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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adelphi Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity and Privacy: Staff were observed entering resident rooms without knocking, announcing themselves, or asking permission, and one resident reported that privacy curtains were not drawn during care for a roommate and that staff often entered without knocking. An LPN and GNAs were observed entering multiple resident rooms without proper announcement, and the DON confirmed staff were expected to knock and introduce themselves before entering.
A facility failed to keep resident belongings safe and secure for three residents, including missing clothing, missing personal items after hospitalization, and a resident’s belongings left in storage after return from the hospital. The facility also failed to maintain a safe, comfortable, and homelike environment when one resident’s window lacked a screen and another resident’s room had dangling cable outlets, exposed wiring, and unfinished bathroom wall repairs.
Two roommates became involved in a verbal dispute over clothing placement that escalated into a physical altercation in which each punched the other, resulting in one resident sustaining facial swelling, a forehead laceration, and documented intracranial bleeding and eye injury. A GNA, alerted by calls for help while passing breakfast trays, found one resident bleeding from the forehead, removed the other resident from the room, and notified nursing staff. An RN Supervisor assessed the injured resident and obtained a history that the roommate had struck the resident in the face after an argument about clothes. Records showed that one of the residents had a prior history of aggressive behavior and a previous fight, and psychiatry notes described this as a second patient‑to‑patient altercation, confirming that the facility failed to protect residents from abuse.
Failure to obtain informed consent for psychotropic medications was identified for two residents. One resident received Buspirone and Oxcarbazepine with multiple dose increases, and another resident received Trazodone, but no psychotropic consent was documented in either chart. The DON stated nursing staff were responsible for obtaining the consents and confirmed they could not be found.
Failure to Invite Resident to Care Plan Meetings: A resident reported not being invited to any care plan meeting since admission. The EMR showed a care plan invitation sent on the same day as the scheduled meeting, but the attendance sheet did not show the resident attended and there was no other documentation of participation. The SSC stated residents who are capable are invited and attendance is documented, and the Administrator and DON confirmed the resident was capable.
Failure to Accommodate a Resident's Wheelchair Needs: A resident who was bed bound and eating lunch in a bariatric bed reported repeated requests for a wheelchair that were not met. An RN supervisor told the resident the facility did not have a wheelchair, and the NHA later stated there was no wheelchair available to fit the resident's size and that staff had failed to notify her of the request.
A resident was transferred to the hospital and the facility failed to provide written bed hold information. Record review found no documentation that the resident received the bed hold notice after the hospital transfers, and the MRC could not locate any form in the bed hold binder. The Administrator confirmed the resident should have received the notice, stating the issue was a communication problem.
Failure to complete a PASRR Level II evaluation for a resident with a positive Level I screen. The resident's PASRR I indicated referral to AERS for further review, but the record did not contain the required AERS evaluation or a PASRR from Telligen, and the SSD confirmed the missing documentation after the resident had also been transferred to the hospital for a psychotic episode.
Failure to Initiate Baseline Care Plan: A resident reported not seeing the SW since admission and not attending any care plan meeting, while record review found no documentation that a baseline care plan was initiated within 48 hours. The DON stated unit managers and supervisors complete the baseline care plan, but the only documentation found was a list of meds with two nurses' signatures and no evidence of an immediate plan of care or confirmation that a copy was provided to the resident or RP.
The facility failed to develop care plans for two residents’ identified needs. One resident received an antidepressant for depression, but the care plan did not address the medication use. Another resident developed a facility-acquired right heel pressure ulcer and received daily treatment, but no care plan was in place for the wound.
A resident had missed quarterly care plan meetings with the IDT. The resident, who had been in the facility since 2024, denied having regular care plan meetings, and the record showed only one meeting documented in 2025 with gaps between documented meetings. The DOSS and Social Services Coordinator both confirmed that care plan meetings were missed.
Failure to Provide Resident-Centered Activities: A resident with a hx of CVA, dysphagia, CKD, and a BIMS score of 9 was observed alone in bed without activity materials or devices, and she stated none had been provided despite expressing interest. Record review showed gaps in 1:1 activity documentation and low interactive contact averages, while the Recreation Director confirmed the resident preferred to stay in her room and that no activity materials or devices were provided.
Failure to provide sufficient Foley catheter monitoring, standard care, and shift documentation was identified for a resident with a Foley order and a new UTI. The Foley drain was observed not draining, the resident reported intermittent bladder pain, and record review showed missing per-shift documentation and that nursing staff did not follow the resident’s catheter care plan.
Insufficient Nursing Staffing PPD: The facility failed to provide the required 3.0 PPD on 3 of 14 days reviewed. Staffing records showed PPD below the minimum on multiple days, and the Staffing Coordinator confirmed that the full building staff listed on the daily schedule was not counted in staffing PPD and was not routinely on the floor; per diem and part-time staff were used to fill call-out gaps.
Medication administration errors exceeded the allowed rate when 2 errors were found in 27 observed opportunities, resulting in a 7.41% error rate. An RN administered 8 morning meds to a resident, but MAR review later showed 2 additional due meds were documented as given even though they were not observed during the med pass.
Medication labeling and storage errors were observed on multiple med carts and in a medication storage room. Several opened insulin vials and pens lacked opened dates, unopened insulin pens were kept on carts instead of refrigerated until opened, and two opened Aplisol vials had no opened or expiration dates. In addition, a cup with three pills was left at a resident’s bedside; the resident said the RN placed them there, did not know what they were for, and would not take them.
Personal items were repeatedly left in kitchen storage and food prep areas, including a cell phone, keys, and drinks observed on a tray cart near the refrigerator area. The Kitchen Manager acknowledged that staff lockers were available outside the kitchen, but personal items continued to be found in the work areas, and the Administrator agreed there was no justification for staff failing to use designated lockers.
A resident with a history of atrial fibrillation, heart failure, and severe cognitive impairment was admitted with a pacemaker, but the care plan did not include any interventions or monitoring instructions for the device. Although staff were informed of the pacemaker through an order, the care plan lacked specific guidance on its management, as confirmed by interviews with the resident and the DON.
