid socks, and keeping the bed in the lowest position. The facility’s policies required the IDT to review and revise the comprehensive, person-centered care plan after such events and when resident conditions changed. However, there was no documentation that the resident’s fall care plan, which already identified fall risk related to deconditioning, gait/balance problems, and immobility, was reviewed or revised following this fall, despite the DON’s description that incident reports are discussed and care plans updated after such events.
Two residents with tracheostomy or laryngectomy tubes did not receive respiratory care in accordance with facility policy and professional standards. One resident with throat cancer and HIV reported not receiving trach care or suctioning despite documented orders, while surveyors observed uncovered and soiled suction equipment, undated respiratory supplies, and no Ambu bag at the bedside; an LPN could not locate needed trach supplies, described care as merely wiping the stoma, and admitted most nurses needed a skills refresher. Another resident with an artificial airway and cirrhosis had care plan interventions for respiratory monitoring and suctioning, but the health care proxy expressed concerns about staff competency to manage the airway and could not confirm the presence of emergency airway equipment. Interviews with the DON, an RN, and the Medical Director confirmed that clean, dated supplies, complete trach care, and an Ambu bag at bedside were expected, yet these standards were not consistently met.
Surveyors found that the facility did not follow its policy for safe storage of outside food, resulting in perishable items such as mayonnaise, milk, and lettuce being kept unrefrigerated in a resident’s room for at least two days, with the resident reporting they used the cool outdoor air as a refrigerator and received no staff guidance on proper storage. Another resident with a PICC line, adrenal insufficiency, atrial fibrillation, limited mobility, and malnutrition had a care plan addressing outside food and visitor education, yet developed Salmonella identified as foodborne during the stay, while the facility’s infection control reports showed no identification, tracking, or trending of foodborne illness and no documented monitoring of perishable food stored in resident rooms, despite routine monitoring of kitchen food temperatures.
Failure to assess and authorize self-administration of meds: two residents had meds at bedside without the required clinical assessment, provider approval, or care plan documentation. One cognitively intact resident had a medication cup with crushed/creamed medication at bedside, and another had collagen peptides, alpha lipoic acid, and Aspercreme at bedside despite no MAR orders; the resident said family brought them in and that they were using them for wound healing.
Soiled Room Conditions and Inadequate Privacy: Two residents shared a room where one resident with dementia and other diagnoses was observed using a bedside commode in an open area, with soiled tissues on the floor and landing strips caked with brown material consistent with feces. The roommate reported repeated soiling of the floor and delays in getting help, while staff described housekeeping and maintenance responsibilities and disputed whether the stains were fecal material.
Failure to provide meal assistance and cueing: A resident with severe cognitive impairment, malnutrition, and weight loss was observed multiple times with meals present but not initiating eating, while staff did not consistently provide encouragement, cueing, or hands-on help. The resident’s care plan identified poor intake and weight loss, family reported concerns about the resident’s inability to feed self independently, and staff interviews showed inconsistent awareness of the resident’s need for supervision and assistance with meals.
Two residents did not receive activity programming aligned with their needs and preferences. One resident with ESRD, HTN, and dementia was observed in bed or in room without activities or staff interaction, despite being near end of life and having no documented one-to-one visits. Another cognitively intact resident with hemiplegia, dementia, and depression said they felt like a prisoner and wanted outdoor time, but there was no documentation of one-to-one visits or outdoor access. The activity calendar also included perfume sampling, which nursing staff and the MD said was not appropriate.
Pain Management and Resident-Centered Support Deficiencies: A resident with dementia and a fracture continued to report pain while staff relied on routine pain scales and morphine without consistent pre-medication assessment. Another cognitively intact resident with chronic pain conditions reported repeated failures to receive PRN narcotic pain meds on time, with MAR gaps and staff confusion about whether doses were due or given. A third resident after knee replacement reported long delays and missed scheduled pain meds, while the record showed inconsistent administration and unclear documentation. The report also noted failures to provide meaningful activity support for two residents, including lack of one-to-one interaction, outdoor time, and an activity agenda item involving perfume sampling.
Medication error rate exceeded the 5% threshold after surveyors found errors during medication pass observations. For one resident, the MAR and blister pack conflicted on Depakote dosing, and the RN, LPN/unit manager, and DON could not determine the correct order. For another resident, medications were being crushed without a located provider order, and the DON could not find the order during the survey.
A resident with hemiplegia, hemiparesis, stroke history, and major depressive disorder had a Depakote dose mismatch between the physician order and the blister pack/MAR. An RN and LPN/unit manager both said to follow the computerized MAR, while the DON could not determine the correct order and stated the facility kept using the old blister pack after order changes until it was finished.
Facility assessment did not accurately reflect tracheostomy care needs. The assessment listed zero residents with special treatment needs despite having residents with tracheostomy/laryngectomy-related conditions. One resident’s bedside lacked an Ambu bag, and an LPN needed the resident’s direction while attempting trach care. Another resident had airway-related care plan needs, but the chart lacked orders for trach/laryngectomy care, suctioning, humidification, respiratory therapy, or emergency airway supplies.
Missing documentation in resident records and narcotic counts: one resident’s pain med order was changed without a signed verbal order in the chart and without MAR documentation showing the scheduled doses were administered, another resident had missing CNA care entries for multiple shifts, and an LPN signed the narcotic shift count in advance instead of at the actual shift change.
The facility failed to maintain infection control practices for two residents. A resident with diabetes had perishable food items, including milk, mayonnaise, and lettuce, stored unrefrigerated on a windowsill in the room, and staff confirmed this was not acceptable. A second resident with a trach and HIV had uncovered suction supplies, cloudy liquid in the canister, and tubing without date identification; an LPN handled unclean suction tubing without gloves and delayed hand hygiene until after leaving the room. Policies required proper food storage, hand hygiene, PPE, and clean trach care supplies.
The facility failed to update comprehensive care plans for three residents after incidents, including falls and alleged sexual abuse. Despite interventions being initiated, these were not documented in the care plans. Staff interviews revealed that assessments were documented but not consistently transferred to care plans, leading to regulatory deficiencies.
