Daughters of Sarah: Family Not Told Before Resident Died - NY
That is what a state inspection complaint found at Daughters of Sarah Nursing Center in Albany, where a resident identified in records only as Resident #1 collapsed during a shower on the morning of May 14, 2026, vomited brown-colored fluid hours later, and died before noon. The family received no call about the collapse. No call about the vomiting. The first contact from the facility came at 12:07 PM, when a staff member told them Resident #1 was gone.
The inspection, completed May 29, 2026, documented the sequence in detail, drawing on interviews with nurses, a physician assistant, the facility's director of nursing, and a family member who had been on a telephone care conference about this same resident just one day before.
On the morning of May 13, 2026, Family Member #2 participated in that care conference by phone. Fatigue and nausea were discussed. Those were the concerns on the table the day before Resident #1 collapsed in the shower.
The next morning, a licensed practical nurse told inspectors that Resident #1 was in the shower when they had what the nurse described as "a vasovagal episode" but did not completely pass out. A vasovagal episode is a sudden drop in heart rate and blood pressure, often triggered by stress or pain, that can cause fainting or near-fainting. The nurse notified Physician Assistant #1, who came to assess the resident after they had been returned to bed.
Physician Assistant #1 told inspectors they believed it was a vasovagal incident and instructed staff to monitor the resident and notify them if anything changed. They offered Resident #1 their morning medication, which the resident accepted.
A short time later, the situation shifted. Resident #1 vomited, and the vomit was brown. Staff notified Physician Assistant #1 again. The physician assistant ordered Ondansetron, a prescription anti-nausea medication, and directed staff to monitor vital signs. Physician Assistant #1 told inspectors they were contacted a second time around 11:15 AM. The resident had passed away. The Ondansetron had never been administered.
Through all of it, from the shower collapse to the vomiting to the death, no one called the family.
Family Member #2 told inspectors they had no idea any of it had happened until 12:07 PM, when the facility called to say Resident #1 had died. They had not been told about the vasovagal episode. They had not been told about the vomiting. The first notification they received was the last one that could ever be given.
The inspection report notes that the physician who oversaw Resident #1's care told inspectors they would expect a patient's family to be notified of an unexpected change in condition, particularly for a resident who could not make their own decisions about treatment. The report does not state explicitly whether Resident #1 fell into that category, but the physician's framing was pointed. A resident who cannot direct their own care depends on their representative to be informed. That representative was not informed.
The Director of Nursing told inspectors that the facility's own standard was clear: family or representatives are to be notified for any change in a resident's baseline, including incidents, accidents, increases in pain, and new signs or symptoms showing a change in medical condition. A collapse in the shower would seem to qualify. Brown vomit following a near-fainting episode would seem to qualify.
Licensed Practical Nurse #1, interviewed separately, described the threshold for family notification as covering severe changes in condition, which they defined as altered mental status, altered respiratory status, or vital signs outside the normal range. They also told inspectors directly that Family Member #2 was not notified of the vasovagal incident when it occurred on May 14.
What the inspection does not answer, and what the records reviewed do not resolve, is who made the decision not to call. The report documents that nurses were present, that the physician assistant was involved and returning to assess the resident multiple times, and that the director of nursing knew what the notification standard required. But no one placed that call.
The care conference the day before adds a layer that is hard to set aside. The family was engaged. They were on the phone discussing this resident's fatigue and nausea on May 13. When those exact symptoms escalated into a medical emergency the following morning, they were left in silence for hours.
The inspection cited the facility under New York Code 415.3(f)(2)(ii), which governs resident rights and, in this context, the rights of residents' representatives to receive timely notification of changes in condition. The level of harm was characterized in the report as minimal harm or potential for actual harm, a classification that reflects the regulatory framework rather than the experience of a family waiting by a phone that did not ring.
Brown vomit following a vasovagal episode is not an ambiguous symptom. It can signal bleeding in the upper gastrointestinal tract. Whether that was the cause of Resident #1's death is not stated in the inspection report, and this article will not speculate about it. What the report does establish is that the sequence was alarming enough to prompt the physician assistant to order medication and vital sign monitoring, and still no one called the family.
The physician assistant was contacted at least three times that morning. The nurse was present and involved. The medication was ordered. The monitoring was ordered. And Family Member #2, who had been on a care conference call the previous day discussing this resident's nausea, sat at home knowing none of it.
When the call finally came, at 12:07 in the afternoon, there was nothing left to decide, nothing left to ask, no question about treatment or transfer or what the family wanted done. The conversation that should have happened at 8 or 9 or 10 in the morning, the one where a family member might have asked questions or pushed for something different or simply been present in some way for what was happening to someone they loved, never took place.
Family Member #2 found out their family member had died at the same moment they found out their family member had been in crisis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Daughters of Sarah Nursing Center from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
DAUGHTERS OF SARAH NURSING CENTER in ALBANY, NY was cited for violations during a health inspection on May 29, 2026.
The family received no call about the collapse.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.