Licensed staff did not have or follow orders to monitor a resident's pacemaker, and the care plan lacked interventions for device monitoring. In a separate case, after a resident with mobility and cognitive issues fell, staff moved the resident without notifying a nurse or obtaining an assessment, contrary to facility policy. Both incidents involved failures to follow established protocols for medical device monitoring and fall management.
The facility did not document a behavioral incident involving a resident with psychiatric diagnoses who became aggressive with staff, nor did it ensure accurate transcription of a medication order, resulting in a medication being recorded for the wrong resident. Staff interviews confirmed that required documentation and verification procedures were not followed.
Surveyors found that several residents did not receive wound and skin care treatments as ordered by a wound NP, including missed or delayed applications of ointments, emollients, and dressings, and incomplete documentation of care. Care plans identified the need for these interventions, but the facility did not consistently implement or record them.
A review of medication records and staff interviews revealed that multiple nurses failed to document the administration of PRN narcotic medications in the MAR, despite signing them out in the controlled substance log book. This discrepancy was identified for several residents, indicating that the facility's policy requiring documentation in both the MAR and controlled substance log was not consistently followed.
Surveyors identified improper storage and labeling of food items, unsanitary conditions in kitchen and nourishment rooms, and incorrect dish handling practices. Observations included unsealed and unlabeled bulk foods, undated opened beverages, debris and insects on kitchen windowsills, and a resident-use ice machine with visible contamination.
Surveyors found that the facility did not provide adequate maintenance services, resulting in stained ceiling tiles, dirty air conditioning units, torn window screens, and patched ceiling holes in several rooms. Widespread peeling paint was also observed in many second-floor rooms and hallways, with staff confirming the issue had persisted for some time. Facility leadership acknowledged the ongoing problems and the lack of a clear timeline for repairs.
A resident assessed to need side rails for bed mobility did not have timely access to them, despite documented family preference and care plan interventions. Delays in obtaining physician orders resulted in the resident being without the required mobility device for several days after both initial assessment and readmission.
A resident with scheduled dialysis orders did not receive a required treatment because both dialysis and facility staff failed to recognize the omission, and the resident was not listed on the dialysis schedule. The missed session was only discovered after a call from the resident's representative, and by then, it was too late to provide the treatment.
Surveyors found that two residents were not provided with information about their right to formulate advance directives, as required. In both cases, documentation was either missing or incorrect, and staff confirmed that there was no evidence the residents had been offered this information.
A resident's medication was incorrectly coded as insulin instead of a hypoglycemic agent on the MDS assessment. Review of the MAR and discussion with the MDS Coordinator confirmed the error in medication classification.
Surveyors identified that two residents did not have accurate or complete care plans reflecting their current medical conditions and needs. One resident with an ileostomy and on hemodialysis was incorrectly documented as incontinent, while another resident's care plan failed to address a new pain complaint and lacked specific details. The DON and NHA confirmed the care plans were not person-centered or complete.
The facility did not consistently invite two residents to participate in their care plan meetings or conduct care plan meetings after each MDS assessment, as required. One cognitively intact resident was not documented as being invited or present at care plan meetings, and another resident had no documented care plan meetings following multiple MDS assessments, with a scheduled meeting not occurring as planned.
A resident who was dependent on staff for ADL care and cognitively intact did not consistently receive showers as ordered in their care plan. Documentation was inconsistent, with some records indicating showers were given, while others showed refusals or lacked explanation for missed showers. The resident reported only receiving bed baths and not being offered showers, and interviews with the NHA confirmed the inconsistency in providing necessary hygiene services.
Two residents with physician orders for continuous oxygen therapy were observed without their oxygen supply during and after transport to dialysis. In both cases, staff failed to ensure the oxygen concentrators accompanied the residents, resulting in periods where the nasal cannula was not connected to supplemental oxygen, despite documented orders and care plans requiring continuous administration.
Staff failed to document the administration of PRN narcotic medications in the MAR for three residents, despite signing out the medications in the controlled substance log. This resulted in multiple undocumented administrations, contrary to facility policy requiring documentation in both records.
Staff did not follow infection prevention protocols for a resident with a PEG tube, including leaving an incorrectly dated water flush bag, unlabeled tube feeding bottles, and failing to remove an old, odorous Xeroform strip from the tube site. The required daily dressing change was not completed as ordered, and the presence of the Xeroform strip was unexplained by staff.
A resident was observed being transported in a recliner chair that did not steer properly and had a faulty reclining mechanism, causing abrupt movements of the head and foot sections. A GNA reported that all similar chairs were in this condition, and a UM confirmed the malfunction.
A resident was found with a mattress that did not fit the bed frame, causing it to hang over the sides and not lay flat. Staff were aware of the issue, but maintenance procedures were unclear and documentation of required bed audits could not be provided. The Director of Maintenance could not confirm the mattress type or origin, and no records of annual bed inspections were available.
Garbage bags were left unattended in a hallway after a GNA placed them outside resident rooms following her rounds. The DON confirmed that this practice was not in accordance with facility policy, as garbage should be taken directly to the dirty utility room.
The facility did not consistently notify residents' legal representatives or responsible parties of changes to the plan of care, as required. In several cases, residents with guardians or responsible parties had changes in care or important notices provided without proper documentation that their representatives were informed or had acknowledged these changes, leading to inconsistencies in records and communication.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents. One resident's care plan and clinical notes inaccurately documented incontinence status despite a history of ileostomy and hemodialysis. In another case, a resident's complaint of wrist pain led to orders for Tylenol and a STAT X-ray, but the MAR did not show Tylenol administration and the X-ray results were missing from the chart until later requested by the DON.
