Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alliance Care Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Report Injury of Unknown Origin: A resident with dementia, Parkinson's disease, and a prior traumatic subdural hemorrhage sustained an unwitnessed head injury after being seen trying to climb back into bed. Staff documented blood on the floor and the resident's head, and the resident was sent to the hospital. Although the injury was investigated and staff negligence was found unsubstantiated, the DON stated the event was not reported to the State Agency because it was not considered abuse or an injury of unknown origin, despite facility policy requiring immediate reporting of injuries from an unknown source.
The facility failed to provide the CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to three residents when their Medicare A therapy services were completed, preventing them from knowing their remaining days under Medicare A. The facility's policy did not instruct staff to complete the CMS Form 10055 at the anticipated end of Medicare-covered stays, as confirmed by the Social Services Director.
A resident with severe cognitive impairment was pushed and hit by another resident with no cognitive decline but with vascular dementia. The incident was reported a day later, and the facility conducted an incomplete investigation. The facility's policy on abuse prevention was not adequately followed, leading to this incident.
The facility failed to thoroughly investigate incidents of resident-to-resident abuse involving three residents. In one case, a resident with dementia was hit by another resident, but the investigation lacked staff and resident interviews. In another case, a resident alleged abuse by a former Social Service Director, but the investigation did not include statements from all involved parties, contrary to facility policy.
A resident with a feeding tube was not consistently positioned with the head of the bed elevated as required by facility policy, risking aspiration. Observations showed the resident lying with inadequate head elevation while enteral feeding was running. Staff interviews confirmed the failure to maintain the required head elevation, despite the facility's policy and standard practice.
A LTC facility failed to provide necessary medications to residents, leading to deficiencies in medication administration. One resident did not receive prescribed dronabinol and magnesium oxide due to delays and lack of stock. Another resident experienced pain without receiving prescribed lidocaine patches, despite documentation indicating they were administered. A third resident had issues with fentanyl patch administration, with lapses in record-keeping and communication among staff.
A resident with hypothyroidism and failure to thrive experienced medication administration errors, resulting in a 12% error rate. The charge nurse administered incorrect dosages of levothyroxine and failed to provide magnesium oxide and dronabinol due to unavailability. The facility's policy on medication administration was not followed, as outdated medication cards were not removed, and there was inadequate communication about unavailable medications.
The facility failed to implement Enhanced Barrier Precautions and proper hand hygiene for a resident with a gastrostomy tube, leading to potential infection risks. Staff did not wear gowns or change gloves during high-contact care activities, contrary to facility policy. Misunderstandings about EBP requirements were evident among staff.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an allegation involving an injury of unknown origin was reported as required for one resident. The resident had diagnoses including traumatic subdural hemorrhage without loss of consciousness, Parkinson's disease, type 2 diabetes mellitus, and dementia, and the quarterly MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. On 06/14/26, the resident was found in the room with an unwitnessed head injury after being observed attempting to climb back into bed. A CNA noted dried blood on the floor and on the left side of the resident's head, the fall protocol was initiated, and the resident was transferred to the local hospital for evaluation. The facility's internal investigation determined the allegation that staff negligence caused the injury was unsubstantiated and concluded the most likely scenario was an unwitnessed, self-initiated attempt by the resident to get out of bed and then re-enter independently, resulting in a loss of balance and head injury. The investigation documented a hematoma measuring approximately 4 cm x 3.6 cm on the left side of the head and stated the exact sequence of events could not be determined because the event was unwitnessed and the resident could not provide a reliable history. Despite this, the DON stated the facility did not report the incident because it was not considered abuse and was not identified as an injury of unknown origin requiring notification to the State Agency. The facility policy stated that injuries from an unknown source are to be reported immediately but not later than 2 hours after the injury has been reported.
Failure to Provide CMS Form 10055 for Medicare Coverage
Penalty
Summary
The facility failed to provide the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to three residents when their Medicare A therapy services were completed. This oversight prevented the residents from being informed about their remaining days under Medicare A coverage. The facility's policy, last reviewed on 07/06/24, did not instruct staff to complete the CMS Form 10055 for residents at the anticipated end of their Medicare-covered stay. The electronic medical records (EMR) for three residents revealed that they were admitted with physician orders for skilled services, including physical and/or occupational therapy. The facility determined that these residents might no longer qualify for Medicare-covered services and issued them a Notice of Medicare Non-Coverage. However, the facility failed to issue the CMS Form 10055, which is necessary for informing residents about their Medicare coverage status. An interview with the Social Services Director confirmed this failure.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident abuse when one resident, identified as R54, pushed and hit another resident, R411, on the back. This incident occurred on 03/24/23. R411, who has severe cognitive impairment due to dementia and bipolar disorder, was admitted to the facility with a care plan that included supervision and reorientation as needed. R54, who has no cognitive decline but has diagnoses including end-stage renal disease and vascular dementia, admitted to pushing and hitting R411 to remove them from his room. The incident was reported to the facility staff the following day, and an incomplete investigation was conducted. The facility's policy on abuse prevention emphasizes the protection of residents from abuse, mistreatment, and neglect, and requires the identification of residents at risk and the development of intervention strategies. Despite this policy, the incident occurred, indicating a lapse in the facility's ability to prevent resident-to-resident abuse. The facility's documentation shows that R54 had not been involved in any other incidents since the event on 03/24/23. The facility's policy also outlines the need for regular reassessment of interventions to prevent such occurrences, which was not adequately followed in this case.