A resident with complex medical needs, requiring two-person assistance for bed mobility, was neglected when a CNA attempted to roll them alone, resulting in the resident falling and sustaining leg fractures. The CNA was aware of the care plan but chose to act independently, leading to the incident.
Failure to Maintain Resident Dignity, Privacy, and Respect for Toileting and End-of-Life Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect and that their quality of life was maintained or enhanced. One resident with end stage renal disease, dementia, and anxiety, who was documented as cognitively intact, was observed over several days in the active dying phase lying in their room with the lights out, no stimuli, and positioned across the bed with feet partially hanging off the bed. On one of these days, the resident was noted to be restless, moaning, with deep respirations and dry mucosa, while several staff walked by the room throughout the day without entering to assess or provide interventions, despite the presence of PRN orders for Lorazepam and Morphine for anxiety and pain. Another resident with a history of a left humerus fracture, dementia, and anxiety, and documented moderate cognitive impairment, was observed using a bedside commode without privacy measures in place. The resident was self-toileting on the bedside commode in an open area with no curtains drawn while attempting to wipe themselves. The area around the commode had landing strips on the floor that were caked with brown material consistent with feces and other unidentifiable stains, as well as several soiled tissues on the floor that appeared to have been intended for the garbage bin but instead landed on the floor. A third resident with malnutrition, anxiety, and depression, and documented moderate cognitive impairment, reported that on a previous evening they requested to use the toilet at approximately 11:20 PM. According to the resident, a CNA stated they were in charge of 20 residents, did not have time to toilet them, and told the resident to relieve themselves in the bed. The resident further stated that no staff returned to their room until the following day shift arrived and got them up just prior to the interview, and that they were unable to identify the CNA because the aide did not wear a name tag and refused to identify themselves.
Failure to Prevent Abuse, Neglect, Misappropriation, and Inadequate Airway Management
Penalty
Summary
The deficiency involves multiple failures by the facility to protect residents from abuse, neglect, and misappropriation of property, and to ensure care consistent with residents’ assessed needs and care plans. One resident with end stage renal disease, dementia, and anxiety, who was cognitively intact, extended a handshake to another cognitively intact resident with dementia and a history of sexually inappropriate behaviors, including touching self in public, staring at women, making sexual comments, and inappropriate touching of staff and residents. During this interaction at an activity, instead of shaking hands, the resident with known sexual behavior issues reached out and touched the other resident’s left breast. The affected resident moved away from the situation and later verbalized distress related to the incident. The sexually inappropriate resident’s care plan documented prior sexually inappropriate behaviors and prior use of 1:1 supervision when out of bed, but at the time of the incident the resident was not on active 1:1 supervision. Another deficiency occurred when a resident with morbid obesity, lymphedema, and generalized anxiety, who was cognitively intact, was provided incontinence care by a single CNA despite the resident’s Care Kardex directing that rolling left and right required two staff with hands-on assistance. During this care, the resident was turned onto the left side and slipped off the side of the bed onto the floor. The incident and accident report documented the resident lying on the left side on the side of the bed, with full range of motion and no injury noted. The DON acknowledged signing off on the fall progress note and that an incident report was completed, but there was no further investigation, no statements collected, and the event was deemed non-reportable to the Department of Health, despite documentation that the resident required two-person assistance for bed mobility. A further deficiency involved another cognitively intact resident with malignant neoplasm of the head, face, and neck, cirrhosis, and an artificial laryngectomy tube. A nurse crushed an oxycodone tablet, placed it in a medication cup in the resident’s room, briefly left, and on return found the medication missing. The nurse assumed the resident had taken the medication, confronted the resident with this accusation, and the resident denied taking it. The nurse nonetheless documented the narcotic as administered on the MAR and did not document any incident in the record. The resident became visibly upset, cried, and contacted law enforcement; police responded but deferred the matter to the facility, and there was no documented facility investigation into the allegation of abuse or misappropriation of the medication. The Medical Director later stated they were not notified of the missing narcotic or missed dose and that the nurse should not have signed it as given if the facts were unclear. In addition, the same resident with an artificial larynx had a comprehensive care plan reflecting multiple high-risk clinical needs, including airway management related to a tracheotomy/artificial larynx, enteral nutrition, cancer-related pain, impaired communication, decreased mobility, and fall risk. The care plan included interventions such as monitoring respiratory status, managing secretions, providing suctioning as needed, maintaining airway patency, administering tube feedings, managing pain, and assisting with ADLs. However, review of the physician order summary for the relevant period showed no physician orders for tracheostomy or laryngectomy care, including suctioning, stoma care, humidification, respiratory therapy involvement, or bedside emergency airway supplies such as a spare tube, obturator, suction equipment, or emergency airway instructions. The orders were limited to general care such as medications, wound care, enteral feeding, and routine monitoring, creating a discrepancy between the resident’s documented clinical condition and care plan needs and the absence of corresponding physician orders.
Unsecured Medications and Improper Use of Floor Mats Create Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident environments were as free from accident hazards as possible and that adequate supervision was provided to prevent accidents for three residents reviewed for accidents and hazards. Facility policies required that medications be administered only by licensed or permitted personnel, that falls be managed through appropriate interdisciplinary interventions, and that accident or incident conditions, including safety hazards, be monitored and evaluated. Despite these policies, surveyors observed unsecured medications and environmental hazards in resident rooms. For one resident, a medication cup containing a cream and crushed medication was observed on the bedside table, accessible to residents, visitors, and staff. Another resident had collagen peptides, alpha lipoic acid, and Aspercreme at the bedside and in the window area; the resident reported taking the collagen peptides and alpha lipoic acid for wound healing and stated that these items were brought in by family. Record review showed the facility cared for residents with diminished cognitive status, and the DON stated that no residents in the facility self-administered medications, while the Administrator stated that self-administered medications would need to be locked up. These observations showed that medications and supplements not ordered or controlled by facility staff were accessible in resident rooms. A third resident, admitted with a left femur fracture, acute respiratory failure, and hypertension, was identified as cognitively intact but at risk for falls due to a history of falls, ambulating without assistance, and rolling out of bed. The care plan for falls included interventions such as maintaining a clutter-free environment, using an upper perimeter mattress, keeping the bed in the lowest position, and ensuring appropriate footwear and non-skid socks. However, surveyors observed two floor mats, approximately two inches thick, stacked on top of each other on one side of the bed, and later observed the same mats still stacked, with the resident in bed and a walker positioned by the wardrobe. Staff interviews revealed uncertainty about the resident’s fall history and the use of floor mats, and both nursing staff and the DON acknowledged that stacked floor mats on one side of the bed were not in the care plan and could increase fall risk, and that floor mats could become a tripping hazard as someone becomes more independent.