Surveyors observed bugs in a resident's room, an elevator, and dead insects and debris on kitchen windowsills, indicating a failure to maintain an effective pest control program. Pest management records showed repeated treatments for roaches and fruit flies in resident rooms, but no evidence of preventative measures in new resident locations or adequate kitchen cleanliness.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents had a dignified existence by not consistently protecting privacy and by allowing staff to enter resident rooms without knocking or announcing themselves. Resident #88 reported that staff did not draw the privacy curtain while providing care to the roommate and did not knock before entering the room, stating that this happened most of the time. During unit rounds and room observations, a surveyor also observed an LPN enter Resident #8's room and Resident #163's room without knocking or announcing his presence, with Resident #163 in bed at the time of entry. Additional observations showed similar conduct by other staff. A GNA entered Resident #21's room without knocking or announcing her presence, and another GNA entered Resident #8's room without knocking or announcing her presence while the surveyor was present. When questioned, the GNA stated she was in a rush and did not knock. In another observation, two GNAs entered Resident #7's room without knocking, announcing who they were, or asking permission to enter. Staff interviews confirmed that the expectation was to knock, introduce themselves, and ask permission before entering resident rooms, and the DON stated that all staff were expected to do so.
Missing Belongings and Unsafe Room Conditions
Penalty
Summary
The facility failed to ensure resident belongings were safe and secure for three residents. One resident reported that a 2-piece outfit sent to laundry was returned missing the top, and the Nursing Home Administrator stated that no grievance form had been completed and that she had not been made aware the item could not be located. Another resident reported that multiple personal items were missing after returning from hospitalization; the resident had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and stated that the NHA told the resident to write down the missing items even though the resident could not write because of the stroke. A third resident’s responsible party reported that all belongings were missing after the resident returned from the hospital and that there had been no follow-up update from the facility. The facility also failed to provide a safe, comfortable, and homelike environment for two residents. One resident reported being unable to open the window in the room because there was no screen, and the window was observed to have no screen or frame in place. The Administrator confirmed that residents should be able to open their windows and that the resident should have a screen, while the Maintenance Director stated he had been waiting for window screen frames and had requested them from corporate office months earlier. In another resident’s room, surveyors observed three cable outlets and casings pulled away from the wall and dangling, with face plates hanging off and exposed wiring visible at the telephone jack. In the bathroom, an unpainted area remained where a toilet paper roll dispenser had been removed, with screws still in place. The Maintenance Director confirmed these issues needed repair but stated he was not aware of them and that staff did not report such concerns.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse, as evidenced by a verified resident‑to‑resident physical altercation that resulted in injuries. On the morning of 01/24/2026, two roommates became involved in a dispute over clothing placement in their shared room. One resident reported that their clothes were initially on a chair by the window, and that the roommate later placed their own clothes in the same location. When the first resident moved their clothes to the foot of the bed and informed the roommate that the clothes at the chair were not theirs, the roommate allegedly began using profanity and then punched the resident in the face, prompting the resident to strike back in self‑defense. Staff accounts and documentation corroborated that a physical altercation occurred between the two residents. A GNA, while passing breakfast trays, heard a resident calling for help, entered the room, and observed one resident sitting on the bed and the other at the edge of the bed with blood on the right forehead area. The GNA reported that the injured resident stated the two had argued and that the roommate hit them in the face. The GNA immediately removed the alleged aggressor from the room and contacted the charge nurse. An RN Supervisor also reported being notified by the GNA, entering the room, and finding the resident with facial swelling and a laceration to the right side of the forehead, with the resident stating that the roommate struck them when they refused to allow the roommate to take their clothes. Clinical records and prior documentation showed that the altercation caused significant injury and that one of the residents had a known history of aggressive behavior. A skin status evaluation completed later that day documented a new laceration to the right side of the forehead and facial swelling for the injured resident. Hospital records indicated the resident was seen after an assault and that a CT scan showed a small amount of blood in the brain from being struck in the head, as well as a small eye scratch. Psychiatry notes for the injured resident referenced follow‑up for a patient‑to‑patient altercation requiring EMS transport, and psychiatry notes for the other resident described evaluation after a second patient‑to‑patient altercation and a documented history of aggressive behavior, including a prior fight and recent initiation of a mood stabilizer. The DON confirmed that the facility’s investigation verified the allegation of a resident‑to‑resident physical altercation based on staff witness statements and both residents’ admissions.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication administration for 2 of 5 residents reviewed. For Resident #9, the medical record showed Buspirone 5 mg three times daily was started on 5/13/2025 and Oxcarbazepine was started on 5/13/2025 at 75 mg twice daily, then increased to 150 mg twice daily on 6/09/2025, 300 mg twice daily on 8/05/2025, and 300 mg three times daily on 10/21/2025. During record review, no informed consent for psychotropic medication was documented for either medication. For Resident #3, the medical record showed Trazodone 50 mg at bedtime for 30 days was started on 12/18/2025, Trazodone 50 mg every 24 hours as needed for 14 days was ordered on 01/29/2026, and Trazodone 50 mg at bedtime was reordered on 02/18/2026. No informed consent for psychotropic medication was documented for Trazodone. The DON stated that nursing staff were responsible for obtaining consent for psychotropic medications and confirmed that consent was expected for Buspirone, Oxcarbazepine, and Trazodone, but she was unable to find that the consent had been completed.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite a resident to care plan meetings and failed to document the resident’s participation or refusal. Resident #138 reported during interview that he/she had not been invited to a care plan meeting since admission to the facility. Review of the medical record showed an admission date in the EMR and a care plan conference invitation dated August 26, 2025 addressed to the resident and responsible party, but the invitation was issued on the same date as the scheduled meeting. Review of the care plan attendance sheet for that meeting showed no indication that the resident attended. A later review of the record with the Director of Social Services found no documentation that the resident attended any care plan meeting. During interview, the Social Services Coordinator stated that care plan meetings are held quarterly, residents who are capable are provided invitations, and attendance is expected to be documented by signatures. The Administrator and DON confirmed that Resident #138 was capable, yet the facility had no additional documentation showing the resident was invited to or attended a care plan meeting since admission.
