Ferncliff Nursing Home Co Inc

Inspectors wroteBased on observation, interview and record review during an abbreviated survey (# 2658277), the facility failed to ensure residents were free from physical abuse by a staff member for one (1) of three (3) residents (Resident # 1) reviewed for Abuse. Specifically, on 10/13/2025, Resident #1 who had severe cognitive impairment was slapped in the face by Licensed Practical Nurse #3 after an argument between Resident #1 and Licensed Practical Nurse #3 over a piece of cake. Subsequently, Resident #1 sustained redness and swelling to their right cheek and was crying. Resident #1 was led to their room by Certified Nurse Aide #1 where they consoled them and encouraged the resident to relax. Applying the reasonable person concept, this resulted in psychosocial harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated (NY00368899) surveys from 2/20/25 to 2/27/25, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. [...]

Inspectors wroteBased on observation and interview conducted during the recertification survey from 2/20/25 to 2/27/25, the facility did not ensure specific food items were maintained in accordance with professional standards for food safety and infection control prevention. Specifically, opened and not dated potentially hazardous foods were observed in one of the refrigerators and the dry pantry, and 3 of 4 dietary aides were observed wearing disposable gloves for meal service and did not change gloves after touching other non-meal service objects.

Inspectors wroteBased on observations and interviews during the recertification and abbreviated (NY00368899) surveys from 2/20/25-2/27/25, the facility did not ensure that the environment was maintained in a safe, clean, comfortable and homelike manner. Specifically, 1.) the shower room on the 3A unit had black stains on the shower curtain, the tiles at the base of the toilet had brown discoloration, and the tile grout in the shower stall was discolored with black and orange stains. Furthermore, there was an air conditioner in the window next to the shower stall that caused a cold draft in the room. 2). Dirty linens were observed on the floor next to Resident #27's bed. 3) A broken handrail with a sharp edge was found on the right side of the entrance to the 3A dining room.

Inspectors wroteBased on observations, record reviews and interviews during the Recertification survey from 2/20/25 through 2/27/25, the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #27) reviewed for activities of daily living. Specifically, Resident #27 required staff assistance with personal hygiene was observed on 3 occasions with long and dirty fingernails.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey from 2/20/25-2/27/25, the facility did not ensure that 1 of 4 residents (Resident #122) reviewed for positioning and limited range of motion, received treatment and care in accordance with professional standards of practice. Specifically, Resident #122 had a history of difficulty swallowing and was not positioned properly while eating.

Inspectors wroteBased on observations, interview and record review, during the Recertification Survey from 2/20/25 to 2/27/25 the facility did not ensure that needed services, care and equipment were provided to assure that resident with limited range of motion and mobility to maintain or improve function based on the residents' clinical condition for 1 of 4 residents reviewed for position mobility. Specifically, a resident #36 had limited range of motion in their lower extremities was observed to have right or left foot dangling off the foot pedal of their wheelchair, not appropriately positioned on the foot pedal.

Inspectors wroteBased on observation, record review and interview during the Recertification Survey conducted from 2/20/25 through 2/27/25, the facility did not ensure each resident received adequate supervision to prevent accidents and/or the residents' environment remained as free of accident hazards as possible for 2 of 10 residents (Residents #183 and #242) reviewed for accidents. Specifically, 1. Resident #183 was at risk for elopement related to wandering in and out other resident's rooms, roaming, trying to open exit doors and get in the elevator without staff supervision and 2. Resident #242 sustained falls on 11/15/24, 11/27/24, 1/10/25, 1/19/25 and 1/25/25.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey initiated on 2/20/2025 and completed on 2/27/2025 the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore continence to the extent possible for one (Resident #112) of one resident reviewed for bowel and bladder. Specifically, Resident #112 was not assessed and care planned to improve and restore continence to the extent possible.

Inspectors wroteBased on observations, interviews, and record review during the recertification survey from 2/20-2/27/2025, the facility did not ensure that 1 of 3 residents (Resident # 93) reviewed for nutrition were monitored within acceptable parameters for nutritional status. Specifically, Resident #93's weight loss a 7.5% in three months, and a 13% weight in four months was not addressed. Additionally, the resident's weight was not recorded for the last 2 months.