Failure to Ensure Nursing Competency in Respiratory Care and Safe Narcotic Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff, including nursing leadership, possessed the competencies and skills necessary to provide specialized respiratory care and safe medication practices, as required by facility policy. The facility’s competency policy required managers to ensure job-specific training and competency validation on hire, annually, upon changes in duties or processes, and when performance concerns were identified, with documentation of training and validation. Despite this, surveyors found that staff providing tracheostomy and respiratory care lacked documented competencies in these areas, and that the Director of Nursing did not carry out required oversight functions related to investigation of incidents, physician notification, and corrective actions. For one resident with throat cancer, a tracheostomy, and HIV, the Minimum Data Set documented that the resident was cognitively intact, required substantial to maximal assistance with activities of daily living, and received suctioning and tracheostomy care. Physician orders required tracheostomy care every shift and as needed. During observations on two separate dates, the resident’s tracheostomy setup included an uncovered suction catheter lying on top of a suction canister containing cloudy fluid, with no dates on tubing or equipment, and later the same setup was seen unchanged with a used urinal directly below and an undated water bottle connected to the tracheostomy collar. The care plan called for an Ambu bag at bedside, but no Ambu bag was present. The resident reported that tracheostomy care and suctioning were not being performed, that staff were not skilled to perform it, and that they did not offer the care. When interviewed, an LPN stated they had performed tracheostomy care for this resident on a specific date, but the supplies in the room appeared unchanged from prior observations. The LPN was unable to locate necessary supplies, could not describe full tracheostomy care, and stated they had required additional training to be competent in proper tracheostomy care. Review of the Treatment Administration Record showed inconsistent documentation of ordered tracheostomy care across shifts, with multiple staff initials and variability in completion, and included directions to encourage the resident to allow staff or self-clean, which was inconsistent with the resident’s documented need for skilled nursing interventions. The LPN’s competency records showed validation for infection control, medication administration, and blood glucose monitoring, but no documented competency validation for tracheostomy care or respiratory equipment management. For another resident with head and neck cancer, an artificial laryngectomy tube, and cirrhosis, the care plan identified pain management needs and respiratory needs related to the artificial airway, including monitoring respiratory status, observing for signs of respiratory distress or changes in secretions, and providing suctioning as ordered. The Medication Administration Record documented that a narcotic pain medication had been administered by an RN and that pain was reassessed and evaluated as effective, with no incident documented in the medical record. However, an incident statement later documented that the RN had placed a crushed narcotic in a medication cup in the resident’s room, left it unattended, and upon return found the medication missing. The RN assumed the resident had taken the medication, confronted the resident, and the resident denied taking it, yet the MAR for the surrounding dates documented the narcotic as administered by the RN. The facility’s narcotic management policy required that all narcotics be secured, accounted for, and discrepancies immediately reported to the Director of Nursing, and the notifications and accident/incident policies required prompt reporting, investigation, and physician notification of incidents and adverse events. The Medical Director stated they were not notified of the narcotic discrepancy and that the medication should not have been documented as administered if the facts were unclear. A law officer reported that they had deferred further action based on the DON’s assurance that the facility would conduct an internal investigation. The DON acknowledged responsibility for oversight of clinical care and investigations but did not provide evidence that a complete investigation was conducted, and there was no documentation of staff interviews, fact-finding, determination of cause, or corrective actions. There was also no evidence that the resident’s physician was notified of the missing narcotic or the allegation that the resident consumed the medication, no documentation of disciplinary or performance action for the nurse involved, and no evidence that performance concerns led to competency evaluation or retraining. Additionally, although the care plan identified airway management and monitoring needs for this resident, physician orders did not reflect airway management needs or emergency equipment. These findings collectively demonstrated that the facility failed to ensure nursing staff competency in respiratory care, safe medication practices, and appropriate investigation and physician notification, as required by policy and regulation.
Failure to Honor Resident Choice for Daily Routines, Meals, and Room Changes
Penalty
Summary
The facility failed to ensure residents could exercise self-determination and make choices about daily routines, meals, and room changes. The cited deficiency involved Resident #9, Resident #47, and another resident reviewed for choices. Facility policies stated residents had the right to self-determination, to make choices about aspects of life in the facility, and to be involved in room change decisions with their preferences considered. Resident #9 was admitted with diagnoses including end stage renal disease, chronic respiratory failure, and adjustment disorder with mixed anxiety and depressed mood. The MDS documented the resident could be understood, understood others, and was cognitively intact. During observation and interview, Resident #9 requested to return to bed, but LPN #1 stated the resident was not their patient and could not return to bed because a Hoyer lift was required. Additional staff also said the resident was not assigned to them when assistance was requested. Later, the DON and Administrator stated residents would have been able to return to bed whenever requested and there was no limitation related to Hoyer lift use. Resident #9 was also not provided with meaningful meal choices. Resident #47 was admitted with diagnoses including sepsis, major depressive disorder, and malnutrition, and the MDS documented the resident could be understood, understood others, and was cognitively intact. The resident stated they were told they needed to move out of their room and were not given a choice, and that lack of signature or consent would not prevent the move because the room was needed for another resident. Record review showed the resident refused to sign the room change documentation, but there was no documentation that the refusal was honored or that the resident had a meaningful opportunity to choose. Unit Secretary #1 stated the resident would have to move, that the move was required to open a bed for a specific gender admission, and that the resident had no choice. Corporate staff stated residents retained the right to refuse a room change and should not be forced to move, while the DON acknowledged the planned room change was to accommodate an outside admission and that residents had been moved despite documented refusal to sign consent.