Failure to Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to ensure a resident's needs were accommodated when Resident #126, who was bed bound and eating lunch in a bariatric bed during observation, reported that the facility would not provide a wheelchair despite repeated requests to nursing staff. The resident stated that Nurse Supervisor #15 said the facility did not have a wheelchair for him/her. The resident also reported that Freedom Mobility had provided a motorized loaner wheelchair in January 2026 with the understanding that a permanent wheelchair would be supplied once Medicaid was approved, but after the loaner was retrieved in February 2026 because Medicaid was still pending, the resident remained bed bound. During interview, the NHA stated that she did not have a wheelchair to accommodate the resident's size and acknowledged that staff had failed to notify her of the resident's request for a wheelchair.
Failure to Provide Bed Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to notify Resident #6 in writing of the bed hold policy when the resident was transferred from the facility to a hospital. Medical record review showed that Resident #6 was sent to and admitted to the hospital on [DATE] and 1/30/2026, but there was no documentation that the resident received the facility Bed Hold Information after discharge to the hospital. During interview, the Medical Records Coordinator stated that the bed hold policy should be given to any resident sent out to the hospital and that copies are kept in a binder, but when she reviewed the binder she could not find documentation that Resident #6 had been given the Bed Hold Information for the hospital transfers. The Administrator later confirmed that Resident #6 should have received the Bed Hold Information after being sent to the hospital from the doctor's office, and stated that it was a communication issue.
Failure to Complete PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that Resident #7 received an assessment for additional services after the resident's PASRR Level I screening indicated a referral to AERS for a PASRR Level II evaluation. Review of the record showed that the PASRR I completed on 04/02/2026 at 10:50 AM identified in Section D that the resident should be referred for the Level II evaluation, but the medical record did not contain an AERS evaluation. During interview, the Social Service Director reviewed the PASRR with the surveyor and confirmed that the resident should have had an AERS evaluation. The surveyor also noted concern that the resident had been transferred to the hospital for a psychotic episode since admission, and no PASRR could be located in the record. On 04/08/26, the Social Service Director reported that she was unable to locate the AERS evaluation or a PASRR from Telligen related to the hospital transfer and stated that there should have been both documents.
Failure to Initiate Baseline Care Plan
Penalty
Summary
The facility failed to initiate a baseline care plan for Resident #163 within 48 hours of admission. A baseline care plan is described in the report as an initial, person-centered care plan developed within 48 hours of admission that includes instructions needed to provide effective and person-centered care based on admission orders and initial assessments. On 04/02/2026, the resident told the surveyor that the social worker had not been seen since admission and that no care plan meeting had been attended, and the resident wanted to discuss discharge. Record review on 04/06/2026 showed the resident was admitted on [DATE], but there was no documentation supporting that a baseline care plan had been initiated. On 04/07/2026, the DON stated that unit managers and supervisors are responsible for completing the baseline care plan within 48 hours of admission and that the plan of care and medications are reviewed with the resident and/or RP, signatures are obtained, and a copy is provided. Further review of the record found documentation dated 03/30/2026 with two nurses' signatures and a list of medications, but no evidence of an immediate plan of care. The DON confirmed that this documentation did not include the baseline care plan and was unsure whether a copy had been provided to the resident or RP.
Failure to Care Plan Medication Use and Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to initiate care plans based on medication use for one resident receiving Fluoxetine HCl 20 mg by mouth once daily for depression. Medical record review showed the medication was active and being administered as ordered on the MAR, but on review of the care plan with the DON, there was no care plan in place for the resident’s antidepressant medication. After surveyor intervention, the DON updated the care plan. The facility also failed to care plan a facility-acquired right heel pressure ulcer for another resident. Record review showed the resident developed the pressure ulcer on 10/14/2025 and received daily treatment during the period under review, but there was no care plan addressing the wound. During interview, the DON stated that facility-acquired pressure wounds require comprehensive assessment and care plan updates, and on review of the record with the surveyor, the DON confirmed that no care plan had been initiated for the resident’s right heel pressure ulcer.
Missed Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to have quarterly care plan meetings with the interdisciplinary team for Resident #15. The resident had been in the facility since 2024, and during an interview on 04/02/2026, the resident denied having regular care plan meetings. A review of the medical record on 4/06/2026 showed the last three documented care plan meetings were on 12/24/2024, 7/29/2025, and 3/31/2026. There were no additional care plan meetings documented between 12/24/2024 and 7/29/2025 or between 7/29/2025 and 3/31/2026. The Director of Social Services confirmed that the care plan meeting and attendance sheet would be documented in the resident's electronic medical record and acknowledged that only one care plan meeting was documented in 2025. The Social Services Coordinator, who reported being responsible for the resident's care plan meetings, also confirmed that care plan meetings were missed.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide ongoing resident-centered activities to meet the needs and interests of one resident who was reviewed for personalized activities. The resident was observed sitting in bed alone with no activity materials or devices at the bedside, and the resident stated that no such materials or device had been provided and expressed interest in receiving them. The resident was able to engage in conversation and move her upper extremities freely, and the resident’s BIMS score was 9, indicating moderate cognitive impairment and the ability to make needs and interests known. Record review and additional observations showed that the resident, who was admitted with diagnoses including a 2015 cerebral infarction with left lower leg weakness, dysphagia, and chronic kidney disease, was seen feeding herself and cleaning her bedside table during two separate observations, but she repeatedly fell asleep during those periods. Activity logs for March and April showed documentation gaps for interactive contact and 1:1 activity, with low averages recorded for those months. The Recreation Director stated the resident was invited to group activities but preferred to remain in her room, and also confirmed that the low percentage of 1:1 visits was accurate and that no activity materials or devices were provided. The Administrator concurred that activity staff failed to provide ongoing resident-centered activities.
Foley Catheter Monitoring and Documentation Not Completed
Penalty
Summary
Failure to provide sufficient Foley catheter monitoring, standard care, and shift documentation was identified for one resident with a Foley catheter order and a new urinary tract infection. The resident had physician orders dated 03/20/26 for Foley catheter placement, with instructions for staff to check the Foley every shift and change it as needed for clinical indications such as infection, obstruction, or a compromised closed system. During observations on 04/02/26 at approximately 10:05 AM and 01:30 PM, the Foley catheter drain was observed not draining. The resident stated that pain occurred sometimes and pointed to the bladder area. Record review on 04/03/26 at 12:32 PM showed a lack of documentation for Foley monitoring or standard care for each shift. The nursing staff also did not follow the resident’s care plan for catheter care on a per-shift basis, and the Unit Manager was unable to locate the required shift documentation for staff review.