Incomplete Investigations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate incidents of resident-to-resident abuse involving three residents. In one incident, a resident with dementia and bipolar disorder was hit by another resident with end-stage renal disease and vascular dementia. The facility's investigation was incomplete, lacking staff and resident interviews, and did not document staff education related to the incident. Although the facility reported the incident to the appropriate authorities and conducted some aspects of the investigation, such as notifying the family and performing skin checks, the investigation was not comprehensive. In another incident, a resident alleged physical abuse by a former Social Service Director, claiming they were pushed out of a wheelchair and had their arm twisted. The investigation narrative included a witness statement from the Director of Rehab, who stated that the Social Service Director was several feet away and did not make physical contact. However, the investigation did not include statements from all involved parties, such as the Licensed Practical Nurse who witnessed the incident or the former Social Service Director. The facility's policy requires statements from all parties involved, but this was not adhered to in the investigation.
Failure to Maintain Proper Head Elevation During Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition through a feeding tube was appropriately positioned with the head elevated, as required by the facility's Tube Feeding Policy. The policy mandates that residents remain in a Semi-Fowler's position, with the head of the bed elevated between 30 and 45 degrees during and for one hour following tube feeding to prevent aspiration. However, observations revealed that the resident, who had severely impaired cognition and was dependent on a feeding tube for nutrition, was frequently positioned with the head of the bed elevated less than 30 degrees while the enteral feeding was running. Multiple observations over several days showed the resident lying in bed with inadequate head elevation, including instances where the resident was positioned on their side or flat on their back. Interviews with staff, including a CNA, a charge nurse, and the LPN Supervisor, confirmed that the head of the bed was not consistently elevated as required. The Director of Nursing also stated that the standard practice was to keep the head of the bed elevated to prevent aspiration, indicating a failure to adhere to this practice.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide necessary medications to residents, leading to deficiencies in medication administration. One resident, admitted with a diagnosis of failure to thrive, did not receive her prescribed dronabinol and magnesium oxide due to delays in obtaining a script and lack of stock. The charge nurse acknowledged the absence of these medications and indicated that the pharmacy was yet to deliver the dronabinol, while the magnesium oxide was out of stock. Documentation in the resident's medical records was inconsistent, with notes indicating the medication was on order or rescheduled, but without clear follow-up actions. Another resident, with a history of surgical aftercare and colostomy, experienced pain but did not consistently receive prescribed lidocaine patches for pain management. Observations revealed the absence of the patches, despite documentation indicating they were administered. The charge nurse admitted to not having the patches available and incorrectly documenting their administration. The resident's care plan lacked specific interventions for managing his pain, further contributing to the deficiency. A third resident, who had been discharged, had orders for a fentanyl patch for pain management. However, there were multiple instances where the patch was not administered, held without explanation, or refused by the resident without documentation of reasons. The facility was unable to provide controlled substance administration records for the fentanyl patches prior to a certain date, indicating a lapse in record-keeping. Interviews with staff revealed a lack of communication and follow-up regarding the availability of medications, contributing to the deficiencies observed.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12 percent error rate during an observation of medication administration. This deficiency affected one resident, who was observed to have received incorrect medication dosages. The resident, who had diagnoses including hypothyroidism and failure to thrive, was prescribed levothyroxine, magnesium oxide, and dronabinol. However, during the medication administration, the charge nurse administered two tablets of levothyroxine 100mcg instead of the prescribed 75mcg tablets, and the resident did not receive the dronabinol or magnesium oxide as they were unavailable. The charge nurse acknowledged the absence of magnesium oxide and the delay in receiving dronabinol from the pharmacy, which required a physician's order. The nurse also failed to remove the outdated 100mcg levothyroxine medication card from the cart, leading to the administration error. Interviews with the RN Supervisor, LPN Supervisor, and DON revealed a lack of communication and follow-up regarding unavailable medications and the need to adhere to the facility's medication administration policy, which includes notifying supervisors and ensuring the five rights of medication administration are followed.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) and hand hygiene protocols for Resident 91, who was identified as having a gastrostomy tube and was at risk for multidrug-resistant organisms (MDROs). The facility's policy required the use of gowns and gloves during high-contact resident care activities, such as dressing, bathing, and device care, for residents with wounds or indwelling medical devices. However, during observations, staff did not adhere to these protocols. On one occasion, a Certified Nursing Assistant (CNA) was observed providing care to Resident 91 without changing gloves between tasks and without wearing a gown, despite the resident's care plan indicating the need for EBP. The CNA performed various care activities, including perineal care and bed linen changes, without changing gloves or donning a gown, which was against the facility's policy for residents with feeding tubes. Additionally, a Charge Nurse was observed handling Resident 91's feeding tube without wearing a gown, contrary to the facility's EBP policy. Interviews with the Charge Nurse and the Infection Preventionist revealed a misunderstanding of the EBP requirements, as they believed gowns were only necessary for isolation precautions. The Director of Nursing confirmed that gloves and gowns should be used for contact activities involving residents with tube feedings, highlighting a gap in staff adherence to infection control protocols.
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 1,305 citations issued within 25 miles in the last 12 months — including the 24 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 Irvington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winchester Gardens Health Care Center | 0.6 mi | ★★★★★ | 1 | 0 |
| South Mountain Hc | 2.1 mi | ★★★★★ | 0 | 0 |
| Brookhaven Health Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| White House Healthcare And Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| New Community Extended Care Facility | 3.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alliance Care Rehabilitation And Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.