Medication Labeling and Secure Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with professional standards of practice on the South Unit medication cart and in the South Unit medication room. During observation, the cart contained three unopened insulin pens that had been delivered two days earlier and were supposed to remain refrigerated until opened, but they had not yet been placed in the refrigerator. The cart also contained two opened insulin pens with no open date or expiration date, one inhaler with no open date or expiration date, one additional inhaler with no expiration date, and a box of hard candy stored in the bottom of the cart. The medication cart also contained a fluticasone/salmeterol inhaler that had been opened but was not labeled with an expiration date, and two Lantus insulin pens and one Novolog insulin pen that were unopened and not labeled with open or expiration dates. An LPN stated the fluticasone had been brought in from the resident’s home by family and placed in the cart for safe keeping. The LPN also stated the unopened insulin pens had been delivered over the weekend and had not yet been placed in the refrigerator. In the South Unit medication room, narcotic lock box #2 was observed with the inside lock left unlocked. The LPN stated the lock was broken and sometimes caught and locked, but at other times did not, and said this was not the first time it had happened. The DON stated all insulins should be labeled when opened with date and time opened, and that narcotics are to be double locked at all times. The Administrator stated new lock boxes had recently been purchased and that staff were aware narcotics are to be double locked at all times.
Failure to Report Alleged Neglect Incident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an alleged incident of neglect to the New York State Department of Health as required. Record review and interviews showed that an alleged violation involving neglect for one resident was not reported within 24 hours after the allegation was made, and there was no documented evidence that the incident was reported at all. The facility’s policy on Accident-Incidents, last reviewed on 6/01/2024, states that the DON and Administrator are responsible for reviewing incidents and investigations to determine if they require reporting to outside agencies such as the Department of Health, and that all incidents and accidents will be evaluated by the interdisciplinary team, which will review the investigation, determine root causes, and document an interdisciplinary team note. During interview, the DON stated the incident was deemed non-reportable to the Department of Health. The resident involved had diagnoses including morbid obesity, lymphedema, and generalized anxiety disorder, and was documented on the Minimum Data Set as cognitively intact and able to understand and be understood by others. The resident’s care Kardex dated 5/01/2025 specified that bed mobility, including rolling left and right, required two staff providing hands-on assistance. On 5/04/2025, an Incident and Accident report documented that the resident was observed lying on their left side on the side of the bed, with full range of motion in all extremities and no injury, after a CNA provided incontinence care alone without a second staff member. During this care, the resident was turned onto their left side and slipped off the side of the bed onto the floor. This event, constituting an alleged neglect incident involving failure to follow the two-person assistance requirement for bed mobility, was not reported to the Department of Health as required by 10 NYCRR 415.4(b)(2).
Failure to Ensure Clinically Appropriate Discharge with Pending Respiratory Testing
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge was appropriate based on the resident’s clinical status and that the resident was prepared for a safe discharge. The facility’s discharge/transfer policy required coordination of a safe transfer or discharge, documentation of the resident’s current medical status, and provision of written interdisciplinary discharge instructions summarizing the resident’s condition at the time of discharge. For this resident, the transfer/discharge notice stated that the resident’s health had improved sufficiently so that they no longer needed the services of the facility, citing successful completion of sub-acute rehabilitation. However, the resident refused to sign the notice, and the administrator signed as a witness. The complainant reported that as the planned discharge date approached, the resident became increasingly ill and incapacitated and was in no condition to be sent home, and that attempts to stop or postpone the discharge were unsuccessful. The resident had significant medical diagnoses including type 2 diabetes, COPD, pulmonary hypertension, congestive heart failure, chronic kidney disease, and hypoxic respiratory failure. A physician treatment encounter note dated several days before discharge documented that the resident was clinically stable to discharge home with family. In the days immediately preceding discharge, a physician order was initiated for PRN guaifenesin liquid for cough, and the medication administration record showed that the cough medicine was given on two occasions, with one administration documented as ineffective and the next as effective. A physician order was also entered for a one-time COVID/influenza swab, and the MAR documented that the swab was collected by an RN. Staff interviews indicated that the resident had cough and congestion one to two weeks prior to discharge, that the family requested COVID/flu testing, and that a respiratory panel for COVID, influenza, and RSV was obtained because the resident was having symptoms, although staff also stated that symptoms were starting to resolve. Despite the ordered diagnostic testing and symptomatic treatment, there was no documentation in the clinical record explaining the rationale for ordering the cough syrup and COVID/flu swab prior to discharge. There was also no documentation that the results of the COVID/flu swab were obtained or reviewed by facility staff, and no evidence that a medical provider evaluated the resident after the 12/31 treatment encounter to reassess clinical status in light of the new cough and respiratory testing orders before discharge. The RN who collected the swab stated they never received the results and were uncertain if the test was sent out, and the DON stated that test results could not be found. The rehabilitation manager recalled the resident reporting not feeling well around the time of discharge and being tested for COVID/flu. The complainant reported that the resident was sent home while vomiting and very weak, and that the resident’s cough did not improve at home. The resident was sent home on oxygen with equipment and services arranged, and the administrator reported that the resident had no acute respiratory distress at the time of discharge and that the testing and cough syrup were ordered largely at the family’s request. Two days after discharge, the resident was admitted to the hospital from the emergency department with shortness of breath, weakness, and a one-week history of malaise, weakness, cough, and shortness of breath, and was found to have pulmonary congestion, a positive viral panel for influenza, and an elevated heart failure marker, with an assessment of acute on chronic heart failure exacerbation in the setting of viral pneumonia. The medical director stated that influenza testing was usually based on symptoms and that they would expect documentation of the rationale for ordering a COVID/flu swab and cough medicine. The DON stated that if a COVID/flu swab was completed it should have been sent out, and that the order would have been canceled if not completed, but acknowledged that results could not be located. The administrator explained that respiratory panels were being sent to outside labs with a four-day turnaround, so results would not have been available before discharge, and maintained that the resident had no symptoms at discharge. Nonetheless, the record lacked documentation of a provider reassessment after the onset of cough and respiratory symptoms and after the diagnostic test was ordered, and there was no evidence that the pending test results were obtained or considered before proceeding with discharge. These omissions led surveyors to determine that the facility failed to ensure the discharge was appropriate based on the resident’s clinical status and failed to ensure the resident was prepared for a safe discharge, in violation of 10 NYCRR 483.21(c)(1).