Insufficient Nursing Staffing PPD
Penalty
Summary
The facility failed to provide a minimum of 3.0 hours of bedside care per occupied bed per day for 3 of 14 days reviewed during the annual recertification survey. A review of the facility's staffing records and census for 03/04/2026 through 03/17/2026 showed staffing below the required 3.0 PPD on 03/07/2026 at 2.89, 03/08/2026 at 2.94, and 03/17/2026 at 2.79. During interview on 04/08/2026, the Staffing Coordinator confirmed that the full building staff listed on the daily staffing schedule is not included in the facility's staffing PPD and stated that when there are call outs, per diem and part-time staff are called to fill staffing gaps, but the listed full building staff are not routinely on the floor.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 2 medication administration errors identified out of 27 observed medication administration opportunities, resulting in a 7.41% error rate during the recertification survey. During a medication administration observation on 04/02/2026 at 8:40 AM, RN #1 prepared and administered Resident #7's morning medications and was observed to have pulled and given 8 medications: ARIPiprazole 10 mg, Furosemide 40 mg, Multivitamin-Minerals, Plavix 75 mg, Vitamin B6 100 mg, BusPIRone HCl 5 mg, Eliquis 5 mg, and oxyCODONE-Acetaminophen 10-325 mg. A later review of Resident #7's MAR at 10:00 AM showed two additional medications due at the time of the observation, Cholecalciferol 1000 units and Omega-3 EPA Fish Oil, which were documented as administered but were not observed to be pulled or administered during the medication pass.
Medication Labeling, Storage, and Bedside Administration Errors
Penalty
Summary
Drugs and biologicals were not properly labeled and stored on multiple medication carts and in a medication storage room. On one medication cart, several opened insulin vials and pens, including Lantus, Humalog, Novolin 70/30, and Insulin Aspart, did not have opened dates documented. On another cart, opened Lantus pens also lacked opened dates. On a third cart, unopened insulin pens, including Lantus, Admelog, and Novolog, were stored in pharmacy bags on the cart even though the bags were labeled to refrigerate until opened. An LPN and an RN confirmed the medications were opened or unopened as observed and acknowledged the labeling and storage errors, and the DON was notified to remove the medications from the carts. In the first-floor medication storage room, two opened vials of Aplisol were found in the refrigerator without opened or expiration dates recorded on the vials. In addition, a cup containing three pills was observed sitting on the overbed table next to Resident #59’s bedside. The resident stated the RN had placed the pills there, did not know what they were for, and said they would not take them. The DON stated the facility process was to watch residents take medications and ensure they swallowed them before leaving the room, and confirmed that leaving medications at the bedside was not the facility process.
Personal Items Left in Kitchen Storage and Food Prep Areas
Penalty
Summary
The facility failed to maintain the food preparation and storage areas in a sanitary manner by allowing personal items to remain in kitchen work areas. During a kitchen tour on 04/02/2026, a cell phone, keys, and drinks were observed on a tray cart outside the refrigerator area. The Kitchen Manager stated that lockers were available for staff use immediately outside the kitchen, but later observations on 04/06/2026 confirmed that personal items were still being left in storage and food preparation areas. In a follow-up interview, the Kitchen Manager acknowledged that personal items were repeatedly left in these areas, and the Administrator later agreed there was no justification for kitchen staff failing to use their designated lockers for personal items.
Failure to Address Pacemaker Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan that addressed the monitoring and care of a resident's pacemaker. Despite the resident having a documented medical history of atrial fibrillation, heart failure, and severe cognitive impairment, the care plan did not include any focus area or interventions related to the presence or management of a pacemaker. The resident's admission records and Minimum Data Set assessment confirmed these diagnoses and cognitive status, and the care plan only addressed risks for cardiac complications without specifying the pacemaker. Further review of the resident's order summary revealed an order indicating the presence of a pacemaker, with instructions for staff to be aware of this every shift. However, there were no corresponding interventions or guidance in the care plan for staff on how to monitor the pacemaker for proper functioning. Interviews with the resident and the Director of Nursing confirmed the existence of the pacemaker and the expectation that it should be addressed in the care plan, but this was not done.
Failure to Monitor Pacemaker and Inadequate Response to Resident Fall
Penalty
Summary
Licensed nursing staff failed to obtain and follow orders for monitoring a resident's pacemaker for proper functioning. The resident, who had a history of cardiomyopathy, heart assist device, and congestive heart failure, was admitted with a pacemaker, but the care plan did not include interventions for pacemaker monitoring. The only order present was an informational note about the presence of a pacemaker, with no directive for staff to monitor its function. Interviews confirmed that the resident could not recall the last time their pacemaker was checked, and facility leadership acknowledged that no monitoring was being performed by staff. In a separate incident, staff failed to follow facility policy regarding the management of resident falls. A resident with muscle weakness, difficulty walking, and moderate cognitive impairment fell out of bed. The assigned Geriatric Nursing Assistant (GNA) enlisted the help of a housekeeper to lift the resident back into bed without notifying a licensed nurse or having the resident assessed prior to being moved, as required by policy. The fall was not reported to nursing staff until the following day, after the resident complained of leg pain. Both deficiencies were identified through interviews, record reviews, and policy review, which revealed that staff did not follow established protocols for monitoring medical devices and responding to resident falls. The lack of appropriate orders and failure to report and assess a fall before moving the resident directly contributed to the deficiencies cited.