Inspectors wroteBased on interviews and record reviews conducted during the recertification and abbreviated surveys (NY 00361358) from 2/19/25-2/27/25 it was determined that for one (Resident #400) of two residents reviewed for notification of change, the facility did not notify the resident's representative timely when there was a change in their plan of care. Specifically, Resident #400's Seroquel (antipsychotic medication) and Sertraline (antidepressive medication) were discontinued after a gradual dose reduction, and their representative was not notified of the change in the plan of care.

Inspectors wroteBased on record reviews and interviews, conducted during an abbreviated survey (NY00355382 and NY00362103), the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 3 residents (Resident #1 and #3) reviewed. Specifically, on 9/3/2024 Resident reported they were bumped by the elevator door [NAME] exiting and reported pain 3 out of 10 to their right hip. 2) On 9/30/2024 while exiting the core elevator on the 4th floor, the elevator door closed hitting Resident #1's right hip causing pain and discomfort. 2) On 11/25/2024, Resident #3 was found inside of the facility housekeeping closet on the 4th floor. Facility investigation revealed the housekeeping door was unsecure due to the striker plate being broken. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 6 residents (Residents #432, #218, #48, and #54,) reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, (1) Resident #432 acquired a stage 4 sacral pressure ulcer at facility and treatments were not completed as ordered. [...]

Inspectors wroteBased on interviews and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of the residents. Specifically, 1) multiple residents reported during confidential interviews and the group meeting that the facility was short staffed at times especially at night and there was a lack of timely staff response to call bells, 2) multiple nursing staff members reported a lack of sufficient staffing, 3) a review of one month of facility staffing revealed the facility did not ensure that the minimum staffing levels for certified nurse aides was met on the night shift.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification Survey completed from 3/13/24 through 3/29/24, the facility did not ensure each resident received drinks, including health shakes and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 17 (Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278) of 36 residents reviewed. Specifically, Residents #1, 6, 11, 34, 53, 63, 65, 84, 85, 145, 177, 204, 216, 237, 250, 258, and 278 did not receive coffee or tea, and health shakes as per meal ticket.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1. Portable food storage bins used for storing bulk dry foods were not maintained in a sanitary condition, 2. A cooling log was not used to monitor cooling of potentially hazardous cooked food (poultry), 3. Storage racks used to store cleaned and sanitized food preparation equipment were not maintained in a sanitary condition and the floor under the storage racks was not maintained in a sanitary condition, 4. Eight (8) food transport trucks used for transport of foods to the resident units were not maintained in a sanitary condition, and 6. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification and abbreviated surveys (NY00334054) from 3/13/24 to 3/29/24, it was determined that the facility did not ensure an effective pest control program was maintained to ensure the facility was free of pests and rodents. Specifically, facility staff and residents reported mice sightings. Additionally, there were multiple observations of mice droppings in resident rooms.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure residents had a right to a dignified existence in an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident #133 was observed on multiple occasions, not shaved with a large amount of facial hair, and hair on the head was disheveled.

Inspectors wroteBased on observation and staff interviews during the recertification survey from 3/13/24 to 3/29/24, the facility did not maintain a homelike environment for 4 of 8 rooms observed on unit 5B. Specifically, for Residents #154, #210, #135 and #131, observations were made of ripped and peeled protective padding in bathrooms, particles of food and other debris on the floor, dirty adult briefs on the floor, and a toilet paper dispenser with fecal remains dried on over a period of 6 days.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure 4 of 5 residents (Residents #114, 161, 216 and 258), reviewed for abuse, had the right to be free from abuse. Specifically, Resident #258 was observed on multiple occasions exhibiting physical and verbal aggression towards other residents including Residents #114, #161 and #216, and the facility did not ensure interventions were implemented to prevent abuse.

Inspectors wroteBased on observations record review and interviews, during the recertification and abbreviated surveys (NY00306213 and NY00316087) from 3/13/24 to 3/29/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 of 4 residents reviewed for accidents and for 2 of 6 reviewed for pressure ulcers. Specifically, (1) Resident #97 had suicide attempts on 11/23/22 and 11/29/22 and the Care Plan was not updated to reflect the second suicide attempt and was not revised with new interventions to prevent reoccurrence; [...]

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey from 3/13/2024-3/29/2024, the facility did not ensure residents received the necessary services to maintain good grooming and personal care for 1 of 5 residents (Resident #152) reviewed for activities of daily living. Specifically, Resident #152 was observed with untrimmed fingernails and visible scratch marks to scalp.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00332770) from 3/13/24 to 3/29/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #382), reviewed for change of condition. Specifically, Resident #382 did not receive antibiotic Flagyl / Gentamicin topical treatment dressings as recommended by the wound care consultant physician; the resident was admitted to the hospital with a malodorous (bad smelling) wound and was started on antibiotics for wound cellulitis (infection of the skin).