Failure to Revise Fall Care Plan After Resident Fall Event
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to review and/or revise a resident’s Comprehensive Care Plan following a fall event. Facility policy on Comprehensive Care Plans required that care plans be comprehensive, person-centered, include measurable objectives and timetables, and be revised as resident conditions changed, including when desired outcomes were not met. The facility’s Fall Management and Prevention policy further required the interdisciplinary team to identify and implement appropriate interventions to reduce fall risk and to review and revise the interdisciplinary care plan when a change was identified after an event. Despite these policies, there was no documented evidence that the Comprehensive Care Plan for one resident was reviewed or revised after a documented fall. The resident involved had diagnoses of end stage renal disease, type 2 diabetes, and chronic respiratory failure, and was documented on the MDS as cognitively intact and able to communicate. An Initial Event assessment documented that the resident slipped from the side of the bed to the floor while being turned on their left side during incontinence care by a CNA; the resident did not hit their head. Interventions initiated after the fall included OT and PT evaluation and treatment as indicated, use of non-skid socks, and keeping the bed in the lowest position. The existing Comprehensive Care Plan for falls already identified the resident as at risk for falls or having had an actual fall related to deconditioning, gait/balance problems, and immobility, but there was no documentation that this care plan was reviewed or revised after the fall event. During interview, the DON stated that incident/accident reports were discussed in morning meeting with the interdisciplinary team and that care plans were updated once agreed-upon interventions were put into place, but the record for this resident did not contain such updates following the fall.
Failure to Provide Competent Tracheostomy Care and Maintain Required Airway Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory and tracheostomy care in accordance with its own policy and professional standards for two residents with artificial airways. For one resident with throat cancer, HIV, and a tracheostomy, the MDS documented the need for suctioning and tracheostomy care, and the care plan required an Ambu bag at the bedside. Surveyors observed an uncovered suction catheter, cloudy liquid in a suction canister, and undated tubing and water bottle connected to the trach collar. The resident repeatedly reported not receiving tracheostomy care or suctioning despite feeling the need, and stated that staff did not know how to perform the care and that there was limited access to staff able to suction. During observed tracheostomy care for this resident, the LPN/unit manager entered the room where the tracheostomy setup appeared untouched, with a deep suction catheter uncovered and resting on a half-full cloudy suction canister and a used urinal directly below. The LPN could not locate necessary tracheostomy supplies in the room, was unaware of where to obtain them, and asked the resident where supplies were kept; the resident wrote that they had not had correct supplies in months. The LPN described prior tracheostomy care as simply wiping the stoma opening, could not clearly describe complete tracheostomy care procedures, and acknowledged that they and most other nurses needed to refresh their tracheostomy skills. The LPN also stated the resident could perform their own tracheostomy care, while the resident stated they were not comfortable doing so. The Treatment Administration Record documented that tracheostomy care had been completed on a date when the resident reported it had not been done. Staff interviews, including with an RN and the Medical Director, confirmed that supplies should have been clean, covered, and dated, that tracheostomy care consists of more than cleaning the site, and that an Ambu bag should be at the bedside; however, an LPN was unable to identify an Ambu bag in the room, and the resident stated an Ambu bag had never been available at the bedside. For a second resident with cancer of the head/neck, an artificial laryngectomy tube, and cirrhosis, the care plan identified respiratory needs related to the artificial airway, including monitoring respiratory status, observing for signs of respiratory distress or changes in secretions, and providing suctioning as ordered. The resident’s health care proxy reported concerns about staff competency to manage the laryngectomy tube, including suctioning and airway care, and stated the resident could not independently manage their own care. The proxy was unable to recall whether emergency airway equipment, including an Ambu bag, was present at the bedside. Corporate nursing staff stated that acceptance of a resident with a tracheostomy or similar airway needs reflected the facility’s determination that it had the capacity and competency to provide the required level of care. The Medical Director reported that tracheostomy care was assumed to be provided by the facility, expressed concerns about the facility’s ability to provide such care, and stated that the lack of ability to provide appropriate tracheostomy care should have been thoroughly investigated. The DON stated the facility was able to provide tracheostomy care, but was unaware of the lack of an Ambu bag at the bedside and acknowledged that this should not have occurred.