Failure to Document Behavioral Incident and Medication Order Transcription Error
Penalty
Summary
The facility failed to document a behavioral incident involving a resident with a history of bipolar and delusional disorders. The incident occurred when the resident became agitated, was verbally aggressive, and struck the Human Resources Director, prompting law enforcement involvement. Multiple staff interviews confirmed that the event was not recorded in the resident's medical record, progress notes, or risk management forms, despite facility policy requiring documentation of significant changes in condition and behavioral incidents. The lack of documentation was acknowledged by the Assistant Director of Nursing, Director of Nursing, Unit Manager, and Administrator, all of whom stated that such incidents should be recorded to ensure proper monitoring and follow-up. Additionally, the facility failed to ensure accurate transcription of medication orders for another resident. A nurse transcribed a medication order for tranexamic acid onto a resident's Medication Administration Record (MAR) without verifying that the order was actually prescribed to that resident. The error occurred because the nurse did not check the name on the hospital discharge paperwork, resulting in a one-time dose of medication being recorded for the wrong individual. The Director of Nursing and Administrator confirmed that the transcription error was due to a failure to match the resident's name with the correct medication order from the hospital discharge summary.
Failure to Provide Ordered Skin and Wound Care Treatments
Penalty
Summary
The facility failed to provide treatments and care according to the orders and recommendations of a wound Nurse Practitioner (NP) for multiple residents with skin care needs. In several cases, the prescribed wound care treatments, including cleansing, application of ointments, and use of emollients, were either not performed as frequently as ordered or were not documented as completed. For example, one resident with chronic wounds and severe dryness was supposed to receive wound care twice daily, but records showed it was only done once per day, and there was a delay in initiating recommended emollient therapy. Another resident with multiple scabbed areas and dry, flaky skin was observed without the recommended dressings, and the treatment administration record indicated that while a topical corticosteroid was applied, other aspects of the care plan, such as Vaseline application and leg wrapping, were not documented as completed. Additional residents with dry, cracked, or flaky skin had recommendations for daily emollient use and other preventive measures, but there was no documentation that these treatments were provided as ordered. Throughout the review, the surveyor noted that the care plans for these residents identified their risk for skin breakdown and the need for specific interventions, yet the facility did not consistently implement or document the recommended treatments. Interviews with the Nursing Home Administrator confirmed that the concerns regarding the lack of adherence to the wound NP's recommendations were reviewed during the survey.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
Surveyors determined that the facility failed to ensure nursing staff were competent in medication administration, specifically regarding the documentation of PRN narcotic medications. During the recertification survey, a review of records and staff interviews revealed that 21 out of 59 licensed nursing staff did not properly document the administration of PRN narcotic medications in the Medication Administration Record (MAR), despite these medications being signed out in the controlled substance log book. This discrepancy was observed during a review of the controlled substance log book on the first floor medication cart, where PRN narcotic medications were signed out but not recorded in the MAR for several residents. The facility's policy requires that after administering medication, staff must document the administration in the MAR or Treatment Administration Record (TAR) and, if necessary, in the controlled substance sign out record. However, surveyors found that this policy was not consistently followed by the nursing staff. The Director of Nursing confirmed that the expectation is for all administered medications to be documented in the MAR, and a list of staff who failed to do so was provided. The Quality Assurance/Staff Development RN also acknowledged the issue during interviews, noting that medication administration competencies are observed monthly or more frequently if needed, but the documentation lapses persisted among the identified staff.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen and nourishment rooms related to improper storage and sanitation of food items and utensils. Specifically, nine large cans of green peas lacked clear delivery and expiration dates, and several bulk food items such as cornstarch, parboiled rice, and orzo pasta were found opened, unsealed, or without labels. Cleaned red cereal bowls were stacked face up, contrary to proper procedure, which could allow water to collect. Additionally, debris, dark spots, and dead insects were found on kitchen windowsills near critical food preparation and storage areas. Further inspection of nourishment rooms revealed the absence of a thermometer in a refrigerator, and several food and beverage items were either undated or had unclear labeling. In the freezer, multiple Styrofoam cups with frozen liquid were also missing date labels. The ice machine used by residents was found to have a black substance on the dispensing flap and rust around the storage bin. These findings indicate failures in maintaining sanitary conditions and proper food storage practices as required by professional standards.
Failure to Maintain Clean and Homelike Environment Due to Maintenance Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed multiple deficiencies in resident rooms, including stained ceiling tiles, dirty and debris-filled air conditioning units, open windows with torn screens, and patched ceiling holes with surrounding stains. These issues were noted in several specific rooms, and not all were included in the facility's maintenance report. The Maintenance Director acknowledged ongoing problems with building leaks and broken window screens, and the Nursing Home Administrator confirmed that staff are expected to report such maintenance concerns. Additionally, surveyors observed widespread peeling paint in 19 rooms and hallways on the second floor, particularly behind beds and chairs. Staff interviews confirmed that the peeling paint had been an ongoing issue, with multiple requests for repairs submitted. The Maintenance Director recognized that paint debris could pose a health hazard but was unable to provide a timeline for completion of the repainting project. The Administrator agreed that the persistent environmental issues were a concern.
Failure to Provide Timely Access to Mobility Device
Penalty
Summary
Facility staff failed to ensure that a resident assessed to need a mobility device, specifically side rails, had timely access to the device. The resident's care plan, initiated on 1/14/25, documented the family's and guardian's preference for side rails, and a bed side rail tool completed on 1/21/25 confirmed consent for their use as an enabler for mobility. Despite these assessments and documented preferences, there was a delay in obtaining a physician's order for the side rails, with the first order not written until 1/29/25. This order was discontinued shortly after due to the resident's transfer out of the facility on 1/30/25. Upon the resident's readmission, the care plan continued to indicate the need for side rails, but no new order was written until 2/7/25, several days after the resident's return. Observations during this period showed the resident in bed without side rails present, despite the documented need and care plan interventions. The deficiency centers on the facility's failure to promptly provide the mobility device as assessed and care planned, resulting in the resident not having access to the required side rails for an extended period.