Inspectors wroteBased on observations, record review and interviews conducted during the recertification survey from 3/13/24-3/29/24, the facility did not ensure for 2 (Residents #74 and #218) of 7 residents reviewed for positioning and limited mobility, that appropriate treatment and services were provided to improve and/or prevent a further decrease in range of motion. Specifically, Resident #74 was observed on multiple occasions not wearing a resting hand splint to the left hand as ordered and Resident #218 was observed with a right hand contracture and on multiple occasions, no adaptive devices were observed in place to prevent a further decrease in range of motion.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00306213 and NY00316087) from 3/13/24 to 3/29/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 2 of 4 residents (Residents #97 and #168) reviewed for accidents. Specifically, (1) Resident #97's supervision was not maintained after an attempted suicide resulting in another attempt 6 days later, and (2) Resident #168 sustained two falls on 5/6/23, the second of which resulted in Resident #168 fracturing their tibia (lower leg) and femur (upper leg).

Inspectors wroteBased on observation, record review and interview during the post survey revisit (PSR) from 5/30/24 to 6/3/24, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for 1 of 6 residents reviewed for pressure ulcers (Resident #500). Specifically, there was no documented evidence that Resident #500 received a 5/22/24 physician ordered fentanyl patch until 5/26/24. Additionally, there was no documented evidence of pain monitoring on 5/30/24 after Resident #500 received physician ordered as needed pain medication for a complaint of 8/10 pain and/or prior to the nurse performing a wound dressing change.

Inspectors wroteBased on observations, record review and staff interview conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that special eating equipment and utensils were provided for residents who need them. This was observed during dining observation for 3 of 15 residents reviewed for nutrition (Resident #135, #229, and #236). Specifically, Resident #135 was observed dropping food when trying to scoop an item from a regular plate. Resident #229 was observed on three occasions eating without the use of an adaptive bowl and cup as indicated in the meal tray ticket and ordered by occupation therapy. Resident #236 was observed on three occasions being fed without the use of the adaptive maroon spoon, as documented on their meal ticket.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 3/13/24 to 3/29/24, the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of infection was maintained for 4 of 5 residents (Residents #12, # 70, #93, #210) reviewed for infection control and prevention practices. Specifically, for Resident #12, during a wound care observation, the nurse did not wash their hands and don clean gloves after cleansing a pressure ulcer and before applying treatments

Inspectors wrote610 Based on record review and interviews conducted on a recent recertification survey, the facility did not ensure that a full investigation was conducted for one of three residents (R #189) reviewed for medication errors. Specifically, there was no documented evidence that a full investigation into a medication timing error involving psychotropic and benzodiazepine medications was performed, or that vital information was communicated to the physician.

Inspectors wroteBased on observation, interview, and record review conducted during a recent recertification survey, the facility did not ensure the comprehensive person-centered care plan was revised for 1 of 2 Residents (Resident # 252) reviewed for vision and hearing. Specifically, (1) Resident #252 Hearing Impairment Care Plan was not revised to reflect the resident's recent complaint of changes in hearing loss, (2) orders for audiology consultation for hearing aids; and (3) to determine if the interventions remained appropriate.

Inspectors wroteBased on observation, interview, and record review conducted during a recent recertification survey, the facility did not ensure that a resident receive proper treatment and assistive device to meet the resident's hearing needs. Specifically, 1of 2 residents (Resident #252) reviewed for vision/hearing complained to the facility staff about hearing difficulties and was not provided the audiology consultation or hearing aids ordered by the physician.

Inspectors wroteBased on interviews and record review during a recertification survey the facility failed to ensure adequate supervision and effective use of the facility's monitoring program to prevent elopement was provided for 1 of 1 resident (Resident #81). Specifically, Resident #81 entered an elevator on the 3rd floor and was found by staff on the 4th floor.

Inspectors wroteBased on interviews and record reviews during a recent recertification survey, the facility did not ensure that one (Resident # 189 ) of three residents reviewed for medication administration was free from significant medication error. Specifically, the nurse did not administer medications at the physican prescribed time placing the resident at risk for dangerous drug interaction/reactions.