Failure to Monitor and Safely Store Perishable Outside Food in Resident Rooms
Penalty
Summary
The facility failed to ensure that food brought in from outside sources was stored, labeled, and maintained according to its own policy and professional standards, resulting in perishable items being kept unrefrigerated in resident rooms. The facility’s policy required all perishable foods to be refrigerated, labeled, and discarded within 48 hours, and specified that foods left without temperature control for more than two hours were to be discarded. Nursing staff were responsible for monitoring resident rooms for spoilage, contamination, and safety, but surveyors found no documentation or evidence that perishable food stored in resident rooms was being monitored or overseen. One resident with diabetes mellitus, major depressive disorder, and exocrine pancreatic insufficiency had documented nutritional problems related to diabetes and was on a therapeutic diet with goals to maintain adequate intake and blood glucose levels. Observations on two consecutive days showed a jar of mayonnaise, two cartons of milk, and a head of lettuce stored on the windowsill in this resident’s room. The resident reported using the cool outdoor air as a refrigerator and stated that family members brought in additional food options, and that staff did not provide further options or guidance regarding storage. During this period, outdoor temperatures ranged between 67°F and 70°F, and the perishable items remained unrefrigerated on the windowsill. Another resident, who had a PICC line, primary adrenal cortical insufficiency, atrial fibrillation, limited mobility, and malnutrition, had a care plan that acknowledged receipt of outside food from visitors and included interventions such as educating visitors on safe food handling temperatures and providing a food safety handout to family. During this resident’s stay, the resident was diagnosed with Salmonella, and emergency room documentation identified the illness as foodborne and related to food consumption. Despite this, the facility’s infection prevention and control monthly reports and associated line lists for the relevant months contained no documented evidence that foodborne illness was identified, tracked, or trended. While kitchen food temperatures were routinely monitored and maintained at appropriate levels, there was no documentation of monitoring or oversight of perishable food stored in resident rooms.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents could safely self-administer medications when clinically appropriate for two residents reviewed for medication administration. Resident #19, who was admitted with paroxysmal atrial fibrillation, hypertension, and depression, had a MDS dated 1/20/2026 documenting that the resident was cognitively intact and could understand and be understood. During an observation on 4/08/2026, a medication cup containing cream/crushed medication was seen at the resident’s bedside, but the medical record did not include documentation that the resident had been assessed for the ability to self-administer medications, did not include physician documentation approving self-administration, and did not include a care plan entry indicating the resident could self-administer medications. Resident #71, who was admitted with end stage renal disease, sequelae of Guillain-Barre syndrome, and congestive heart failure, also had a MDS documenting cognitive intactness and ability to understand and be understood. During an observation on 4/08/2026, collagen peptides, alpha lipoic acid, and Aspercreme were observed at the bedside and/or in the window, and the resident stated they took collagen peptides and alpha lipoic acid for wound healing and that the items were brought in by family. The MAR for April 2026 did not include orders for these items. During interviews, the DON and Administrator stated there were no residents self-administering medications, and the Administrator stated that if a resident chose to self-administer, they would need to demonstrate the ability, be assessed by the interdisciplinary team, and have medications stored in a locked box; the Administrator also stated it had been discussed that vitamins, antifungal powders, and OTC medications needed provider orders.
Soiled Room Conditions and Inadequate Privacy
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for two residents in a shared room. Resident #10, who had diagnoses including a humerus fracture, dementia, and anxiety, and whose MDS documented moderate cognitive impairment, was observed with a bedside commode and landing strips beside the bed that were caked with brown material consistent with feces, along with several soiled tissues on the floor. Resident #58, the roommate, stated that soiled materials were often left at the room entrance and that they frequently had to call for assistance when Resident #10 soiled the floor. During another observation, Resident #10 was seen self-toileting on the bedside commode in an open area with no curtains drawn and attempting to wipe themselves, then throwing tissue onto the floor instead of into the garbage bin. Resident #58 stated that Resident #10 often used the commode and threw soiled tissues on the floor, and that there were times Resident #10 attempted to self-toilet but defecated on the floor. Housekeeping staff stated they had not yet cleaned the room and that nursing picked up bulk waste, while Maintenance stated housekeeping was responsible for reporting stained or soiled landing strips and that the brown stains were from chocolate cookies rather than feces.
Failure to Provide Meal Assistance and Cueing
Penalty
Summary
The facility failed to provide necessary assistance and cueing during meals for a resident with traumatic subdural hemorrhage, hypertension, malnutrition, and severe cognitive impairment. The resident’s care plan identified a nutrition problem with 7% weight loss in 1 month and directed staff to monitor weights, offer snacks, evaluate intake and preferences, and review meal and fluid intake. The record review showed frequent poor, inconsistent intake with minimal consumption and refusals, along with continued weight loss from 137.2 pounds on 03/23/2026 to 132.1 pounds on 04/15/2026. During multiple observations, the resident was seen with meals present but did not initiate eating, and staff did not provide consistent encouragement, cueing, or hands-on assistance. On one occasion, the resident sat in front of a meal tray without beginning to eat while staff remained at a distance. On another, the resident remained alone in the room with an untouched tray until a CNA entered, removed the tray, and left without assisting. Additional observations showed the resident attempting to open containers and handle food without successfully accessing the meal, then lying down without eating; a CNA later entered, asked if the resident was going to eat, and removed the tray without helping. Interviews supported that the resident required direction and encouragement for daily functioning and did not initiate tasks independently. The family member reported concerns about the resident’s inability to feed themselves independently and staff not consistently providing supervision or assistance during meals. An OT stated the resident should have supervision with ADLs and would expect to be notified if the resident was not able to carry out eating skills. Staff interviews reflected that some believed the resident was independent or ate only sometimes, while the RD stated they were aware of the weight decline and low intake but had not been aware of the lack of assistance or encouragement with meals.
Failure to Provide Individualized Activities and Appropriate Activity Content
Penalty
Summary
The facility failed to ensure an ongoing program of activities that supported each resident’s interests and physical, mental, and psychosocial wellbeing for two residents. Resident #6 had diagnoses of end stage renal disease, hypertension, and dementia, and the MDS dated 4/01/2026 documented severe cognitive impairment with the ability to be understood and to understand others. During observations on 4/08/2026 and 4/10/2026, the resident was in their room or in bed, no activities were present, and there were no staff interactions throughout the morning; on 4/10/2026 the resident was lethargic, had a dusky ash appearance, dry mucosa, and periods of apnea, yet no activities were present in the room. The Director of Activities stated clergy had visited and that one-to-one visits were normally provided, but there was no documented evidence that one-to-one visits were provided to Resident #6. Resident #9 had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, dementia, and depression, and the MDS documented the resident was cognitively intact and could be understood and understand others. During interview, the resident stated they felt like a prisoner, reported they had lived at the facility for 6 years, and said they only went outside for medical appointments, though they wanted to go outside and sit in the sun. The Director of Activities stated the resident refused to come out of their room but activities were provided in the room, and when asked for a log of one-to-one visits, no documentation was produced. The Director also stated the resident had not been outdoors and would be offered outdoor time going forward. In addition, the activity scheduled for 4/14/2026 included perfume sampling and history; nursing staff raised concerns that perfume sampling could cause reactions in some residents, the activity was altered, and both the Regional DON and Medical Director stated perfume sampling was not appropriate in the facility setting.