Missed Dialysis Treatment Due to Scheduling Oversight
Penalty
Summary
A deficiency was identified when a resident with a provider order for dialysis on Tuesdays, Thursdays, and Saturdays did not receive the required dialysis treatment on one scheduled day. Record review showed no treatment notes for the missed session, and interviews revealed that both dialysis and facility staff failed to recognize the missed treatment. The Dialysis Clinical Manager confirmed the missed session and stated that by the time the issue was discovered, it was too late to provide the treatment, and the dialysis center was subsequently closed due to weather. The Director of Nurses reported that the facility only became aware of the missed treatment after a phone call from the resident's representative, and that the resident was not on the dialysis schedule, which led to staff not realizing the omission. The resident was monitored for symptoms, but no issues were reported as a result of the missed treatment.
Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to inform residents of their right to formulate advance directives, as evidenced by the review of two residents' records. For one resident, a psychosocial assessment documented that the resident did not have advance directives, but there was no documentation indicating that information about initiating advance directives was offered. For another resident, conflicting documentation was found regarding the presence of advance directives, and it was later clarified by staff that the resident did not have any. In both cases, interviews with facility staff and administration confirmed that there was no documentation to show that these residents were offered information about formulating advance directives. These findings were based on record reviews and staff interviews, which revealed a lack of proper documentation and communication regarding residents' rights to be informed about and to formulate advance directives.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to accurately code a resident's medication on the Minimum Data Set (MDS) assessment. During a review of one resident's medical record, surveyors found that the quarterly MDS indicated the resident received an injection of insulin for one day. However, examination of the Medication Administration Record (MAR) for the same period showed that the resident was administered Trulicity by injection, which is a hypoglycemic agent, not insulin. Upon review with the MDS Coordinator, it was confirmed that Trulicity had been incorrectly coded as insulin on the MDS assessment.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents. For one resident, the medical record showed a history of ileostomy and hemodialysis, with no urine output, following a recent hospital readmission. However, the care plan inaccurately documented the resident as incontinent of bladder and/or bowels due to medication use and impaired mobility. This discrepancy was confirmed by the DON during an interview, acknowledging the care plan did not reflect the resident's actual condition. For another resident, after reporting new pain in the left foot following a treatment, the care plan was found to be incomplete and not resident-centered. The care plan only noted a risk for pain and constipation, without specifying causes or addressing the new complaint. The NHA confirmed during an interview that the care plan lacked completeness and person-centered details.
Failure to Invite Residents and Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were invited to participate in their care plan meetings and that care plan meetings were conducted after each Minimum Data Set (MDS) assessment, as required. In the case of one resident, who was cognitively intact as indicated by a BIMS score of 15, there was no documentation that the resident was invited to or attended care plan meetings following admission. The only invitation on record was sent to the resident's guardian, and there was no note in the medical record indicating that the resident was invited or declined to attend. The Social Work Coordinator acknowledged that she did not document the resident's invitation or declination, and there was no explanation for the resident's absence from subsequent care plan meetings. For another resident, there was no documentation of care plan meetings being conducted after multiple MDS assessments throughout the year. Although a care plan meeting was scheduled, the resident was not present at the scheduled time, and there was no record of who attended the meeting or if it was conducted. The lack of documentation persisted until a care plan meeting was finally documented at a later date. These findings were confirmed through interviews with facility staff and review of medical records.
Failure to Provide Ordered Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a cognitively intact resident, who was dependent on staff for activities of daily living, reported only receiving bed baths and not being offered showers as per their care plan. The resident's medical record included an order for showers twice weekly on specific days and shifts. Documentation reviewed by the surveyor showed inconsistencies: only three showers were documented in the point of care system, while shower sheets indicated refusals on some dates and a lack of explanation for missed showers on others. Additionally, the Treatment Administration Record (TAR) showed showers marked as given on multiple dates, but corresponding shower sheets were missing or indicated refusals, creating discrepancies in the records. Interviews with the resident and the Nursing Home Administrator (NHA) confirmed that the resident was not consistently offered or provided showers as ordered. The lack of consistent and accurate documentation, as well as the resident's own report, demonstrated that necessary services to maintain good personal hygiene were not reliably provided to the dependent resident, resulting in a failure to meet the resident's care needs as outlined in their plan of care.
Failure to Provide Continuous Oxygen Therapy During Resident Transport
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for oxygen administration for two residents who required continuous supplemental oxygen. In one instance, a resident with an order for continuous oxygen at 2 liters per minute via nasal cannula was observed being transported to dialysis without the oxygen concentrator, despite having a nasal cannula in place. The staff member responsible for the transport confirmed that the resident required oxygen and returned later to retrieve the concentrator. The resident's medical record included orders and care plan interventions specifying the need for continuous oxygen and monitoring, as well as documentation of ongoing shortness of breath and a goal to maintain oxygen saturation above 92%. In another case, a resident with a diagnosis of COPD and an order for continuous oxygen at 2 liters per minute via nasal cannula was found in bed with the nasal cannula not connected to any oxygen source. The resident stated that the concentrator had likely been left in dialysis, and a staff member subsequently retrieved and reconnected the device. The facility's policy on respiratory care and oxygen equipment required that oxygen support not be initiated or adjusted without a provider's order and described the need for continuous therapy as ordered. The Nursing Home Administrator acknowledged that residents with continuous oxygen orders should not be taken off oxygen for transport convenience.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
Facility staff failed to appropriately document the administration of PRN (as needed) narcotic medications in the Medication Administration Record (MAR) for three residents who were prescribed controlled substances for pain management. Record reviews revealed that, although staff signed out PRN narcotics in the controlled substance log book, they did not consistently record these administrations in the MAR. For one resident, this discrepancy occurred 30 times in a single month. Interviews with nursing staff confirmed that the facility's expectation is for all administered medications to be documented in the MAR, but staff did not notice discrepancies between the narcotic log and the MAR. Further review of the controlled substance sign out logs and MARs for two additional residents showed similar failures to document PRN narcotic administration in the MAR, despite proper sign-out in the controlled substance log. The facility's medication administration policy requires documentation in both the MAR and the controlled substance log after administration. The DON confirmed that several nurses administered PRN narcotics without documenting them in the MAR, as required by facility policy.
Failure to Maintain Infection Control in Enteral Feeding Tube Care
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. During observation, the resident's tube feeding water flush bag was found hanging with an incorrect date, and two unopened Jevity bottles were left unlabeled on a draw table. Record review confirmed that the resident's orders required tube feeding via pump and daily cleansing and dressing of the PEG tube site with split gauze, which was to be dated each shift. Further bedside observation of a PEG tube site dressing change revealed that there was no split gauze covering the insertion site from the previous day, and an old Xeroform strip, which was not part of the resident's care order, was discovered under the external fixation plate. The Xeroform strip was discolored and emitted an odor, and nursing staff could not explain its presence or duration. The unit manager confirmed that staff had omitted to remove the old Xeroform strip, and both the administrator and infection preventionist acknowledged that these findings did not meet infection prevention standards or the facility's standard of care.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, as evidenced by observations of a resident being transported in a malfunctioning recliner chair on two separate occasions. During both observations, the chair did not steer straight, and the reclining mechanism failed to maintain its position, causing the head and foot of the chair to abruptly move. A Geriatric Nursing Assistant (GNA) was seen struggling with the chair, and when questioned by the Unit Manager (UM), the GNA indicated that all the chairs were in similar condition. The UM acknowledged that the chair was not functioning correctly. These findings were based solely on direct observations and staff interviews.
Failure to Ensure Proper Mattress Fit and Document Bed Inspections
Penalty
Summary
A deficiency was identified when a resident's mattress was observed to be too large for the bed frame, causing the mattress to hang over both sides and preventing it from lying flat. The issue was initially reported by the resident, who used the call light to request assistance after previously notifying staff that the bed was not working. Upon investigation, a Geriatric Nursing Assistant responded and indicated that the nurse was already aware of the problem. The Registered Nurse confirmed that maintenance had been contacted, but also revealed unfamiliarity with the facility's computerized repair request system, relying instead on phone calls to notify maintenance. Further inspection by maintenance staff confirmed that the mattress did not fit the bed frame. The Director of Maintenance was unable to identify the origin of the mattress and stated that it was not appropriate for either regular or bariatric beds used in the facility. When asked about regular annual inspections of beds, the Director referenced a computer system for scheduling preventive maintenance but could not provide documentation of completed bed audits. The Nursing Home Administrator also could not produce records of bed audits performed, and no documentation was provided to the surveyor by the time of exit.
Improper Disposal of Garbage in Hallway
Penalty
Summary
The facility failed to maintain a sanitary environment in the common hallway of the East Wing. During an early morning observation, three garbage bags full of waste were found left in the hallway with no staff present. A Geriatric Nursing Assistant (GNA) was observed exiting a resident's room with a garbage bag and explained that she placed garbage outside the door after completing her rounds. Shortly after, two staff members collected the garbage bags and took them to the dirty utility room. The Director of Nursing (DON) confirmed during an interview that garbage should not be left outside resident rooms and should be taken directly to the dirty utility room when emptied.
Failure to Notify Resident Representatives of Care Plan Changes
Penalty
Summary
The facility failed to properly notify residents' legal representatives or responsible parties of changes to the residents' plans of care, as required. In one case, a resident with a court-appointed guardian was given Medicare non-coverage and liability notices without documented notification or acknowledgment from the guardian, despite the guardian being the legal decision-maker. The social services staff stated they had contacted the guardian, but there was no documentation to confirm the guardian was aware of or had acknowledged the notices. In another instance, a resident who was determined unable to make decisions and had a temporary guardian had documentation inconsistencies regarding who was acting as the responsible party. Some records indicated the resident was his or her own decision-maker, while others referenced the guardian, and there was a lack of clarity and documentation about who was notified of care plan changes. A third resident with established guardianship had inconsistent documentation about whether the responsible party was informed of changes to the plan of care, with some notes indicating communication with family members and others lacking evidence that the legal representative was updated.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in documentation that did not align with accepted professional standards. For one resident who was readmitted after a hospital stay and had a history of ileostomy and hemodialysis, the care plan and multiple clinical notes inaccurately described the resident as incontinent of urine and stool, despite the resident no longer producing urine. The Director of Nursing confirmed these inaccuracies during an interview, acknowledging that the documentation regarding incontinence was not correct. In another case, a resident admitted for rehabilitation and colostomy care reported right wrist pain to an LPN, who documented the complaint, obtained a physician's order for Tylenol and a STAT X-ray, and noted that Tylenol was administered. However, the medication administration record did not reflect any Tylenol given for the relevant period, and the X-ray results were not present in the resident's medical chart at the time of review. The Director of Nursing later confirmed that the X-ray results were not in the chart and had to be requested from the imaging facility, and also confirmed the lack of documentation for the administered medication.
Deficient Pest Control Program and Insect Activity Observed
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of insect activity in resident rooms, common areas, and the kitchen. During an interview with a resident who reported feeling things crawling on them, surveyors observed bugs crawling on the floor and wall of the resident's room. Pest management records showed that the room had been treated for roaches and general insects, and that another room had a history of fruit flies and roaches, with recommendations for additional interventions that were not documented as completed. After the resident was transferred to a new room, there was no evidence of preventative pest control measures or evaluation in the new location, where bugs were also observed. Additionally, a bug was observed by surveyors in an elevator, and the DON confirmed the presence of the insect, which was similar to those seen in the resident's room. During a kitchen tour, surveyors and the kitchen manager observed debris, dark spots, and dead insects on multiple kitchen windowsills near food preparation and storage areas. The kitchen manager confirmed the need for cleaning, and the NHA stated that housekeeping was responsible for monthly cleaning of the kitchen, but evidence of pest presence and debris was still found during the survey.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,569 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Adelphi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Althea Woodland Nursing Home | 0.9 mi | ★★★★★ | 1 | 0 |
| Sligo Creek Healthcare | 2 mi | ★★★★★ | 6 | 0 |
| White Oak Rehabilitation And Nursing Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Sterling Care Hillhaven | 2.5 mi | ★★★★★ | 0 | 0 |
| Sacred Heart Home Inc | 3.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.