Pain Management and Resident-Centered Support Deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate pain management for residents who required pain services. The report also describes failures related to resident-centered activities and psychosocial support, including a resident who was nearing end of life and was not provided stimulation, one-to-one interaction, or visits, and another resident who stated they felt like a prisoner and were not provided outdoor time per their preference. In addition, perfume sampling was listed on the activity agenda, which could have caused adverse reactions for some residents. Resident #10 had diagnoses including a left humerus fracture, dementia, and anxiety, and the MDS documented moderate cognitive impairment. During observations, the resident complained of pain and had swelling in the left hand. The resident continued to report pain and asked when pain medication would be available. Staff stated that if a resident complained of pain they would assess the resident, collect data, and notify the Medical Provider. An LPN stated the resident had a standing morphine order and that a pain scale was completed every shift rather than prior to administering pain medications. The LPN also stated there had not been any other interventions besides morphine. The DON stated that if pain medication was routine, they did not ask the resident for a pain level and only did so for PRN medications. Resident #47 had diagnoses including rheumatoid arthritis, fibromyalgia, and osteoporosis, and was cognitively intact. The resident stated their pain was not controlled when they could not take their medication and reported multiple occasions when their narcotic pain medication was not available or not responded to in a timely manner. The care plan identified decreased comfort related to chronic pain conditions and included interventions to administer medications as ordered and evaluate effectiveness. The MAR documented that hydrocodone-acetaminophen was not given on one day, that a pain evaluation was not completed on another day when no pain medication was given, and that the resident reported delays of hours in receiving pain medication. The NP stated the resident should not have gone an entire day without pain medication because the order was not renewed, and the DON stated the resident must not have requested it. Resident #65 had diagnoses including chronic pain syndrome, dorsalgia, COPD, and a recent left total knee replacement, and was cognitively intact. The resident reported repeated delays in receiving PRN pain medication, including waits of up to an hour and a half and one report of receiving medication much later than expected. The resident also reported limited access to ice packs. The care plan included monitoring for pain, administering medications as ordered, and reporting complaints of pain. The MAR showed inconsistent administration of hydrocodone-acetaminophen, including missed scheduled doses and gaps between doses. Staff interviews reflected confusion about whether the medication was due, whether the resident had actually received it, and whether the medication had been signed for in the EMR. The DON stated some residents did not understand how PRN medications worked and noted other pain relief options were available, while the Medical Director stated narcotic orders could lapse and sometimes needed to be changed.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility did not ensure that its medication error rate remained below 5 percent. During 25 medication administration observations involving 7 residents, surveyors identified errors involving 2 residents, resulting in a 24 percent medication error rate. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, with the medication label checked three times to verify the right medication, dosage, time, and route before administration. For one resident with hemiplegia, hemiparesis, a history of cerebral infarction, and major depressive disorder, the physician order directed Depakote delayed release 125 mg, 3 tablets by mouth three times daily, but the blister pack instructions read 3 tablets by mouth two times daily. The nurse administering the medication and the LPN/unit manager were unable to determine which order was correct, and the DON also could not ascertain the correct order during interview. For another resident with Alzheimer’s disease, osteoporosis, and status post hip fracture, the MAR directed multiple medications with special instructions to crush medications, but staff could not locate a physician order authorizing crushing. The DON was also unable to locate the crush order and entered it during the interview. The medical director stated that medication discrepancies must be clarified with the medical director or NP and that orders must be signed in real time by the ordering provider.
Medication Order Discrepancy Not Clarified for Anti-Seizure Drug
Penalty
Summary
Resident #9, who was admitted with hemiplegia, hemiparesis following cerebral infarction, and major depressive disorder, had a medication dose discrepancy involving Depakote delayed-release 125 mg. The physician order dated 3/19/2026 directed 3 tablets by mouth three times a day, while the medication blister pack instructions read 3 tablets by mouth two times a day. During an observation on 4/9/2026, the RN prepared the medication using the blister pack instructions, and when the discrepancy was identified, the RN stated they were told to follow what was in the computerized MAR. The LPN/unit manager also stated they were told to follow the computerized MAR, but neither could determine which order was correct. The DON was also unable to determine which order was correct and stated that when there is an order change, the facility continues to use the old medication blister pack until it is completed before placing the new order with pharmacy services. The Administrator later located the order change that had increased the Depakote dose from twice daily to three times daily and stated the change should have been sent to pharmacy for a new blister pack or further instructions. The Medical Director stated that with any medication discrepancy, the medication nurse is responsible for notifying the medical director or nurse practitioner for clarification, and that orders must be signed in real time by the ordering provider so the medication can be administered.
Facility Assessment Did Not Reflect Tracheostomy Care Needs
Penalty
Summary
The facility failed to conduct and document an updated facility-wide assessment that accurately reflected the resources needed to care for residents with special treatment needs, including tracheostomy care. The assessment dated [DATE] listed the number/average or range of residents with special treatment and conditions as zero, even though the facility had one active resident and one discharged resident with tracheostomy-related needs at the time of review. The assessment also listed special care needs such as dialysis, hospice, ostomy care, tracheostomy care, bariatric care, palliative care, and end-of-life care, but the tracheostomy resident count remained documented as zero. Resident #7 was admitted with malignant neoplasm of the larynx status post laryngectomy with tracheotomy and COPD, and the MDS documented the resident was cognitively intact and able to understand and be understood. The care plan identified respiratory alteration risk and included tracheotomy stoma care, suction setup at bedside, and humidified therapy. During observation on 4/13/2026 at 11:00 AM, there was no Ambu bag at the resident’s bedside, and an LPN was observed attempting to provide tracheotomy care but required direction from the resident on how to perform the care. Resident #87 also had diagnoses including malignant neoplasm of the head, face and neck and presence of an artificial laryngectomy tube, with a care plan addressing airway management, suctioning, secretion management, tube feedings, pain, mobility, and fall risk; however, the physician orders reviewed did not include tracheostomy or laryngectomy care orders, suctioning, stoma care, humidification, respiratory therapy involvement, or required bedside emergency airway supplies.
Missing Medication, CNA, and Narcotic Count Documentation
Penalty
Summary
The facility failed to maintain resident records in accordance with accepted professional standards for two residents. For one resident, there was no documentation in the electronic medical record that a verbal order was received from the medical provider to schedule pain medication, and there was no documentation that nurses administered the pain medication after the order was changed. The resident was cognitively intact, had chronic pain syndrome, dorsalgia, COPD, and had been admitted after a left total knee replacement. The resident stated they were supposed to receive pain medication at 7:00 AM, but instead received it at 7:00 PM and again at 1:00 AM, and reported confusion about why the medication was not given as expected. The record showed an order for hydrocodone-acetaminophen 7.5/325 mg every 6 hours for pain, but the order was not signed and there was no documented evidence of a verbal order to schedule it. The MAR for the month did not reflect that the resident received the scheduled medication during the evening and overnight period. Staff interviews confirmed that the medication had been given by evening and night shift nurses, but they could not sign it in the electronic record because the order was not signed, and they had not yet entered progress notes documenting administration. The DON stated the order had been received by phone with the RN present, entered and transcribed, but the provider did not sign it. For the second resident, CNA task documentation was missing entries showing that care was provided on multiple shifts. The resident was cognitively intact, had diagnoses including rhabdomyolysis, atherosclerotic heart disease, and COPD, and had a care plan requiring assistance with toileting transfers, toileting hygiene, and sit-to-stand. The CNA documentation record showed no support that care was provided on one day shift, one evening shift, and one night shift. Staff stated the care was done but not documented, and the DON confirmed the care had been provided but was not recorded. In addition, the south unit narcotic book shift count was signed in advance for a shift change, and the LPN stated they signed it ahead of time so they would not forget.
Infection Control and Food Storage Failures
Penalty
Summary
The facility did not maintain an infection prevention and control program to ensure a safe, sanitary, and comfortable environment for two residents reviewed. The report cited failures in food storage practices and infection control practices, including hand hygiene, use of PPE, and handling of contaminated equipment. The facility policies required proper infection prevention measures, safe food storage temperatures, and tracheostomy care using aseptic technique, sterile suctioning, PPE, and hand hygiene. Resident #2 had diagnoses including diabetes mellitus, major depressive disorder, and exocrine pancreatic insufficiency. The resident’s assessment documented that the resident was cognitively intact, required minimal assistance with activities of daily living, and needed moderate assistance with ambulation. The care plan addressed nutritional problems related to diabetes and included a therapeutic diet. During observation, mayonnaise, milk, and lettuce were stored on the windowsill in the resident’s room and were not refrigerated. On re-observation the next day, two milk cartons and lettuce remained on the windowsill while outside temperatures ranged from 67 to 70 degrees Fahrenheit. Staff interviews confirmed it was not acceptable for perishable food items to be stored unrefrigerated, and leadership stated food should not be kept in resident rooms without proper temperature control. Resident #7 had diagnoses including malignant neoplasm of the larynx, tracheostomy, and HIV. The resident’s assessment documented that the resident required substantial to maximal assistance with activities of daily living and received suctioning and tracheostomy care. The care plan identified ESBL, MRSA, and HIV and included enhanced barrier precautions with gown and gloves during high-contact care. During observation, a suction catheter was uncovered, cloudy liquid was present in the canister, and tubing lacked date identification. During care, an LPN disconnected unclean deep suction tubing without gloves and did not perform hand hygiene until after leaving the room. Staff interviews stated the supplies should have been clean and covered, tubing should not have been handled without gloves, and hand hygiene should have been completed immediately.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for three residents. Resident #1, who had a history of falling, experienced five falls between January and April 2024. Despite interventions such as non-skid socks being initiated, these falls and interventions were not documented in the resident's care plan. Resident #2 was involved in an incident of alleged sexual abuse in April 2024, but the care plan was not updated to reflect this incident or the necessary interventions such as monitoring for further behaviors and enhanced monitoring. Resident #3, with a history of falling, experienced a fall in April 2024, but the care plan did not document this fall or the intervention to keep a front-wheeled walker within reach. Interviews with facility staff revealed that while assessments and interventions were documented in the initial event documentation, they were not consistently transferred to the comprehensive care plans. The Assistant Director of Nursing and the Registered Nurse Manager acknowledged that it was not the facility's practice to document the date of each fall on the care plan focus, and the responsibility for updating the care plans was not adequately fulfilled. This lack of documentation and updating of care plans led to deficiencies in the facility's compliance with care planning regulations.
Neglect of Resident Care Plan Leads to Injury
Penalty
Summary
The facility failed to ensure that residents were free from neglect, as evidenced by an incident involving Certified Nurse Aide #1 and Resident #3. Resident #3, who had diagnoses including hemiplegia, hemiparesis, conversion disorder with seizures, and spastic hemiplegic cerebral palsy, required physical assistance from two staff members for bed mobility. Despite this requirement being clearly documented in the resident's care plan, Certified Nurse Aide #1 attempted to roll the resident in bed without assistance from another staff member. During the incident, Resident #3's left leg began to slide off the bed, leading to the resident's entire body sliding to the floor. This resulted in fractures to both of the resident's legs. Initially, the resident reported no pain or discomfort immediately following the fall, but later reported pain the following morning, leading to a hospital transfer where the fractures were confirmed. Certified Nurse Aide #1 acknowledged awareness of the care plan requirement for two staff members but believed they could manage the task alone. The facility's investigation confirmed that the aide acted against the care plan, and the facility was sufficiently staffed at the time of the incident. The resident expressed frustration with the aide for not heeding their warning about the improper positioning, which led to the fall and subsequent injuries.
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Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Queensbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glens Falls Center For Rehabilitation And Nursing | 3.4 mi | ★★★★★ | 0 | 0 |
| The Pines At Glens Falls Ctr For Nursing & Rehab | 4.9 mi | ★★★★★ | 15 | 0 |
| Fort Hudson Nursing Center Inc | 8.5 mi | ★★★★★ | 0 | 0 |
| Washington Center For Rehab And Healthcare | 13.9 mi | ★★★★★ | 11 | 0 |
| Slate Valley Center For Rehabilitation And Nursing | 18.3 mi | ★★★★★ | 0 | 0 |
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